Sometimes murder by spreadsheet is too subtle to detect

Today my father gets his second cycle of chemotherapy for lung cancer. He is 77 years old and in reasonably good health for his age. He had no symptoms of lung cancer; it was just an incidental finding on a chest X-ray. He, and we, are so lucky it was found early, when it is considered potentially curable with surgery followed by chemotherapy.

Unfortunately, the HMO that administers his Medicare benefit did not see it this way. They saw a 77-year old man who was about to eat up a lot of their dollars if he got chemotherapy. So they down-played the potential benefits and talked up the toxicities. They actively discouraged him from receiving potentially curable treatment. My dad is from the generation that doesn't question doctors; he assumed he was getting good medical advice. Fortunately, my dad has me, and I wasn't about to let this HMO get away with it...

LoriKP's diary :: :: You see, I've worked in cancer medicine for nearly 20 years now. I'm a clinical pharmacist by training. I was in public health school in the early 1990s during the "Hillary care" debates and initially thought I might move into a career in health policy. But instead, I focused on studying clinical studies. I decided that I wanted to understand and practice evidence-based medicine, and you have to know how to evaluate and interpret clinical research results to do this.

A few days after surgery, we learned that my dad's disease was not in fact Stage I, but rather Stage IIA. I knew immediately that that meant that chemotherapy was now the next treatment of choice. Studies in the last decade have made it clear that chemotherapy extends how long you live after lung cancer surgery if you have Stage II disease. Some people appear to be cured.

"Adjuvant chemotherapy for patients with stage II, but not stage I, NSCLC is well established." American College of Chest Physicians (ACCP) Practice Guidelines, 2007.

My dad's HMO employs one oncologist in a metropolitan area of 2.8 million people, so this is who my dad had to see. She told him that he was likely to die of other causes in the next 5 years anyway, which would mean that he would be unlikely to benefit from chemotherapy. That is exactly how she put it. She told him to go home and think hard about whether he wanted quality or quantity of life. Did he want to spend his last few years dealing with the side effects of chemotherapy or enjoying time with us?

Now, you have to understand that my dad has no medical conditions that are a threat to his life in the short-term, other than this lung cancer. No uncontrolled heart disease, no diabetes, no obesity, no kidney or liver disease. You get my point. According to Social Security data, the average 77-year old man can expect to live 9 additional years. My dad's 90-year old sister helped take care of him after surgery, so you also see, longevity runs in the family.

"Age should not prevent appropriate treatment of cancer in older individuals, especially in those with adequate life-expectancy and functional reserve. The National Cancer Center Network (NCCN) has issued a series of guidelines to minimize the toxicity and promote the effectiveness of cancer treatment in older patients..." Cancer Treatment Reviews 2005;31:380-402.

I was absolutely appalled that the HMO doctor was encouraging him to skip potentially curative chemotherapy. Was it a case of ageism? We talk about this a lot in oncology. Age alone is not a reason to skip treatment. Chronologic age is not the same as physiologic age. Was it to save money for the HMO? Why waste precious dollars treating an old man who might die of something else in the interim anyway? They'd rather just keep collecting his monthly premiums for as long as possible without having to provide any actual care...

Continued>>>
http://www.dailykos.com/storyonly/2009/8/18/768810/-Sometimes-murder-by-spreadsheet-is-too-subtle-to-detect

:(

That doctors could so easily just discount patient's lives and withhold information and steer discussions of treatment towards doing less or doing nothing just to save money is a really scary thought.

I have serious chronic health problems, so I have two doctors I see regularly. When I see a new specialist I run their advice by both regular doctors (my General Practitioner and my Pain Management dr.) If either one has a concern, I get second opinions. I've changed specialists because this feedback triggered warnings.

But most people don't have this kind of warning system, or the benefit of relatives who know medicine like the author of that article. :(

not the government.

Pure and simple.

Apart from reducing inefficiency, it's how you save money when you have finite resources and out-sized demand. You decide who's going to get treated and who's not going to get treated.

We mostly do it by who can afford treatment. But we also look at how much a treatment costs, how effective it is, what the long-term result is. Both Medicare and private insurers engage in precisely this "game".

I was sitting in an office waiting once when a woman came in to consult a dietician: She had numerous health problems and needed to put together a diet that avoided too much vitamin K, had enough Ca, avoided this and included that. The receptionist asked if she had certain private types of health insurance, and she said 'no, Medicare'; the receptionist said that Medicare didn't cover it unless a doctor certified that the dietician's input was absolutely required, and that would only constitute part of the documentation to appeal for a waiver.