field notes
1
field notes Costs, blogs, and rationing. In 1985 I was invited to take part in an Office of Technology Assessment project on the impact new tech- nologies would have on the future of Medicare. The study concluded that those technologies would cause great problems, inexorably driving up costs. Some limits would, sooner or later, have to be set on Medicare spending. I was immediately hooked by that problem, wrote a book about it, and have followed it ever since. Yet even though the problem of rising Medicare costs was identified nearly twenty-five years ago, not much was done about it, and it became politically hazardous even to talk about it. Now it has become an immediate issue, but the rhetoric of urgency and the cost projections driv- ing it have yet to make a difference. The Affordable Care Act promises to cut many Medicare expenses, but how effective that will be is uncertain at best. My essay in this issue focuses in part on the difficulty of even having a public discussion of rationing. It is acceptable to talk of it in academic and policy circles but dangerous business in the public arena. Do you want your life controlled by government death panels? My interest in costs led me, in 2009, to institute a Hastings Center blog, the Health Care Cost Monitor (http://healthcarecarecostmonitor.the hastingscenter.org). We suspended the blog after a year because the reform legislation took the steam out of the issue for a time. Now it is back, and so is the blog. This time it will reflect a somewhat broader scope, aiming to put costs into the context of a wider, interlocking set of problems. In my own post to reopen the blog, “The Cost Conundrum,” I note some longstanding political problems when trying to control costs. These are bad enough to cope with. But I also note a different kind of resistance, even among those who fully understand the need to cut costs. They worry that cost control efforts will harm the quality of health care, that some costs, though high, are worth having, and that some expensive upfront costs are necessary for long-term benefits (such as prevention). The dilemma with all those worries is that they are probably valid: seri- ous cost-cutting may well do harm, and it is good to be reminded of that possibility. But the harm of failing to control costs is not thereby eliminated and probably undermined by that line of thought. Even worse, I have come to believe that the much-touted generic solution to the cost problem— ridding the health care system of waste and inefficiency and eliminating treatments without proven efficacy—is only part of the problem, and the easy part at that. The hard part is dealing with expensive treatments that do work, and whose curtailment will do harm. That is where the ultimate ethical problem lies. We must choose between two goods: beneficial but expensive treatments that are good for individuals against cost control that is beneficial, even necessary, for health care systems. Or, put differently, we must choose between two evils: depriving patients of treatments that will do them good, or refusing to deal with costs because of a loss of patient benefit, thereby harming the system. My article on rationing tries to deal with one feature of the cost crisis, that of actually cutting costs, thereby rationing care. The Health Care Cost Monitor will continue watching an ethical dilemma of major proportions being played out in Congress, state legislatures, and in public opinion. The only thing that can be said with certainty: we have just begun the struggle, and it will not soon end. —Daniel Callahan Senior Research Scholar and President Emeritus Officers of The Center – 2011 David L. Roscoe Chairman Thomas H. Murray President & Chief Executive Officer Lyn Traverse Secretary Andrew S. Adelson Treasurer Board of Directors – 2011 Andrew S. Adelson Anita Allen University of Pennsylvania Law School Joshua S. Boger Vertex Pharmaceuticals Gilman S. Burke Satterlee Stephens Burke & Burke Daniel Callahan (ex officio) Joseph J. Fins (ex officio) Weill Cornell Medical College Alan R. Fleischman March of Dimes Willard Gaylin (ex officio) Francis H. Geer St. Philip’s Church in the Highlands Thomas B. Hakes C/S Group Geoffrey R. Hoguet GRH Holdings, LLC Patricia Klingenstein Ilene Sackler Lefcourt Sackler Lefcourt Center for Child Development Robert Michels Weill Medical College of Cornell University Michele Moody-Adams Columbia College Thomas H. Murray (ex officio) Sherwin B. Nuland Yale University Michael E. Patterson Richard Payne Duke Divinity School Harriet S. Rabb Rockefeller University David L. Roscoe Blair L. Sadler Institute for Healthcare Improvement Francis H. Trainer, Jr. John Eu-Li Wong Yong Loo Lin School of Medicine, National University of Singapore
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Transcript of field notes
field notesCosts, blogs, and rationing. In 1985 I was invited to take part
in an Office of Technology Assessment project on the impact new tech-nologies would have on the future of Medicare. The study concluded that those technologies would cause great problems, inexorably driving up costs. Some limits would, sooner or later, have to be set on Medicare spending. I was immediately hooked by that problem, wrote a book about it, and have followed it ever since. Yet even though the problem of rising Medicare costs was identified nearly twenty-five years ago, not much was done about it, and it became politically hazardous even to talk about it. Now it has become an immediate issue, but the rhetoric of urgency and the cost projections driv-ing it have yet to make a difference. The Affordable Care Act promises to cut many Medicare expenses, but how effective that will be is uncertain at best. My essay in this issue focuses in part on the difficulty of even having a public discussion of rationing. It is acceptable to talk of it in academic and policy circles but dangerous business in the public arena. Do you want your life controlled by government death panels?
My interest in costs led me, in 2009, to institute a Hastings Center blog, the Health Care Cost Monitor (http://healthcarecarecostmonitor.thehastingscenter.org). We suspended the blog after a year because the reform legislation took the steam out of the issue for a time. Now it is back, and so is the blog. This time it will reflect a somewhat broader scope, aiming to put costs into the context of a wider, interlocking set of problems.
In my own post to reopen the blog, “The Cost Conundrum,” I note some longstanding political problems when trying to control costs. These are bad enough to cope with. But I also note a different kind of resistance, even among those who fully understand the need to cut costs. They worry that cost control efforts will harm the quality of health care, that some costs, though high, are worth having, and that some expensive upfront costs are necessary for long-term benefits (such as prevention).
The dilemma with all those worries is that they are probably valid: seri-ous cost-cutting may well do harm, and it is good to be reminded of that possibility. But the harm of failing to control costs is not thereby eliminated and probably undermined by that line of thought. Even worse, I have come to believe that the much-touted generic solution to the cost problem—ridding the health care system of waste and inefficiency and eliminating treatments without proven efficacy—is only part of the problem, and the easy part at that. The hard part is dealing with expensive treatments that do work, and whose curtailment will do harm. That is where the ultimate ethical problem lies. We must choose between two goods: beneficial but expensive treatments that are good for individuals against cost control that is beneficial, even necessary, for health care systems. Or, put differently, we must choose between two evils: depriving patients of treatments that will do them good, or refusing to deal with costs because of a loss of patient benefit, thereby harming the system.
My article on rationing tries to deal with one feature of the cost crisis, that of actually cutting costs, thereby rationing care. The Health Care Cost Monitor will continue watching an ethical dilemma of major proportions being played out in Congress, state legislatures, and in public opinion. The only thing that can be said with certainty: we have just begun the struggle, and it will not soon end.
—Daniel CallahanSenior Research Scholar and President Emeritus
Officers of The Center – 2011
David L. RoscoeChairman
Thomas H. MurrayPresident & Chief Executive Officer
Lyn TraverseSecretary
Andrew S. AdelsonTreasurer
Board of Directors – 2011
Andrew S. Adelson
Anita AllenUniversity of Pennsylvania Law School
Joshua S. BogerVertex Pharmaceuticals
Gilman S. BurkeSatterlee Stephens Burke & Burke
Daniel Callahan (ex officio)
Joseph J. Fins (ex officio)Weill Cornell Medical College
Alan R. FleischmanMarch of Dimes
Willard Gaylin (ex officio)
Francis H. GeerSt. Philip’s Church in the Highlands
Thomas B. HakesC/S Group
Geoffrey R. HoguetGRH Holdings, LLC
Patricia Klingenstein
Ilene Sackler LefcourtSackler Lefcourt Center for Child Development
Robert Michels Weill Medical College of Cornell University
Michele Moody-AdamsColumbia College
Thomas H. Murray (ex officio)
Sherwin B. NulandYale University
Michael E. Patterson
Richard PayneDuke Divinity School
Harriet S. RabbRockefeller University
David L. Roscoe
Blair L. SadlerInstitute for Healthcare Improvement
Francis H. Trainer, Jr.
John Eu-Li WongYong Loo Lin School of Medicine, National University of Singapore
