Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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The Subtle, Cynical Rationing of “Good Enough”

It took exactly one week. One whole week before we had our first adverse reaction to the not-so-new new generic eyedrop. Not a one of us was surprised because we’d been here before. The branded version of this particular medicine, version 1.0, did the same exact thing. Thankfully, branded version 2.0 and 3.0 worked like a charm with pretty much no side effects. Yup…one week forward to end up 7 years in the past. Our own little front row seat for the spectacle of the subtle, cynical rationing of “good enough”.

We’ll see more, of that I am sure.

Let me share the back story here before I expand and move on. In eye surgery, specifically cataract surgery, there is a very inconvenient complication called “Cystoid Macular Edema”, swelling of the center of the retina also known as CME. As a natural phenomenon it occurs in 6-9% of cataract surgeries, and unfortunately it occurs even in people without any risk factors who had perfect, uncomplicated surgery. However, if you treat cataract surgery patients with a Non-Steroidal Anti-Inflammatory Drug (NSAID), kind of like Motrin in a drop form, you decrease the likelihood of CME by a factor of 10, down to 0.6-0.9%. Wild, huh? A real no-brainer. A classic example of that chic and trendy outcome-based medicine thing, especially since CME is costly to treat and very scary for the patient.

This 10X decrease originally came with a cost, however. The original versions of these NSAID drops stung and burned, and some 30% of patients had swelling and inflammation in their cornea which caused a temporary DECREASE in vision. So, stinging and burning which reduced the number of people who actually took the medicine, and an inflammatory side effect that decreased vision and forced you to stop the medicine. Tough call. But we live in America. Lo and behold out come versions 2.0 and 3.0 which still have a 10 times decrease in CME, only this time without any stinging or burning, and without any inflammation and decreased vision. BINGO! Another no-brainer, right? Same benefit with pretty much no side effects. Sure. Easy. Right up until a generic of version 1.0 comes out. It took exactly one week to be reminded why 1.0 was bumped by 2.0 and 3.0.

It’s like they used to say in Amish country when my wife was a kid: it’s good enough for who it’s for.

And there’s the rub, of course. Right now it’s for “them others”, but eventually it’ll be good enough for YOU. That’s the whole name of the game with this rationing stuff, you know. All you have to get to is “good enough” and then the only thing that matters is cost. No consideration for compliance, convenience, or quality of life, the only consideration on the board is cost.

Why does this matter? Isn’t the cost of medical care in the United States the single greatest fiscal challenge facing our local, state, and federal governments? Simply put, yes, the cost of caring for an increasingly unhealthy population is, indeed, getting out of hand. Rationing based on “good enough” is based on a very superficial analysis of this problem, however. This is part of the cynical aspect of this type of rationing, because a true effort at cost containment demands a deeper root–cause analysis of the “why” it’s getting so expensive. “Good enough”, by its very nature, brings healthcare to at best a standstill, and as I noted above generally involves rolling back the clock.

Reasonable people have asked why this isn’t actually, truly, good enough. In truth, what we have available to treat diseases today, or even stuff available in 2003, is at least one full order of magnitude better than that which is available in second and third world countries today, or available in first world countries in 1975. Why WOULDN’T this be good enough? Well, how do you think we got where we are today? We did so, of course, by always seeking BETTER. Not only that, but at least in America we did so by always seeking better for EVERYONE. Even “them others”.

Rationing is the great chameleon of health care cost reduction. It’s not just the forced use of generic medications (some are actually exactly equivalent to their branded counterparts) but it takes many other forms as well. The effective denial of access to both primary and specialty care for those individuals “covered” by Medicaid. The myriad, byzantine rules and regulations that are so opaque that individuals throw their hands up in disgust and dismay and fail to seek care for fear of the financial consequences of doing so. Scarcity of resources which is either real (there is an inadequate number of neurologists practicing in the United States), bureaucratic (operating room privileges for specialty surgeons are limited by governmentfFiat in Canada), regulatory (exciting new uses for established medications go undiscovered because of FDA gag rules). or arbitrary ( payment for cataract surgery is denied if the visual acuity is not decreased to a particular level regardless of how it is affecting an individual’s life). Seriously, I could go on and on.

“Good enough” is okay, I suppose, if it is used as the floor beneath which we will not allow healthcare to fall. It’s okay if that floor is constructed by carpenters whose only consideration is the real “boots on the ground” outcome from that healthcare, NOT people whose major concern is cost alone. Finally, it’s really only okay if that floor is actually the floor of an elevator, always and ever moving upward, because even “good enough” has to get better. Every example of “good enough” is actually the result of some yesterday’s healthcare breakthrough. Some yesterday’s effort at achieving “better.” Every version of “good enough” is actually trickle-down “better”.

“It’s good enough for who it’s for” is all well and good as long as you remember that, eventually, who it’s for is you.

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