Neurosurgery 2012: Innovation or Rationing? Meet the “QALY”: Obamacare on the Frontlines.

I had the honor of attending the annual meeting of the American Association of Neurological Surgeons in Miami this last week.  Amazing work was presented that will help me and my fellow brain and spine surgeons improve the lives of patients.  Curing or treating cancer, ending pain, restoring function to paralyzed and disabled bodies.  Sadly, a more profound current ran through the meeting:  how some neurosurgery leaders will work within Obamacare to ration care our patients need. They are helping the administration create the data that will be used to deny care and to define an unethical rationing tool:  the “QALY” or “Quality Adjusted Life Years”. The QALY is a rationing tool used in Britain to deny care to those the government deems as “too expensive” to the system. For instance, if a treatment can provide an extra year of life for more than $50,000, then that treatment will not be covered.  A Cuban expatriate neurosurgery friend of mine recounts to me how Castro’s government would talk of tools like this in his dictatorial regime, so called “comparativa de la eficacia” or Comparative Effectiveness Research” – now part of Obamacare. Details on how the researchers are creating QALY data are below. 

I left the meeting seeing two roads before us. One was of innovation and the other was of rationing. The two are mutually exclusive and can’t co-exist.  Innovation will be embraced by many doctors but other doctors will not be able to stop or stand up to rationing.  Some will be mislead to believe they must participate or face closure of their practice or have such hopelessness before them that they see no other way.  Only patients can stop rationing and demand innovation, better access to care and enact the changes that will lower costs and ensure their freedom. 

Here are the some examples of innovation and rationing I heard at the Annual neurosurgery meeting and a more detailed discussion follows below. You can decide which path you prefer: innovation or rationing.

Innovation in Neurosurgery


Rationing in Neurosurgery

Deep Brain Stimulators under development that can significantly remove symptoms of depression, obsessive compulsive disorders or help with obesity.

More Medicare price controls that make brain stimulators unavailable for more people.

Robotic arms that are controlled by electrodes on the surface of the brain for those who are paralyzed or amputees.

Taxes on instrumentation company revenues (not profit) that will remove the profit motive and prevent development of such hardware and devices.

Spinal hardware and fusions that will restore upright position and relieve pain in those with adult scoliosis and other deformities.

Cost analysis that exclude patients with congestive heart failure and subservience to artificial patient budgets set by Medicare (*see more below).

Brain tumor drugs that will double and triple life expectancies and prevent disabling paralysis and other loss of function.

Studies that will be designed to determine who is most likely to “respond” to such drugs but will be used to deny such drugs to people with only a “small chance” or responding.

Small catheters with ultrasound waves implanted in the brain hemorrhages to dissolve clots without major brian surgery.

Administrators holding up actual surgery in progress to “approve” life saving medications during removal of blood clots – endangering lives that hang in the balance.

Researchers from Vanderbilt presented data from an “Outcomes Database” or “registry” they have been using to record a great deal of information about their patients (without the patient’s name or identifying data). Patient’s age, pre-existing illnesses, symptoms, x-ray findings, treatments, results and complications are recorded along with the cost of care.  The researchers then determine a cost per QALY.  In other words, how often was the cost below what they thought was the “accepted” $50,000 per QALY gained that the government would allow?  (The authors never address what happens when regulators lower that cost to $40,000?) They found that certain people cost “the system” more: those with Congestive Heart Failure, those with infections after surgery and those who had to return to the hospital within 30 days after discharge from the hospital. They, being good hearted physicians who trust the government and insurance companies far too much, feel that such data will ONLY be used to prove that surgery is better than medical care (injections, medications and physicial therapy) for those requiring repeat back fusions. They can’t seem to comprehend, or perhaps don’t care, that the data will actually be used to deny these surgeries to those who “cost too much” or cost more than others. This is the basis of “comparative effectiveness research” (CER) that is built into Obamacare along with these registries. CER was actually first passed in February 2009, more than a year before the Obamacare law (PPACA), but it is still a major part of it and built into PPACA.  Once the government (and insurance companies) figure out who cost more, they will simply “not cover” the surgery for these patients. These are some of the patients who most need the help; those debilitated from pain or with more profound medical problems that get worse when they are debilitated. They will be made to suffer and doctors will avoid operating on these patients to avoid a bad “efficiency profile”. 

It is sad to see leaders in neurosurgery being led down the primrose path of the regulators. Like all regulators and their accomplices they are motivated by “good intentions” but always produce unintended consequences of hurting real people.  This neurosurgeon will not record data in such database and there will come a point when I and those like me will be denied the chance to have an insurance or government contract to care for these patients.  When that happens, the only doctors left in “the system” will be those willing to ration.

I left the meeting disillusioned with these leaders who seem to be taking over medicine and feeling a deep sense of remorse for what seems to be a resignation by them and others to accept and engage in this unethical behavior merely as a means to protect their own hides.  It is time for patients to stand up and say “no” to Obamacare and for neurosurgeons who disagree to refuse to participate in such registries.


5 Replies:

  1. Donna

    Wow. My thoughts are that most people will deny that rationing is a part of this. You simply will not convince them. The ones that you do convince about rationing have no problem with it because they no longer respect life. Thanks for your report, as chilling as it is. In an unrelated event, I saw the video of Van Jones saying that the Conservatives where willing to kill children to create a job. Yet he ignores the killing of unborn babies on a whim.

  2. carol petrone

    Now we know why we fought “values clarification” and the use of “lifeboat” games used in schools in the 1970s

  3. Donna

    I forwarded this article to a friend and she pointed out that it reminded her of what happened in the book, “Motherless.”
    If you haven’t read the trilogy by Brian Gail, you should take the time to acquire his 3 books: Fatherless, Motherless, and Childless.

  4. EM Sharp

    Great article. As a health care specialist I’ve experienced rationed care creeping in slowly for some time now. NOW it has arrived.

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