Let’s begin with a couple of clinical questions:
Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.
When would you have him see his primary-care provider?
a. In two days;
b. In one week;
c. In two weeks; or
d. In four weeks.
Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.
What do you do?
a. Order an exercise stress test;
b. Order a dobutamine stress echo;
c. Refer the patient to cardiology; or
d. Discharge the patient to home and have her follow up if she has further symptoms.
Scenario One: We don’t know.
Scenario Two: We don’t know.
Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.
A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.
So is healthcare rationing Obama’s solution to healthcare reform?
More Equals Less
There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1
And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2