Sunday, September 20, 2009

Triage in a Finite World

There is always triage. If nothing else, there is never enough time, and everything done excludes something there was not enough time to do as well. In every area of choice, choices have to be made. In addition, for most of us, there are financial and political limits, as well as limits to risk. Nikita Khrushchev may have ruled Russia with an iron fist, but he could not obtain a day at Disneyland for all his power.

Currently, the limits of time and money are coming to the fore in health care. Oregon faced it head on. They ranked treatments by cost effectiveness and then matched them up with State resources. If there is money, and your treatment does not mean someone else is denied a more effective treatment (for spending the money on your treatment instead), you get the treatment at state expense. If the answer is different, they will pay for counseling and for euthanasia treatments (which are legal in that state).

The easiest way to finance health care for all is to take the current dollars spent and pour them over into a new system that covers everyone. But if that is done, you will get different triage choices than the current system offers.

Now triage happens. Insurance will often not pay for things (which reminds me of battles in past years to force insurers to pay for treatments now known to be failures). But there are often improvements. Hypoplastic left ventrical used to be a death sentence. Now 60% of those treated with surgery survive, though year after year after year of failures occurred first.

We need an open, honest and extensive national discussion on triage in a finite world. Not only about what we cannot accomplish, but about the things we can.