In Retooled Health-Care System, Who Will Set Limits?

By Alec MacGillis
Washington Post Staff Writer
Wednesday, July 8, 2009; 12:16 PM

The question came from a Colorado neurologist. "Mr. President," he said at a recent forum, "what can you do to convince the American public that there actually are limits to what we can pay for with our American health-care system? And if there are going to be limits, who . . . is going to enforce the rules for a system like that?"

President Obama called it the "right question" -- then failed to answer it. This was not surprising: The query is emerging as the ultimate challenge in reining in health-care costs that now consume $2.5 trillion per year, or 16 percent of the economy. How will tough decisions be made about what to spend money on? In a country where "rationing" is a dirty word, who will say no?

The question permeates all levels of medicine: the use of tests that many argue are unnecessary (U.S. doctors order five times as many MRIs as doctors do in Germany); how early to intervene with common conditions such as heart disease and prostate cancer; how aggressively to treat patients nearing their life's end.

Although Obama and his advisers have held up providers' spending patterns as the crux of the crisis, proposals in Washington go only so far in addressing the thorniest questions about who gets what care. Instead, cost-saving measures are focused on introducing a public insurance option to compete with private insurers, or on general cuts in Medicare and Medicaid payments to hospitals.

Vice President Biden announced an agreement today to cut $155 billion in payments to hospitals for Medicare and other subsidies. But hospital officials cautioned that the deal, like an earlier one that Obama's administration reached with the pharmaceutical industry, is contingent upon the passage of a broad-based reform effort that would place new burdens on all of the players in the health care field.

The reform bills being written would put new emphasis on evaluating treatments according to their "comparative effectiveness," or weighing the risks and benefits of different types of treatment for the same illness, but the bills stop short of incorporating cost-benefit analyses into the findings or of requiring that providers abide by conclusions.

Lawmakers are also considering ways to reform Medicare payments to emphasize the overall quality of care over the quantity of treatments. But lawmakers are not going as far as Massachusetts did; it is considering shifting entirely from a fee-for-service model to one where salaried physicians would be paid an overall annual price for covering a given person or family.

Such a shift would probably be a shock to the system of many Americans, who have grown used to having any and all health-care options, regardless of cost, available to them.

"The questions of who gets what, these difficult choices . . . really are not posed in the current health reform legislation," said Drew E. Altman, president of the Kaiser Family Foundation. "The challenge," he said, "is us, the American people: We want the latest and the best, and we want it now."

The Democrats' caution has not kept Republicans from accusing them of embracing rationing. They raise the specter of the British agency, which goes by the acronym NICE, that decides whether that country's nationalized health-care system will pay for items such as costly cancer drugs that extend lives a few months on average.

"You're going to be saying to people, 'We're not going to care for you, because we've decided it's too expensive to care for you,' " said Robert E. Moffit of the right-leaning Heritage Foundation.

Others retort that the United States already has rationing: The uninsured and under-insured do not get the care they need. "We're already doing it," said Stanford University epidemiologist Randall Stafford. "We're just doing it in such way that it doesn't service societal interests."

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