A healthcare/philosophical question

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Originally Posted by commonlaw

I have a friend who just told me that her father-in-law was diagnosed with stage 4 cancer in the liver. This is a man who has drank heavily for decades, knowing full well what he was doing to himself and those around him. He is now in his mid-sixties.

Apparently, he has been moved to the "top of the list" for a new liver.

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I have a hard time believing that you are getting the full story. I knew a guy who was 16 (close to 20 years ago) and had a disease in his liver or some other organ. He wasn't a good friend or anything but hung around with a bunch of people I knew. The doctors put him on the transplant list and told him if they caught him doing any drugs they would immediately take him off the transplant list. They caught him doing meth a week later through a wiz-quiz and they did just what they said they would. He died a few months later.

The medical community would NEVER give a guy a new liver if they knew he was still drinking (I guess you never said either way). His age is also another reason that would put him lower on the list due to more complications as people get older in these types of operations. In any case I'm sure the guy must have to prove that he isn't drinking or has been dry for quite some time if they were giving him such a high place on the list.

Considerations When Referring for Liver Transplant
Pre-Liver Transplant Evaluation Protocol

All patients referred for Liver Transplant Evaluation will be reviewed by the nurse coordinator.

If any of the following exist, the patient will be scheduled for a Hepatology consult and Liver Transplant Surgery consult only:

* Use of alcohol or drugs in the last 6 months
* Significant comorbid medical history
* History of cancer in the previous two years
* MELD score below 7
* Ideal Body Weight greater than 150%
* Age of patient greater than 75 years old

Coordinators may discuss any case with Hepatologist or Liver Transplant Surgeon prior to scheduling to determine appropriate tests.
Transplant Eligibility Criteria

* End-stage liver disease
* Absence of serious systemic illness or other medical conditions that may affect immediate or long-term survival.
* Full understanding of transplant procedure, its limitations and long-term compliance to follow-up requirements.
* Strong social support network.
* Free from active drug, nicotine or alcohol abuse.
* Weight less than 150% of IBW.

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.
Indications for Liver Transplant

* Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation
* Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life
* Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival)
* Cholestatic Diseases: primary biliary cirrhosis, sclerosing cholangitis, secondary biliary cirrhosis, biliary atresia, cystic fibrosis
* Chronic Hepatitis: hepatitis B, hepatitis C, hepatitis D, autoimmune chronic active hepatitis, cryptogenic cirrhosis, chronic drug toxicity or toxin exposure
* Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.
* Metabolic Diseases: hemochromatosis, Wilson's disease, Alpha-1-antitrypsin deficiency, glycogen storage disease, tyrosinemia, familial amyloidotic polyneuropathy, other metabolic disorders treatable by liver replacement.
* Fulminant Acute Hepatic Necrosis: viral hepatitis, drug toxicity, toxin, Wilson's disease.
* Primary Hepatic Tumors: selected patients with hepatocellular carcinoma

Specific Biochemical and Clinical Indications for Liver Transplantation
Cholestatic liver disease

* Serum albumin < 3.0 g/dL
* Intractable pruritus
* Progressive bone disease
* Recurrent bacterial cholangitis

Hepatocellular liver disease

* Serum albumin in < 3.0 g/d L
* Prothrombin time >3 seconds above control

Both cholestatic and hepatocellular liver disease

* Recurrent or severe hepatic encephalopathy
* Refractory ascites
* Spontaneous bacterial peritonitis
* Recurrent portal hypertensive bleeding
* Severe chronic fatigue and weakness
* Progressive malnutrition
* Development of hepatorenal syndrome
* Detection of small, coincidental hepatocellular carcinoma

Absolute Contraindications for Liver Transplant

Factors which place individual at highest risk for poor outcome,
poor quality of life or increased mortality

If your doctor thinks you might need a liver transplant, then you should do everything you can to keep healthy and strong. Some of the things that might prevent you from getting a liver transplant include:

* Continuing to use alcohol or illegal drugs
* Being at high risk of using drugs or alcohol again after the surgery
* Being unable to follow your doctor's instructions, like taking your medicine when you are supposed to
* Having too little support from people at home to care for you after the operation
* Having advanced cancer of the liver
* Having another kind of cancer in the past 3 to 5 years
* Having severe heart, lung or kidney disease
* Having advanced HIV disease (AIDS)
* Severe hardening of the arteries
* Systemic infections

Relative Contraindications for Liver Transplant

Factors which place individual at higher risk for poor outcome,
poor quality of life or increased mortality

* Obesity (>150% of IBW).
* Active systemic illness that would limit long-term survival.
* Previous extra hepatic malignancies
* Prior portosystemic shunts
* Malnutrition

http://www.transplant.emory.edu/live...s/referral.cfm

Protocols can vary somewhat by institution.

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Originally Posted by Trackhead

3. Low Income: Qualifying based on income. Many who are pretty damn poor still don't qualify for medicaid. But unfortunately, many who do blatantly abuse it every day by seeking non-emergent health care in Emergency Rooms instead of making appointments with family physicians.

facts.

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Part of the issue here is that many family physicians will not accept patients on medicaid. There are multiple reasons, most of them financial.

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Originally Posted by DharmaBum

Part of the issue here is that many family physicians will not accept patients on medicaid. There are multiple reasons, most of them financial.

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There are community-based indigent care clinics that are subsidized by state and federal programs to fill the the gap. Patient compliance is a huge factor and that spans socioeconomic groups.

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Originally Posted by Trackhead

It's too complex for me to come up with any reasonable solutions.

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Welcome to the club.

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Originally Posted by Trackhead

Currently, from what I see, this is who has socialized medicine in America.

1. Elderly: At a qualifying age, they get some level of medicare coverage. Many near retirement individuals delay retirement ONLY because they can't afford private healthcare, and medicare isn't active for them yet. Bummer.
2. Military: Tri-U would know better than I. But even our military is getting screwed with benefit cuts. So you can serve your country for pennies, but you still get screwed in the end.
3. Low Income: Qualifying based on income. Many who are pretty damn poor still don't qualify for medicaid. But unfortunately, many who do blatantly abuse it every day by seeking non-emergent health care in Emergency Rooms instead of making appointments with family physicians.

The uninsured are middle income, often self employed who can't afford private healthcare, but are paying for the existing social programs and gaining no benefit. They are the ones with huge hospital bills, collection agencies after them, etc.

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1. Yes. But still, Medicare doesn’t cover all costs, and several poor elderly are still stuck trying to decide between food and meds. Under the right circumstances Bush’s Medicare Prescription plan might help, but is ridonkulously Byzantine for many, if not most seniors.
2. Yes. Amazingly the VA gets by despite being perennially starved for funding. Though AKPogue can prolly attest to long waits, staffing issues and facilities that aren't latest-and-greatest, it should be said that overall healthcare outcomes for Vets in the VA system in general are as good or better than the regularly-insured population, taking into account comorbid conditions and socioeconomic status.
3. Yes. There are abusers, sure, and you see more than your share in your line of work. There are also plenty of hard working good living people who would be dead or barely alive without the coverage Medicare provides. The perverse thing is that indigent folks usually can't make appointments with family physicians for numerous reasons. The community clinics Tourette Dude mentions don't really fill the gap AFAIC.

And then there are the middle income self-employed uninsured - they do get a raw deal, for sure. Different people will espouse different solutions, more often than not based primarily on their ideological bent rather than experience or the facts you seek.

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Originally Posted by Trackhead

So I'm babbling. I don't know the answer. Maybe someone can enlighten me with sound facts.

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Sound facts? On a TGR political thread??!?! You're kidding, right? ;)

An incredibly civil discussion in what could otherwise be rabid.

I 'wish' I could believe a socialized healthcare system would work, but I'm incredibly cynical. The thought of health insurance being for profit is disturbing, to say the least. But so is the thought of a HUGE government managing it. Not sure what the lesser of two evils really is.

I've never lived abroad, but Tri-U, you know Tony (The Kiwi friend of mine). He's from NZ, and has some good insight. I've also worked with many Canadian health care workers who have interesting things to say.

Yeah, I realize things aren't perfect in NZ and Canukistan, especially if you go by anecdotes, but looking at the big picture in re: overall public health, they don't do as badly as some anecdotes might lead one to believe. And a damn sight better than our current system re: cost/benefit.

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Originally Posted by Tri-Ungulate

but looking at the big picture in re: overall public health, they don't do as badly as some anecdotes might lead one to believe.

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Well, we in 'merica aren't exactly know for our healthy, illness prevention lifestyles.

Cue: Walmart electric carts.

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Originally Posted by Tri-Ungulate

Yeah, I realize things aren't perfect in NZ and Canukistan, especially if you go by anecdotes, but looking at the big picture in re: overall public health, they don't do as badly as some anecdotes might lead one to believe. And a damn sight better than our current system re: cost/benefit.

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How does their cost/benefit do better than us? I know that Canukistan pays way more in taxes than we do. They aren't paying for a war and just barely have a military.

Tricare/Military Health System is amazingly unwieldy. Not a big fan of it and neither are a lot of people that both work in the system and try to get care from the system.

It is amazing that there are some discussions these days that are somewhat reasonable. Some these guys must be tired from a long hard summer of BS.

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Originally Posted by Tri-Ungulate

Yeah, I realize things aren't perfect in NZ and Canukistan, especially if you go by anecdotes, but looking at the big picture in re: overall public health, they don't do as badly as some anecdotes might lead one to believe. And a damn sight better than our current system re: cost/benefit.

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I have to agree that the cost/benefit might be better in Canada -- that seems reasonable.

I am in a unique situation in that I work with all Canadians (only American employee). When the owner of our company needed urgent, high quality care he came to the US -- that tells me something.

Our health care system isn't great. Being in such a small company I don't get health benefits through my company. I still think it's a slippery slope if we head towards socialized medicine though. If a person needs an MRI they typically don't have months to wait for one here in the US.

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Originally Posted by Crass3000

If a person needs an MRI they typically don't have months to wait for one here in the US.

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We also have an incredibly impatient society when it comes to non-urgent healthcare.

"I was here first, why did you bring him back to see the doctor before me?"

"Well mam, he was having a fucking heart attack, and you......you're here for dental pain."

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Originally Posted by Trackhead

We also have an incredibly impatient society when it comes to non-urgent healthcare.

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I guess you're right. When I want to see a doctor I certainly am not going to wait a week. If I need an MRI I certainly am not going to wait a couple weeks. While I see your point there are many reasons one may need an MRI in which waiting a couple months could be disasterous. When a person realizes that they need medical care they are not going in for the hell of it.

We are impatient but at times it is with good reason. Sometimes waiting could and is the difference between life and death.

i love it when trackhead and tri-u chime in.

i'm as cynical as trackhead but i would like to see something implemented just to say that we gave it our best shot.

maybe some sort of hybrid gov't/private health care system that is uniquely american?

i don't have any simple solutions either and it is something often discussed in my household.

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Originally Posted by 13

maybe some sort of hybrid gov't/private health care system that is uniquely american?
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CBC did a multipart series a couple of years ago comparing the Canadian system to, from what I remember, Switzerland and Denmark. The Euro model was a two tiered system that provided quality basic service for everyone with some delays for non-high acuity procedures, limited formulary and stricter criteria for ordering diagnostics. The basic system benefited from economies of scale when contracting with the pharmas on drug prices and decreased costs for larger scale runs of lab tests. Second tier was cash/private insurance that catered to those with the$$$, which offered quicker turn around on procedures, more generous with the diagnostics and things such as private rooms in hospitals.

The lawsuit mentality is also differnet. The euro docs do not need to practice defensive medicine(treating the horse and not the zebra). Tort reform here is essential. People need to realize there is a difference between a mistake and negligence. Perfection is IMPOSSIBLE.Some areas have severe shortage in some specialties(OB, neurosurg, ortho) because of outragiously high liability insurance.

People need to realize too, that they don't need the latest and greatest pill that their TV brainwashes them into thinking they have to have. With large scale contracts with the pharmas(like the VA does) you restrict the formulary and get much better pricing with large scale contracts. The US is getting royally screwed by the pharma industry. Medicare Part D will go down in history as one of the greatest corporate coups.

We need campaign finance reform first before anything of value is going to be done to reform the system. Dems/Repubs are bought and paid for.

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Originally Posted by Tri-Ungulate

Yeah, I realize things aren't perfect in NZ and Canukistan, especially if you go by anecdotes, but looking at the big picture in re: overall public health, they don't do as badly as some anecdotes might lead one to believe. And a damn sight better than our current system re: cost/benefit.

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I have to agree, as my Canadian and Swedish coworkers take great glee in rubbing my nose in this. See health care and life expectancy stats for OECD countries at http://www.ecosante.org/OCDEENG/411000.html

Canukistan spends about 10% of it's GDP on health care and has an average life expectancy of 80 years. The US spends 15% of its GDP on health care and has a life expectancy of 78 years. And yet, no material differences in rates of smoking, alcohol consumption or obesity between the two countries. Same basic genetic heritage, although the US does have a greater proportion of non-europeans. What's left in the equation? Would violent deaths explain 2 years of average life expectancy?

I have to laugh at the comments about waiting time in our fantastic private system. I just enjoyed a two week wait to see a resident for annual physical at an OHSU clinic here in PDX. Had blood drawn same day, but it took a month to get the results.

My Doc then decides I need a camera shoved up my colon - one month wait for that, because the "Digestive Health" dept. lost the referral info - twice. Then they couldn't get the pre-test instructions to me without a serious clusterfuck and my frank assessment of their competence to the clinic supervisor. And only a $200 copay for this privilege, on top of the $1,000 monthly premium our company pays for medical and dental insurance for my wife and I. And our insurance broker is coming by next week to tell me that our rates are going up "a lot" next year, after a 15% increase last year.

I've had two MRIs in the last two years, and both involved three week waits (again at OHSU). No really serious issues - one showed I needed a discectomy and the other showed 75% of my supraspinatus tendon was detached http://www.tetongravity.com/ubb/confused.gif
:confused:

Like a lot of people here, I've a bias against goverment programs, but employer-paid health care is becoming incredibly expensive and I'm not seeing any great wonders compared to our "socialist" counterparts in Canukistan and Europe.

^^^
Healthcare isn't the only thing that influences health outcomes. Class makes a huge difference. Having a job with the flexibility to take time off to wait for a clinic appointment, being able to leave kids with someone to come in, having enough education to understand what drugs one's on and how to take them, being able to give a good history...there're a ton of differences that depend, at least in part, on class. Even with patients who are admitted to the same teams and have access to the same care, class disparities make a difference in how they do.

I believe we'd see an improvement in health outcomes with an improvement in the US educational system and a more progressive distribution of wealth. On an ethical level, I'm not sure what the US taxation/wealth distribution structure should be, but I think it has an impact on health outcomes independent of the effect on healthcare access.

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Originally Posted by 13

i don't have any simple solutions either and it is something often discussed in my household.

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I've asked everyone I work with..........nurses, doctors, CEO's of hospitals. Nobody has an answer they are confident in. It's so beyond simplistic morals.

Unfortunately like everything else in a democracy I don't think it will get fixed until it is in a huge crisis!! Then it will cost way more than it would if it got fixed now.

How come it seems to me that taxes in Canada are way more than in the States? Is it not true? If it is true and only 10% GDP is spent on healthcare in Canada and 15% in the US. What do the Canadians spend all their money on?

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Originally Posted by 13

i love it when trackhead and tri-u chime in.

i'm as cynical as trackhead but i would like to see something implemented just to say that we gave it our best shot.

maybe some sort of hybrid gov't/private health care system that is uniquely american?

i don't have any simple solutions either and it is something often discussed in my household.

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Welcome to France :D

(And, yes, our system is bankrupt for years...)

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Originally Posted by AKPogue

How come it seems to me that taxes in Canada are way more than in the States? Is it not true? If it is true and only 10% GDP is spent on healthcare in Canada and 15% in the US. What do the Canadians spend all their money on?

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I'm guessing, but maybe it's because they are the second largest country in the world (by area) and have less people than California to support things like infrastructure, etc.

Maybe a Canuck will chime in.

I had an annual checkup today. At annual checkups, I ask doctors to order several labs either common at one point in time or that I personally track over time: CBC, MP, urinalysis, lipids, A1C, thyroid, PSA, total T, and free T. This is probably a larger set of labs than most people get but the labs are not uncommon. I have a high-deductible health plan so costs are negotiated but largely out-of-pocket.

No doctor has had a problem ordering the labs even if some questioned the T. Until today, when my new doctor would not order any of them. None. The doctor said they are concerned an erroneous result in one of the tests would do more harm than the rest of the tests would do good. It is a bizarre position to take in general, but especially so for preventative care. We went back and forth a few minutes but the doctor would not budge. So, I'm doctor shopping and questioning the utility of an annual if I can do everything at home.

you sound like a bad customer

How so? I'm willing to listen.


Edit: Fuck that. I'm not a customer at all. I'm a patient who knows what he wants.

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Originally Posted by Mazderati

I had an annual checkup today. At annual checkups, I ask doctors to order several labs either common at one point in time or that I personally track over time: CBC, MP, urinalysis, lipids, A1C, thyroid, PSA, total T, and free T. This is probably a larger set of labs than most people get but the labs are not uncommon.

No doctor has had a problem ordering the labs even if some questioned the T. Until today, when my new doctor would not order any of them. None. The doctor said they are concerned an erroneous result in one of the tests would do more harm than the rest of the tests would do good.

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PSA testing is no longer recommended. You can read more here.
https://www.uspreventiveservicestask...ncer-screening

Can't answer why other labs were not ordered. But not knowing your age, med hx, the discussion is largely meaningless.

You can't do everything at home, because you might be able to order the labs, but can you effectively interpret them? My guess is no.

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Originally Posted by Mazderati

How so? I'm willing to listen.


Edit: Fuck that. I'm not a customer at all. I'm a patient who knows what he wants.

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if not for the edit I would have been concerned