- Does it improve quality of life for the patient?
- Does it extend the patient's life?
- How much does it cost?
The first step is not demonizing even the asking of the questions. This would represent a profound shift in our culture, and is needed. We need to grow up and learn how to talk about limits in medicine. Then we will have to learn how to give practical answers to these questions, and the answers will have to be knowable and usable at the bed side as doctors and nurses are caring for actual people--you, me, my parents, grand parents and kids.
Then we will have to decide what to do with the answers. None of this will be easy.
The good bad news is that there is a good deal of care that is non-productive, which I would define as care that does not improve quality of life or extend life. We should start there. I don't know how much health care spending could be reduced by stopping care that didn't improve quality of life or extend life, but this is the correct way to think about our attempts to slow health care cost inflation. We might have to get into the very hard business of deciding that some care that was productive but very expensive shouldn't be done. But, we might not; we won't know until we start asking these 3 questions.
Austin Frakt links to the comments of Rep. Issa (R-Ca), who is going to be the chair of the House Oversight Committee in January, who states his openness to using cost effectiveness research to make medical coverage decisions. Issa quite reasonably notes that we have got to learn how to ask questions about whether the use of expensive technology makes sense, and whether patients are getting the least aggressive care that will meet their needs. Austin praises these comments, but also notes that Issa's use of 'bureaucrats' is not helpful in the same way that the use of rationing and 'death panels' has been unhelpful, as Issa himself notes.
Any physician who is named to a panel such as the Independent Payment Advisory Committee (IPAB) will immediately be labeled a bureaucrat by anyone opposed to the work of the IPAB. One practical solution is to name one of the Republican members of Congress who is a physician to the IPAB. Heck, make them the chair. Anything that moves us in the direction of beginning to ask these questions.