economics at the bedside: a bridge too far? -...
TRANSCRIPT
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Economics at the Bedside:
A bridge too far?
Rakesh Patel M.D. Pharm.D. M.Sc
September 29th, 2016
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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
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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
Regret, Religion and Rationing: A bridge too far?
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Economics at the bedside: A bridge too far?
“Do not try to live forever,
You will not succeed”
1906
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“the art of medicine is to humour the patient while nature does the healing”
Economics at the bedside: A bridge too far?
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Dilemmas to ponder:
The most expensive care is not the best care. .. . .
Economics at the bedside: A bridge too far?
Man-made & influenced
healing
what can we afford?
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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 bedside: A bridge too far?
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Economics at the bedsider: A bridge too far?
Psychiatry ward?
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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
Economics at the bedside: A bridge too far?
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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.
Economics at the bedside: A bridge too far?
You inadvertently drive up the cost of Pneumonia management!
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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?
Economics at the bedside: A bridge too far?
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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
Economics at the bedside: A bridge too far?
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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?
Economics at the bedside: A bridge too far?
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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?
Economics at the bedside: A bridge too far?
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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
Economics at the bedside: A bridge too far?
Not enough personal / family responsibility for healthcare. What should we do here?
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Economics at the bedside: A bridge too far?
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
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Economics at the bedsider: A bridge too far?
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)
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Economics at the bedside: A bridge too far?
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
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Economics at the bedside: A bridge too far?
Is there a place for the principles of;
1. Cost-effectiveness2. Opportunity cost
In medical education and at the bedside?
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Economics at the bedside: A bridge too far?
“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?
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Economics at the bedside: A bridge too far?
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
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Economics at the bedside: A bridge too far?
1. Cost-effectiveness
2. Opportunity cost
How should we go about equitably distributing finite resources?
See example of Pietro
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Economics at the bedside: A bridge too far?
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
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Regret, Religion and Rationing: A bridge too far?
The Canada Health Act:
Public Administration Comprehensiveness Universality Portability Accessibility
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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
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I now have
cancer, where is my cure?
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I am entitled to my entitlements!
I’ve paid my taxes!I want everything done!
Economics at the bedsider: A bridge too far?
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Economics at the bedside: A bridge too far?
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
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Regret, Religion and Rationing: A bridge too far?
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
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Economics at the bedside: A bridge too far?
QOL
&
IADLs
100%
Time
Life is a sexually transmitted fatal disease
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ICU team – Family communications:
Existence versus Life
Regret, Religion and Rationing: A bridge too far?
I want life in my years…..
not years of life….
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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?]
Regret, Religion and Rationing: A bridge too far?
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Economics at the bedsider: A bridge too far?
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
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Regret, Religion and Rationing: A bridge too far?
Autonomy of city states
18th Century Philosophers
Autonomy of people
20th CenturyIndividual
Patient Autonomy
A bridge too far ?
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Regret, Religion and Rationing: A bridge too far?
“an injustice anywhere,is a threat to justice
everywhere!”M.L. King
Distributive justice
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Economics at the bedsider: A bridge too far?
Beach MC et al
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Economics at the bedsider: A bridge too far?
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Economics at the bedsider: A bridge too far?
83% response rate, n=414/500
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Economics at the bedsider: A bridge too far?
Rationing vs Waste avoidance?
So… … …. . .Waste
Eliminate waste: one-time savings approach only? [demand?]
Stop spending on non-beneficial interventions [I want an MRI!]
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Economics at the bedsider: A bridge too far?
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Economics at the bedsider: A bridge too far?
So… … What drives Cost?
Virtually unbounded patient demand and expectations
Technological advances: tests, meds, devices, procedures
Intervention drift / creep
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Panacea!
Poison!
Pedestrian
The life cycle of any Drug
Bernard McDonald M.D. Ottawa Heart Institute
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Economics at the bedsider: A bridge too far?
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
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Economics at the bedsider: A bridge too far?
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]
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Economics at the bedsider: A bridge too far?
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
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Economics at the bedsider: A bridge too far?
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
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Economics at the bedsider: A bridge too far?
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
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Regret, Religion and Rationing: A bridge too far?
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Regret, Religion and Rationing: A bridge too far?
Think globally?
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Economics at the bedside: A bridge too far?
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Regret, Religion and Rationing: A bridge too far?
Never forget…
“the patient is the one with the disease”
Rule # IVThe House of GodSamuel Shem M.D.
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Questions, Questions, Questions?