We discussed the new computer model that supposedly can predict how much longer one has to live in the context of whether a patient should be told they have less than ten years. But the NYT’s take on the same story raises another issue we only tangentially touched before; whether a computer program predicting how long a patient has to live could be put to pernicious heatlhcare rationing effect, similar to the “quality adjusted life year” (QALY) that was used by NICE to ration medicine in the UK. From “Using Interactive Tools to Assess the Likelihood of Death:”
Now, researchers at the University of California, San Francisco, have identified 16 assessment scales with “moderate” to “very good” abilities to determine the likelihood of death within six months to five years in various older populations. Moreover, the authors have fashioned interactive tools of the most accurate and useful assessments. On Tuesday, the researchers published a review of these assessments in The Journal of the American Medical Association and posted the interactive versions at a new Web site called ePrognosis.org, the first time such tools have been assembled for physicians in a single online location.
“We think a more frank discussion of prognosis in the elderly is sorely needed,” said Dr. Sei Lee, a geriatrician at U.C.S.F. and a co-author of the review. “Without it, decisions are made that are more likely to hurt patients than help them.” Dr. Lee and his colleagues cautioned that while the best assessments are reasonably accurate, there is insufficient data on whether using them improves patient care in clinical settings. The researchers stopped short of urging widespread use.
For now, perhaps. But wait until Obamacare bureaucrats grab ahold.
One doesn’t have to be paranoid to see where this can lead. Under QALY systems, roughly stated, a cost benefit analysis is done to justify providing or withholding an intervention based on the time it is expected to give a patient, adjusted for the quality of life during that time. Thus, the same intervention that would give me, say, five years of life, might be only worth two years of QALYs if the time would likely include my being disabled. And something worth five QALYs might be paid for but not something worth two. The same type of thing could easily be fashioned with this computer model–and don’t think some people aren’t thinking about doing just that.
Do we want people to have information to properly give informed consent and refusal to potential interventions? Absolutely. Do we want doctors to not offer particular efficacious interventions–or the government/private insurance company refusing to pay for them–because the computer model opined that the patient has a 78% chance of, say, living less than three years? I think not. Could this kind of information to be used to justify medical discrimination? You betcha! Indeed, I fear some want to do just that–particularly given the bureaucratic cost saving impetus behind Obamacare’s many cost/benefit panels.
Could this become a hope killer? You betcha again! We should tread with very great care here.
January 14th, 2012 | 8:46 pm
Hospitals and doctors will no doubt use these kinds of predictive systems for general guidance, since I think we all know that the statistics of a group are predictive ONLY for the group and not in individual cases. To suggest that they’ll be used otherwise, for some sinister purpose, because you disagree with Obama’s healthcare reform is, to say the least, just a bit over the top.
HW
January 15th, 2012 | 3:53 pm
I agree with most of what you say. And, of course, I am just an uneducated lay person who became interested and obsessed by in the subject matter of medical futility and passive euthanasia because of a personal trauma. I read you and Professor Pope almost daily.
But I can’t agree with all of your opinions and especially this one about “computer models to ration health care treatment.”
Certainly, you know that the insurance companies and all businesses use statistical data arranged in computer programs to conduct their businesses more efficiently. The digital age is upon us and is not to be denied.
If the computer programs are used to educate patients as well as physicians to recognize futility, etc.. and this results in “self rationing” of outpatient and inpatient care, would you agree that this is a good thing?
Doesn’t your strong opposition to “no rationing of any kind” really only help the insurance companies —-because the insurance companies/CMS are already rationing life saving and life-extending treatment for the elderly on Medicare by means of their “value-based purchasing program???)
Sometimes, I find it hard to understand your position! If physicians had been placed under the 1991 Patient Self Determination Act which permits hospital-assisted euthanasia of the elderly, why weren’t physicians put under this law? Wouldn’t this have resulted in “informed consent” for palliative care and wouldn’t this result in the patients rationing of both outpatient and inpatient care?”
Wasn’t it the Private Insurance Companies who invaded government Medicare who lobbied to have this law passed by the Congress? And don’t the private insurance companies who partner with government Medicare/Medicaid use Computerized Computer Models right now to deny treatment?
HistoryWriter Reply:
January 16th, 2012 at 7:28 am
@Carol Eblen,
What makes you think I’m opposed to rationing of any kind? I favor it.
HW
January 15th, 2012 | 4:03 pm
I agree with most of what you say. And, of course, I am just an uneducated lay person who became interested and obsessed by the subject matter of medical futility and passive euthanasia because of a personal trauma. I read you and Professor Pope almost daily.
But I can’t agree with all of your opinions and especially this one about “computer models to ration health care treatment.”
Certainly, you know that the insurance companies and all businesses use statistical data arranged in computer programs to conduct their businesses more efficiently. The digital age is upon us and is not to be denied.
If the computer programs are used to educate patients as well as physicians to recognize futility, etc.. and this results in “self rationing” of outpatient and inpatient care, would you agree that this is a good thing?
Doesn’t your strong opposition to “no rationing of any kind” really only help the insurance companies —-because the insurance companies/CMS are already rationing life saving and life-extending treatment for the elderly on Medicare by means of their “value-based purchasing program” that denies reimbursement and penalizes those who don’t provide “best-practice care.”
Sometimes, I find it hard to understand your position! If physicians had been placed under the 1991 Patient Self Determination Act (which permits hospital-assisted euthanasia of the elderly and why weren’t physicians put under this law?) wouldn’t this have resulted in “informed consent” for palliative care and wouldn’t this result in the patients’ rationing of both outpatient and inpatient care?”
Wasn’t it the Private Insurance Companies who invaded government Medicare who lobbied to have this law passed by the Congress? And don’t the private insurance companies who partner with government Medicare/Medicaid use Computerized Computer Models right now to deny treatment and reimbursement?
HistoryWriter Reply:
January 16th, 2012 at 7:40 am
@Carol Eblen, Oops, sorry; I misread your question.
I favor the rationing or even the withdrawal of care in cases in which it’s demonstrably useless (e.g., Schiavo), since such efforts represent the triumph of ideology over practical medical economics.
With respect to government’s unholy alliance with insurance companies, I see it as the product of conservative opposition to ANY purely governmental health care plans (which they persist in characterizing as “socialized medicine”). Republican protectors of the insurance industry have always demanded that their paymasters be included in any health care initiative, rather than have them compete with government entities. Interestingly, these same politicians have no complaint at all about being the beneficiaries of a single-payer plan run by — you guessed it — Uncle Sam.
HW
January 15th, 2012 | 10:08 pm
If the computer models turn out not to be very good at predictions, will we ever hear about that? Methinks probably not.
HistoryWriter Reply:
January 16th, 2012 at 7:42 am
@Lydia,
Maybe. Maybe not. But I think there’s more than enough oversight out there to “keep honest people honest.” Surely you don’t think Wesley will let them get away with anything, do you? [WJS: I'm serious. Really.]
HW
January 16th, 2012 | 8:31 am
Have you been following this story out of Philadelphia? http://www.wolfhirschhorn.org/2012/01/amelia/brick-walls/
A two year old is being denied a live donor kidney transplant from a family member because she has an intellectual disability. I haven’t been able to get much more than blog info about the story. I don’t know if any of the local media is covering it. So far only on social networks I think.
January 16th, 2012 | 9:42 am
We already ration health care. If you’re sick, you call your insurance company and they give you permission to get whatever treatment you need.
In any event, almost no one favors a totally free-market health care system. Could you imagine if the liver transplant went to the highest bidder?
January 16th, 2012 | 5:44 pm
There is so much dishonesty about health care, etc.. and the fact is that “Medicare Hospice and palliative care” is already a premeditated voluntary form of rationing of expensive treatments and ICU time for the elderly on Medicare/Medicaid and Privately supplemented policies.
Additionally, the Value Based Purchasing Program of Medicare, results in further arbitrary rationing of treatment for the elderly when hospitals/physicians are NOT reimbursed for errors/omissions, etc.. and/or failure to provide “best practice care” as determined by administrative rules developed by CMS.
As Earl E. Appleby, Jr. and others indicate” “Of course, when cost drives the engine of euthanasia, the cover of “choice” is discarded.” (as happened to my husband and me in a Christian Hospital with an unauthorized DNR/DNI because the hospital/physician were afraid we would make the wrong choice and they would have to eat the costs of the ICU time, etc..)
Obviously, the physicians didn’t want to be put under the 1991 Patient Self Determination act and lobbied not to be subject to the provisions of this law.
There would be self-rationing by patients of much futile/unnecessary “outpatient” care if physicians had the same mandate as the hospitals and were required to seek “informed consent” for outpatient palliative and curative care.
Mandated informed consent to outpatient palliative and/or curative treatment would require the disclosure of statistics and odds and “computer models”
that would permit elderly outpatients to make more informed end-of-life choices.
But, of course, it would or could RATION PROFITS for the suppliers (the incorporated physicians and clinics) in the outpatient setting and place a greater legal burden for “informed consent” on the treating physicians in the outpatient and the inpatient setting.
It isn’t surprising that the unholy trinity (the insurance companies, Medicare and the hospitals) didn’t explain why physicians weren’t included in the 1991 Patient Self Determination Act.
Would “HistoryWriter” comment on this?
January 19th, 2012 | 10:01 am
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