Good care, cheap care and secret decision-making

It seems a simple choice.

If you have an abdominal aneurysm - a bulge and weak spot in an artery - there are two treatment options.

Doctors can cut you open from breastbone to hips, push your organs over and sew in a plastic tube to replace the weak spot. After a week or so in hospital, you face a long recovery.

Or they can make a small incision in your groin and insert a stent - a little compressed metal mesh tube - into the artery and then slide it into place and expand it. A day or two in hospital and you�re as good as new.

Personally, I�d like option two. That�s what Bill Clinton had last week and he was home the next day.

But for health authorities it�s complicated. And a dispute between vascular surgeons and the Vancouver Island Health Authority is opening the door on the world of health care rationing. It�s not pretty.

The surgeons want to do more of the stent procedures. The health authority wants to control costs so it sets a quota on the number on them - 38 this fiscal year.

The surgeons are supposed to manage so that about 100 patients get the traditional surgery and the 38 people at greatest risk of complications get the stent treatment.

The surgeons got so frustrated they went public. Patients who needed the stent surgery were being made to wait because of the quota, they said. Patients said they felt the authority was playing Russian roulette with their lives. An aneurysm can burst without warning.

And, the surgeons said, the costs are the same if you include the extra time in acute care beds required by patients who undergo the traditional surgery.

It gets interesting here.

VIHA costs the traditional open surgery at about $1,500. A nurse, anesthetist and surgeon.

A stent procedure, it figures, costs $19,500. The little mesh tubes, perhaps an inch long, cost about $13,000 each. The surgeons say you can�t just look at operating costs. As well as being better for high-risk patients, the stent procedure means about a week less in hospital, so the real costs are in the same range.

The authority�s response explodes a health care myth. We tend to think care is limited by hard factors � too few beds or nurses, not enough MRI scanners.

VIHA said the savings from having patients spend a week less in hospital aren�t real. Some other sick person would just occupy the bed and the money would still be spent.

The health authority, because of the funding from government, needed that sick person waiting at home, not getting care.

Logically, the correct response would be to do the stent procedure and then leave the bed vacant for a week. The cost would be the same and the patient would be better off.

But that wouldn�t happen. People could accept their child waiting for needed care because there just wasn�t a bed. But not to meet an arbitrary budget quota.

The health authority said the doctors were being unreasonable, perhaps unprofessional, in seeking to use the stent surgery when it wasn�t warranted.

The surgeons said they limited the use to necessary cases and the arbitrary cap was foolish and dangerous. They had tried to work with the health authority to come up with a rational approach and been turned down.

And the public got a jarring look at health care. Even if you don�t know who is right, this process looks ridiculous.

It�s not just VIHA. The Fraser Health Authority went through a similar dispute last year.

And it�s not just stents. A wide range of cuts and rationing are being made without clear rationale, the support of doctors or any public discussion.

Ultimately, that�s the biggest concern. The government sets a funding level and the health authorities make life-and-death decisions about service levels behind closed doors.

And the public is left far on the outside.

Footnote: Stents are gold for the companies that have the patents. As all this was being reported, Boston Scientific Corp. said it would pay Johnson & Johnson $1.7 billion to settle a stent patent dispute. The two companies sell about $2 billion worth of stents a year; globally it�s a growing $7 billion a year business.