Society is stuck in a medicare trilemma. Attempts to control cost through price setting and rationing leave patients disappointed. People used to getting what they want end up with less than they need. We elevate patient autonomy but eliminate meaningful choice.
3 Points of Medicare Trilemma
1. Great clinical care meets the needs of individual patients. Patients have individual needs beyond clinical guidelines. Cookbook care gives everyone exactly the same care for the ‘same’ diagnosis (even though diagnoses are rarely clear and singular).
2. As medicare eats up 50% of provincial spending, payers try to decrease spending by setting prices and targeting the lowest cost for care. Medicare pundits pressure physicians to provide the same, low-cost care to all.
3. Technology continually advances and always costs more overall. The best technology improves diagnosis and management of disease decreasing morbidity and mortality.
Trilemma
Consider a classic trilemma about communism:
You can be honest.
You can be smart.
You can be Communist.
You can only be 2 of these at the same time. A trilemma exists when you have 3 possible options such that any 2 are true when taken together.
Medicare Trilemma
If we want individualized care and the best technology, we can’t have set or low costs.
If we want individualized care and low costs, we can’t offer the best technology.
If we want low costs and the best technology, we can’t offer individualized care.
Voters need to grapple with this.
If patients want the best technology and care individualized to their needs, costs will escalate.
Medical ethics rests on patient autonomy and choice, but our system can’t offer the best treatment options and makes it illegal to buy care privately. Offering second-rate medical technology is not an option. Costs cannot be controlled and will exceed the public purse. Something has to change. Which point of the medicare trilemma will we abandon?
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Framed the way it is and with no definitions, you present a difficult dilemma that no matter what, is sacrificial – something must be sacrificed – is it cost? care? technology? A cautionary note might be wise! I am not convinced yet that all three are not possible together … I suggest the way forward would be to be clear about our terms – what is “best” care; what is “best” technology; what is “best” cost. We must be concerned with appropriate use of available technology; of what best really means (is it just in episodic care of one problem – the current acute care model)? Where does primary, secondary and tertiary prevention fit in a best care model? What cost are we talking about – is it just direct costs now, opportunity costs/benefits later, is human suffering considered a cost or is this a purely mathematical cost benefit model?
I think the question is framed too simply – there is trap there if we accept the assumption that we can only have two of these three. I’m not prepared to accept that premise! Perhaps a better question would be, “How shall we determine what the right care is and how it is to be provided, where, when, by whom, with what goals in mind?” I suggest that part of the answer resides in much closer and more meaningful relationships between health care providers and patients, and dare we also say researchers, policy-makers, … best is a slippery concept that means different things to different people – it is very dependent on what knowledge people have and what values and perspectives they hold. You have presented “best” as if there is universal agreement about that is – one right answer as it were. With respect, I suggest this is not so.
Medical ethics for Richard Neibuhr is not about autonomy and choice as much as it is about the exercise of our necessary human freedom – the need to choose among options that continuously emerge in the context of our interdependent relationships with one another – where patient/health care provider/family/societal norms all interact iteratively over time with decisions continuously arising as we inform one another’s thoughts and actions. There is no single, sustainable right answer – no single best practice, best technology, best cost … it’s an impoverished frame that could lead to equally impoverished answers. And too often, that is what happens in policy decisions that cannot take the wondrous complexity of life into account.
Well – if nothing else, your comment certainly got a reaction from me! Well done Shawn!
Hello Marion!
What a great comment; I would expect nothing less from someone so thoughtful. You are right to question whether I’ve oversimplified to the point of losing meaning. My hope was to bring out the kind of thought and comments you shared. I hoped to ‘poke the bear’ as my admin Director likes to say; try to goad discussion from readers. I worry that we lose the urgency of this topic by failing to continually engage. Continual engagement requires gentle provocation.
Thank you so much for taking the time to read and comment! I’m just thrilled that it got a reaction from you 😉
Cheers,
Shawn