Economics at the Bedside: A bridge too far? -...

Economics at the Bedside:

A bridge too far?

Rakesh Patel M.D. Pharm.D. M.Sc

September 29th, 2016

Regret, Religion and Rationing: A bridge too far?

Edvard Munch “The Scream” 1893-94

“In my job as a physician, I have been troubled, at times, by my role in the lives that we extend through our interventions”

Letter to the Editor

Ottawa Citizen March 2008

S. Kravcik M.D.

Div. General Internal Medicine, TOH

The nature of suffering and the goals of medicine.

Cassel EJ NEJM 1982;306:639-45

“the relief of suffering and the cure of disease must be seen as the twin obligations of a medical profession

that is truly dedicated to the care of the sick”

“Physicians” [ and families] failure to understand the nature of suffering……..

Becomes a source of suffering itself


Economics at the bedside: A bridge too far?

“Do not try to live forever,

You will not succeed”

1906

“the art of medicine is to humour the patient while nature does the healing”


Dilemmas to ponder:

The most expensive care is not the best care. .. . .


Man-made & influenced

healing

what can we afford?

Cases to ponder:

1. Meet Pietro:

21yo who overdoses, ends up in ICU. He desperately needs psychiatric help

His family: feels helpless, hopeless and dismissed

How do we break his cycle of ED / ICU visits?

What should we consider / do?


Economics at the bedsider: A bridge too far?

Psychiatry ward?

Cases to ponder:

2a. Meet Letisha:

Based upon your history taking, physical examination and Chest X-ray review, you diagnose

her with Pneumonia

She and her family want a C.T scan

Your Attending wants a differential of what else may be causing her breathing problem


Cases to ponder:

2b. Meet Letisha:

You order a C.T. The family adores you because you are an attentive & thoughtful, comprehensive doctor “they felt they were in your care!”

Your Attending rewards you for thinking broadly & ordering more tests to assess your hypotheses.


You inadvertently drive up the cost of Pneumonia management!

Cases to ponder:

2c. Meet Letisha:

And so it begins for doctors – the wrong incentives framework subliminally placed during training

Lifelong lesson

Patient-centred care, right?


Cases to ponder:

3a. Meet Jasna:

You are the head of the P&T committee at your hospital.

A 57yo who has a rare disorder with very few effective treatment(s) for control, none for cure

She desperately needs treatment or she will die

The cost of tx = $10K per cycle [n=5 cycles]

She & her family feel helpless & hopeless


Cases to ponder:

3b. Meet Jasna:

The treatment team presses you to approve the costly tx’s

The hospital cannot afford multiple cycles

The MoH refuses to pay for tx – lack of evidence

What would you consider / do?


Cases to ponder:

4. Meet Vishnu

Vishnu is now seen for the 3rd time in a month with hyperglycemia despite being prescribed 2 different medications and being taught how to check his sugar daily

You ask him, “are you taking your insulin?”

He answers, “yes” Wrong question!

Patient-centred care, right?


Cases to ponder:

5. Meet Penelope

Penny has a wicked family hx of HTN & its complications

Penny was wilfully non-compliant with her HTN tx

Penny is now in the ICU with a large stroke

Penny has cost our health-care system a lot of money


Not enough personal / family responsibility for healthcare. What should we do here?


Cases to ponder;

6. Trying to get folks home

Limited community palliative care resources

Limited home-care resources

Forces patients and families to seek out acute care hospital resources


Universal Case;

My __________ is a fighter(!), doctor. I forbide you to give up!

We don’t want to believe that the patient has given up - that is unthinkable of our hero(s)


1. Cost-effectivenessThe degree to which something is effective or

productive in relation to its cost.

2. Opportunity costA $ spent here cannot be spent there


Is there a place for the principles of;

1. Cost-effectiveness2. Opportunity cost

In medical education and at the bedside?


“the ethics of the Hippocratic physician makes yes or no decisions on the basis of the benefit of a single patient without taking into account what economists call, “alternative costs”

R.Veatch 1991

Will this thinking destroy;1. The patient-physician relationship2. A publicly-funded health care system?


1. Cost-effectiveness2. Opportunity cost

Can a Clinician remain a patient advocate while serving as a steward of limited health-care resources?

Can we define / teach ethical Clinician advocacy?

See example of Letisha


1. Cost-effectiveness

2. Opportunity cost

How should we go about equitably distributing finite resources?

See example of Pietro


1. Cost-effectiveness

2. Opportunity cost

How should we help clinicians appreciate that their decisions translate into expenses for their patients?

See example of Vishnu


The Canada Health Act:

Public Administration Comprehensiveness Universality Portability Accessibility

Clash of cultures, values & priorities? Changing demographics [“silver tsunami”]

Life-extending therapies

Greater & unrealisticexpectations of the health-care system

Are we making publicly-funded

health-care unsustainable?

Patient-centred care

I now have

cancer, where is my cure?

I am entitled to my entitlements!

I’ve paid my taxes!I want everything done!



MEDICAL ASSISTANCE IN DYING:

A PATIENT-CENTRED APPROACH

Report of the Special Joint Committee

on Physician-Assisted Dying

Hon. Kelvin Kenneth Ogilvie and Robert

Oliphant

Joint Chairs

FEBRUARY 2016

42nd PARLIAMENT, 1st SESSION


Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those cold gradations of decay, so distressing to himself and to his friends

W. Osler


QOL

&

IADLs

100%

Time

Life is a sexually transmitted fatal disease

ICU team – Family communications:

Existence versus Life


I want life in my years…..

not years of life….

Major Principles of Health Care Ethics:

Respect for Individual autonomy

Beneficence: do good

Nonmaleficence: don’t hurt

Distributive justice: equal access and save some for the next guy [Egalitarian?]



Rationing [yes] vs Waste avoidance [yes]?

Ethical imperative; Unlimited demand Limited resources

Fairest means of allocating such resources equitably?

Accommodation of Distributive justice & Patient autonomy


Autonomy of city states

18th Century Philosophers

Autonomy of people

20th CenturyIndividual

Patient Autonomy

A bridge too far ?


“an injustice anywhere,is a threat to justice

everywhere!”M.L. King

Distributive justice

http://images.google.ca/imgres?imgurl=http://members.aol.com/klove01/images/martin.jpg&imgrefurl=http://members.aol.com/klove01/martinsp.htm&h=300&w=347&sz=22&hl=en&start=50&tbnid=ALlvZS7zGPpY1M:&tbnh=104&tbnw=120&prev=/images?q=Martin+Luther+King&start=40&gbv=2&ndsp=20&hl=en&sa=N


Beach MC et al



83% response rate, n=414/500


Rationing vs Waste avoidance?

So… … …. . .Waste

Eliminate waste: one-time savings approach only? [demand?]

Stop spending on non-beneficial interventions [I want an MRI!]



So… … What drives Cost?

Virtually unbounded patient demand and expectations

Technological advances: tests, meds, devices, procedures

Intervention drift / creep

Panacea!

Poison!

Pedestrian

The life cycle of any Drug

Bernard McDonald M.D. Ottawa Heart Institute


So… … What drives Cost?

Physicians: self-interest & remuneration incentives

Physicians: refusal to have difficult conversations

Physicians: remain loathe to consider costs of care in their decision making

Flawed Evidence or application thereof


Barriers to thinking about Cost;

Single minded advocacy for any amount of benefit for every patient

Peer admonishment / violation of Hippocratic Oath

Patient autonomy [perceived violation]

Tyranny of choice [autonomy ≠ endless choice]


Barriers to thinking about Cost;

In-patient demands of patient flow: cost driver [LOC paper-chase]

Physician remuneration [procedures vs cognition]

Lack of knowledge of economic principles[price of everything, the value of nothing]

Jurisprudence


Solutions to facilitate thinking about Cost;

Acknowledge the myth of doing everything, at all cost, for every patient

Recognize that autonomy ≠ endless choice

Learn how to assess “value” [NNT / NNH]

Acquire communication skills to engage in “value” & EOL discussions with patients / SDMs


Solutions to facilitate thinking about Cost;

Teach about the financing of our health-care “system” e.g. CHA

Teach about stewardship of resources [e.g. abx

stewardship]

Encourage EOL care planning



Think globally?



Never forget…

“the patient is the one with the disease”

Rule # IVThe House of GodSamuel Shem M.D.

Questions, Questions, Questions?

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