Wednesday, August 26, 2009

Health Care Notes

Some random thoughts on health care, and the reform there of.

This is an old story but it bears some examination. In October, 2008, then-Senator Obama's grandmother was reported as having broken her hip. She had "hip replacement" surgery. She died about a week later.

On April 14 of this year, President Obama gave an interview about health care reform to the New York Times, in which he said:

"THE PRESIDENT: I don't know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she's my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn't have a hip replacement and she had to lie there in misery in the waning days of her life -- that would be pretty upsetting.

NYT: And it's going to be hard for people who don't have the option of paying for it.

THE PRESIDENT: So that's where I think you just get into some very difficult moral issues. But that's also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

NYT: So how do you -- how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that's part of why you have to have some independent group that can give you guidance. It's not determinative, but I think has to be able to give you some guidance. And that's part of what I suspect you'll see emerging out of the various health care conversations that are taking place on the Hill right now." [The New York Times Magazine, 4/28/09]

There's a lot here that needs to be unpacked. Let's start with the term "hip replacement". First some anatomy. The hip is basically a ball and socket joint. The ball is the end of the femur (the large bone between the hip and knee). The ball is known as the "head of the femur". The head of the femur is joined the the rest of the femur by a column of bone known as "the neck". The socket of the joint is in the pelvis and is known as the "acetabulum". Normally bone gets its blood supply from the tissue surrounding it know as "periosteum". However, because the head of the femur rotates within the acetabulum blood can not get to it from surrounding tissues. So the head gets its blood supply from the periosteum of the neck of the femur. Without blood supply a bone will die.

When most people hear the term "hip replacement" what comes to mind is what is known as a "total hip arthroplasty", or simply "total hip". Total hips are usually done for patients with hip pain from arthritis. In it the head of the femur is replaced, and the a new socket lining is placed in the acetabulum. It is essentially an elective, quality of life surgery.

This is not what was done for the President's grandmother. She broke her hip. What is done for a broken hip depends on the nature on location of the break. If the break is below the neck, then a variety of plates, screws and other hardware can be used to hold the bone in place until it heals naturally. If the break is across the neck and the head has not moved in relation to the neck, then some screws can be placed across the break, and the bone will usually heal naturally. If, however, the head has moved in relation to the neck, then the blood supply through the neck to the head has been disrupted. The head is going to die, so it must be replaced. Until it is, the patient must be kept in traction to reduce the movement of the joint, because every time the joint moves the ends of the broken bone will grind together, which is very painful. Traction reduces, but does not eliminate movement of the joint.

This, then, is the surgery that the President's grandmother received. She did not receive the hip replacement that the nice old man down the block got so that he could continue to play golf. She got the hip replacement that people get to relieve the constant pain from a broken bone. Unless a patient is within hours of death, it is cruel to not perform this procedure. This is the procedure that the President feels that society should consider denying to the terminally ill.

Let's talk about the other issues. The President clearly sees a two-tier system here. HE would pay for the procedure out of pocket, because he loves his grandmother, and he is rich. My grandmother? Sucks to be me.

Now let's talk about the last paragraph. "Not determinative", but "guidance". Congress did not act in a determinative manner when it wanted a 55 mph speed limit. The states were free to choose any speed limit they wanted, but Congress offered "guidance", along with consequences for not following that guidance. Guidance from the body that holds the purse strings is determinative.

Let's also discuss the term "terminally ill". Ted Kennedy was terminally ill for over a year. If he had broken his hip on the same day as the President's grandmother, should he have been denied treatment?

Here's another interesting tidbit. "the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here." Oh, he means sick people. Turns out that sick people use most of the health care resources. Who would have thought that? If we could just keep from spending health care resources on sick people, the health care crisis would be over.

In short, what the President seems to be saying is that there should be some sort of "independent group" that operates outside of the normal political process, that offers guidance. This group would consider whether, in the aggregate, certain treatments are appropriate in certain circumstances. These guidelines will not be "determinative", but they will be guidelines and they will be pushed by those with the purse strings. Part of the goal will be to reduce the cost of sick people to the health care system. But there will be no Death Panels.

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