Economics at the Bedside: A bridge too far? Rakesh Patel M.D. - - PowerPoint PPT Presentation

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Economics at the Bedside: A bridge too far? Rakesh Patel M.D. - - PowerPoint PPT Presentation

Feb 20, 2024 160 likes •686 views

Economics at the Bedside: A bridge too far? Rakesh Patel M.D. Pharm.D. M.Sc September 29 th , 2016 Regret, Religion and Rationing: A bridge too far? In my job as a physician, I have been troubled, at times, by my role in the lives that we

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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 &
  • rdering 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-effectiveness

The degree to which something is effective or productive in relation to its cost.

  • 2. Opportunity cost

A $ 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-effectiveness 2. 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

  • r 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 relationship
  • 2. A publicly-funded health care system?
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Economics at the bedside: A bridge too far?

  • 1. Cost-effectiveness
  • 2. 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 & unrealistic

expectations 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

  • n 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

  • f people

20th Century

Individual 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 # IV The House of God

Samuel Shem M.D.

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Questions, Questions, Questions?