Death Panels

By Roger Stark, MD, FACS
One of the most controversial issues during the debate over federal health care reform was the concept of government committees or agencies deciding who would receive health care and who wouldn't.

Those who opposed the President's health care plan called these agencies "death panels" and worried the panels would allow people to die rather than provide costly treatments at government expense.

The President's supporters called this "fear mongering" and assured Americans the legislation would not establish government agencies to make life and death decisions for us.

It is true the new national health care law does not specifically create a new agency that would dictate patient treatments. It does, however, establish a private nonprofit bureau to carry out comparative effectiveness research (CER) that will affect the medical care we all receive. CER does several things. It studies the clinical effectiveness of a particular treatment or test and then compares that treatment to alternatives to measure clinical results and cost effectiveness.

It is estimated that up to 30 percent of all health care spending in the United States is wasteful or not effective. CER would theoretically reduce this wasteful spending and would standardize treatments for patients with the same diagnosis. Supporters of the new law say it specifically prohibits using CER for clinical decision-making or for health guidelines.

CER has been used by the federal government since 1989 and by Washington state since 2006. The purpose at the federal level is to establish clinical guidelines for "best practices" that can be used in both private practice and government programs like Medicare. Expanding CER via the new legislation will undoubtedly increase the list of the government's clinical guidelines.

In Washington state, CER is performed by the Health Technology Assessment program (HTA). This is a state-managed agency that uses a committee of eleven professionals to decide the most cost effective treatments for patients in state-funded health care plans such as Medicaid. Providers and medical facilities are not reimbursed by the state if they use non-approved treatments. Other states, as well as the federal government, are monitoring the HTA program for effectiveness and cost savings.

CER rules represent a real threat to the day-to-day practice of medicine. Doctors spend four years in medical school and then four to six years in specialty training. A large part of that education is learning how to interpret medical treatment research and how to apply those treatments to individual patients. Very few physicians want to practice "cook book medicine" and treat all patients the same.

Much of our superb health care is based on the development of new drugs and medical devices. Using CER, bureaucrats will pick "best" drugs and devices and refuse to pay for alternatives, which will stifle innovative research into newer and better treatments.

During the debate, the country was assured the reform legislation would bend the cost curve down. After passage, even the chief actuary for the Administration estimated the new law would increase health care costs from 17 percent to 21 percent of our gross domestic product by 2020. Cost will still be the main problem with health care in the United States.

Consequently, government officials will search for ways to control costs within the next ten years. The enlarged CER will be established by 2013 and will decide what patients benefit most from what treatments. The next step will be to reimburse providers for using only approved treatments. CER, therefore, will become the mechanism for rationing health care in this country.

Great Britain has had socialized medicine since 1948. The country has an agency that uses CER to ration health care - the National Institute for Clinical and Health Excellence (NICE). The new Director of our country's Medicare and Medicaid services, Dr. Donald Berwick, says he is a "big fan" of the British system in general and of the NICE program in particular.

Recently the Federal Drug Administration (FDA) banned the use of a cancer drug, Avastin, for patients with breast cancer in the United States. Avastin does not cure breast cancer, but has allowed women the possibility for a longer life. Provenge is a new cancer drug developed in Seattle that the FDA did approve for use. However, Medicare officials have disallowed the costly drug saying Medicare patients don't need it.

"Death panel" is an inflammatory term. However, under pressure to control costs and by the use of CER, government officials already have a mechanism in place to decide who will receive treatment, which in some cases will mean who lives and who dies. The Administration's enthusiasm for the British NICE program and recent bans imposed by the FDA and Medicare should make all Americans worried about the direction our government is taking in managing our health care.