The legal right to medical decision-making

Hi, readers!  Long time, no blogging.

In the few years, there has been a huge push to legalise assisted suicide. Brittany Maynard became a national figure for the right to assisted suicide before she took her life.  Several states have legalised it.  Proponents of assisted suicide have argued that dying individuals, not the State, have a right to determine their medical care, and that swift death can be a compassionate alternative to prolonged, hopeless suffering.  (For the record, I do not find these arguments to be persuasive.)

Given that Americans are embracing this logic, it’s ironic that the same logic does not apply to the F.D.A.’s approval and clinical trial process for experimental, potentially life-saving, drugs.  The New York Times (hat tip) reported that the FDA is streamlining the process after its oncology chief, Dr. Richard Pazdur, lost his wife to ovarian cancer.

The F.D.A. has a notoriously slow approval process for new drugs.  This is largely a result of the thalidomide crisis in the 1960s, when pregnant women who took an anti-nausea drug gave birth to children with severe deformities (including flippers instead of arms).   F.D.A. medical officer Dr. Frances Kelsey refused to approve the drug after he found that it had not been tested on pregnant animals.  As the drug was never approved in the United States, American babies avoided the devastating harm that other children faced in countries where thalidomide had been approved.  The F.D.A.’s cautiousness in approving the drug has been used to justify its slow approval process in the half-century since the crisis.

Much of the problem with thalidomide was that its costs were out of proportion with its benefits: it reduced nausea, but could cause lifelong severe deformities.  As a general rule, we are more willing to approve drugs that cause a lot of harm if they also do a lot of good (e.g. a drug that has chemotherapy’s side effects would never be approved to reduce headaches, but is fine when it could save someone’s life). As such, the F.D.A. has a “compassionate use” programme, wherein severely ill people can apply to take unapproved drugs in the hope of saving their lives.  The rationale is that the patient will probably die anyway, so the additional risk of taking the unproven drug is minimal.  As the NYT explains,

That decision was made in a separate category of “compassionate use” drug approvals for individual patients. Every year, the F.D.A. receives about 1,000 similar applications from terminally ill people seeking experimental medications, and agency officials say they approve 99 percent of them. The approvals are distinct from those for drugs that have gone through clinical trials and that are for broad distribution.

So every year, about a thousand people apply for “compassionate use” drugs.  Every year, over a half-million people die from cancer.  Obviously, many of those people pass away from types of cancer that are not the target of any drugs in clinical trials or the approval process; but whatever that percentage of cancer patients who could benefit from a drug in the pipeline is, it is probably higher than 0.5%.  In fact, the number of people who apply for and receive permission for “compassionate use” of an experimental drug is approximately equal to the number of people who undergo euthanasia every year in America (even though assisted suicide is limited to a small number of states).

In effect, we are a country wherein a cancer patient is just as likely to commit suicide via a lethal dose of legal drugs as he is to receive experimental, potentially life-saving medical treatment.  Analytically, the laws governing each are different: the “drug cocktail” that is used for assisted suicide is an off-label use and therefore not governed by the F.D.A., and state law, not federal law, governs assisted suicide.  But in a discussion about the policy that governs the approval process for potentially life-saving medication and the availability of compassionate use, it is damning that Americans are just as likely to use legal drugs to kill themselves as they are to apply for life-saving ones.

 

Our current health care system does not resemble any sort of free market

This, however, is free market health care.  Oklahoma doctors are putting their prices up online and starting bidding wars for patients.  Patients have gone to their own hospitals with a plane ticket to Oklahoma in hand, then asked the hospital to match the all-inclusive price of surgery.

Dr. Keith Smith’s medical group also does not accept Medicaid or Medicare, because the regulations would prohibit them from posting their prices online and charging what they charge.  Yes, my friends, as I’ve long said, you can’t give discount health care and be a Medicare/Medicaid provider.  (This is also why plastic surgery and cosmetic dentistry are so transparent with their prices, and have the better quality/lower price trend that is seen in computers, iPods, and pretty much anything in the free market.)

As a final point, Dr. Smith says this:

“What we’ve discovered is health care really doesn’t cost that much,” said Smith. “What people are being charged for is another matter altogether.”

I’ve heard that primary care doctors spend $47 per patient filling out insurance forms; the insurance company spends approximately the same amount of money.  Your premiums will pay for, in roughly equal numbers: your doctor’s visit; your doctor’s costs to fill out insurance paperwork; and your insurance company to process the payment.  If you want to pay for medical care plus administrative overhead, be my guest, but please don’t force the entire nation into that system.

A better use for those sixteen thousand IRS agents (or the money used to hire them)

Back in 2009 and 2010, conservatives repeated that ObamaCare provided funding for 16,000 new IRS agents but additional funding for physicians.  PolitiFact suggests that this may not be accurate, since the number is generated from the $5 billion to $10 billion in additional funds budgeted to the IRS.  (It did not, however, dispute that ObamaCare gives many billions to the IRS but no additional funds to doctors or for doctor training.)

Then there is this from Bloomberg Businessweek: in coming years, America will probably need 130,000  more doctors than it currently has.  Alex Wayne explains,

One major reason: The residency programs to train new doctors are largely paid for by the federal government, and the number of students accepted into such programs has been capped at the same level for 15 years. Medical schools are holding back on further expansion because the number of applicants for residencies already exceeds the available positions, according to the National Resident Matching Program, a 60-year-old Washington-based nonprofit that oversees the program.

Then this:

[Teaching hospitals] support bipartisan legislation introduced this month that would add 3,000 residencies a year through 2017 at a cost to taxpayers of about $9 billion. Deficit-watching Republicans, including Price, say private funding needs to be identified instead.

Let’s go for the obvious solution: spend the $5 to $10 billion that would have been given to the IRS on training more doctors.  Fewer metaphorical headaches for all Americans, more primary-care physicians, less government intrusion.

The Law of Unintended Consequences

Four years ago, the New York Times reported that many of the best medical students in the country are seeking out residencies in dermatology and plastic surgery. Many of those students cite the low rates of physician pay and their high student loans as reasons to avoid fields like family medicine.  Yesterday, NPR confirmed the same – that the U.S. is facing a critical shortage of primary care physicians due to medical students’ desire to be able to make a living.

Now, even primary care doctors are moonlighting as plastic surgeons to make extra money (no, that does not always work out well for those who get plastic surgery), or ending their primary care practises and going into plastic surgery instead.  Their reasons for doing so functionally amount to under-payment by insurance companies and the government.

Medical school, even at state universities, is expensive. UMass Medical School charges in-state residents almost $200,000; UConn charges between $220,000 and $330,000 (the latter for out of state).  Private schools are similar: over $300,000 for Tufts, Harvard, and BU.  Nationwide, medical school tuition and fees (note: the above figures account for living expenses) at public medical schools average $28,812 per year.

I don’t think that many medical students started school with the intention of going into plastic surgery or dermatology.  However, when doctors report that they lose money on every Medicare patient they see, or that some procedures have such low reimbursement rates that physicians can barely break even, aspiring doctors will understandably look to fields that do not require them to be at the mercy of with Medicare/Medicaid or insurance companies.   Thus, they gravitate towards cash-pay specialties; unfortunately, cash-pay specialties are exactly the ones that are least needed by the sick.

Ideally, we would create a system for delivering primary care that looks more like plastic surgery from a physician’s perspective: reasonable hours, relatively high salaries, straightforward payment and reimbursement.