Health Reform

I just got out of yet another talk on health reform. There is no question that the current rate of health care spending is unsustainable, and something has to be done...We talk a lot about patient safety and quality, guidelines, and resource utilization, but are we just blowing smoke? If we look at health outcomes, we’ve all seen the data that the US spends more per capita on health care than any other industrialized country yet has worse outcomes. So why is this?

Technology has been blamed for a lot of it...we embrace utilization of the latest, greatest, newest, hottest toy without necessarily having the data to support the cost-effectiveness of these technologies. And even when we have guidelines for the appropriate utilization of technologies, many continue to practice outside these boundaries. I was recently questioned about why I don’t utilize breast MRI as much as some of my colleagues, and while I proceeded to spew an evidence-based dissertation on the data, controversies, and guidelines surrounding its appropriate use, I suppose I could have also added that I was doing my civil duty to utilize healthcare resources in a judicious and appropriate manner.

Another area where we spend vast resources without much in terms of outcomes is in end-of-life care. If you think that ~50% of CMS resources are spent in the last 6 months of life, you wonder how much of this is futile. I was at a recent Schwartz rounds where a case was discussed of a patient with advanced gastric cancer that was refractory to all treatment who was a full code until hours before her death...In addition to her pain and suffering in her last days and weeks, significant health care resources were spent on additional rounds of chemotherapy and ICU care that offered her little in either quality or quantity of life.

Don’t get me wrong – I’m all about autonomy. But our patients rely on us as partners in their health care decision-making. They need us to interpret the data and advise them as to whether they will benefit from an expensive test, or whether a treatment is futile. If we simply “do what the patient wants” without having a constructive conversation about the indications, risks and benefits of therapy, we are abdicating our responsibility both to the patient and to society. We often criticize everyone else (governments, hospitals, insurance companies, etc. ), for the current healthcare crisis and they certainly have a share of the responsibility, but it may behoove us to think about what each of us can do in our own little ways to make a difference. How do you contribute to the solution, or at least don’t add to the problem? And how can ASCO play a role in these efforts? I look forward to hearing from you!


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