Category Archives: Ethics

Without rules (regulation) banks seek ways to manipulate the system to maximize profits. The current financial mess was facilitated by banks’ ability to make bad loans and then pass the risk to someone else.

In health care we have similar situation. We insist on autonomy for patients (deregulation). It’s in our ethical code that patients and their providers are free to make health care decision that best fit the needs of the patient. Our system of insurance facilitates this by passing the financial ramifications (risk) of this decision on to someone else–insurers and ultimately government health programs.

In the financial system some form of regulation is apparently essential to prevent financial collapses–we’re had several major financial crises related to deregulation over the past 25 years. It appears that Friedman, Milton that is, was wrong and financial markets are unable to regulate themselves without collapsing.

In healthcare we need a similar check on poorly considered treatments. Our system is collapsing. It’s estimated that up to 30% of health care services are unnecessary. Many approaches are overpriced and not cost-effective–that is they have some efficacy but the cost is beyond which any health care system, much less most individual, can afford.

Conservatives believe that by passing costs on to the patient we will force them to make better decisions and the system will self regulate (Medicynical note: as effectively as our financial system? ). They propose health savings accounts and high deductible insurance plans, with an emphasis on patients sharing the cost. Not a bad idea if we all had high incomes and lots of savings. But it’s a fact that the median income in our country is just $50,000/household and most citizens have very limited savings. Believe me, most families cannot afford several thousand dollars/year more in health expenses (deductibles and cost sharing)–above and beyond the several thousand already paid for insurance. In such a system, if implemented, those who become sick and can’t afford their cost sharing will continue to seek care and gravitate, just as now, into the public system. The conservative solution leads to a dead end.

A better approach is more comprehensive health coverage with moderate deductibles but with a system that assesses health technology and advances for efficacy and cost effectiveness. Hopefully when developers of new approaches realize that the system won’t pay exorbitant prices for modest advances, value will become a part of health care.

We literally have to change the culture of medicine.

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It’s fascinating to watch the health care debate develop. This today in the Post:

“We could charge the elderly more for Medicare. We could tax employer-provided health insurance as ordinary income. We could create a dedicated federal tax to cover government health costs — if health spending increased more than revenue, the tax would automatically rise. People would quickly feel the costs of our present system. Of course, that would be unpopular, because it would compel Americans to face a discomforting issue — how important is health care compared with other priorities?”

Medicynical note: Mr. Samuelson seems to think we need to increase the costs to people by increasing taxes on health care. His proposal, however, will increase those who cannot afford health care much less more expensive insurance. He believes this will decrease use of the health care system and decrease costs. A little like the “let them eat cake” solution.

Free market approaches in health care simply don’t work. Patients are not in a position to comparison shop and cannot be fully aware of cost implications and all the options. Health insurance, for example, has been a “free market” for years and failed to providing affordable comprehensive care. Insurers are more concerned with their bottom line than quality care.

As noted by the McKinsey study, health care has become unaffordable. Insurance is overpriced; cost effectiveness is not a consideration; and utilization in some areas is excessive. Overpricing, as advocated by Samuelson, increases the uninsured, the tendency to delay preventive medical services and the use of expensive inefficient emergency rooms. His solution is more of the same and does nothing to decrease inefficiency and waste in the system.

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In Oregon, PacifiCare, a division of United Health, has been fined for denying claims without investigating whether the patient’s problem was covered by their policy.

“The consumer and business services’ insurance division found that PacifiCare Life Assurance had refused to pay for claims without first contacting enrollees or their health-care providers, Martinis said.”

“State officials also determined that PacifiCare failed to act promptly on claims and made enrollees with pre-existing medical conditions wait one year for coverage. Oregon law requires insurance companies to cover pre-existing conditions after a person has been enrolled in a health plan for six months.”

“As a result of the state’s investigation, PacifiCare Life Assurance performed an internal review and paid nearly 5,000 claims that it previously denied without first conducting an investigation.”

“The insurer also took corrective action and paid more than 2,000 claims to which it had applied a 12-month pre-existing conditions provision.”

Medicynical Note: This company insures only 13,000 people in Oregon. They apparently denied 7,000 claims from this small population. Does anyone believe that these practices are limited? Are limited only to Oregon? Only to this division of UnitedHealth?

Private insurers are not there to provide coverage for or access to quality health care, they are in it for the money. The sooner we understand that the fiduciary responsibility of these companies is not to do good, the sooner we will be able to have a better, more responsive, possibly less expensive health care system.

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Our non-system of health care has institutionalized the most inefficient, most costly and least effective way of paying for and delivering health care. The problem is most extreme for those who are indigent and/or have no health insurance coverage. They/we pay more for lousy health care. No wonder our health care outcomes are so mediocre.

People who are uninsured and have no access to health care are forced to delay care. Minor problems become major and costs for care, when sought, are higher. Guess who pays these higher costs when the uninsured can’t pay their bills?

When the uninsured and/or indigent become sick their problems are handled inefficiently (at ER’s for example) and other higher cost facilities. Guess who gets to pay for these excess costs when the uninsured are unable to pay?

If an uninsured person is fully indigent he/she may qualify for Medicaid. Guess whose taxes pay for this insurance?

Finally, w hen an uninsured person shows up at a hospital or other facility he/she pays retail. That is, their charges do not reflect the discount that insurers and industry insiders negotiate. So those least able to pay end up paying the most. That’s the reason one of the leading causes of bankruptcy in the U.S. is medical bills. Guess who pays for these unpaid bills with increased charges for their own services?

All of this goes away with universal coverage in a national insurance program. We need that change, now!

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At a tumor board today we discussed a case of a 80 year old woman, with a 55 year smoking history that continues to today. She presented with moderately severe chronic lung disease and a lung mass that impinged on her bronchi. A biopsy showed this to be a non small cell lung caqncer. There were several small indeterminate satellite lesions that were thought likely to be tumor–too small to biopsy.

The pulmonologists thought her poor breathing capacity eliminated the possibility of surgery to remove the tumor. The surgeons also didn’t think the tumor was resectable. The radiation oncologist thought she should have a PET scan to see if her disease was curable with radiation treatment–highly unlikely in similar cases even in the best of circumstances. His thinking was that he would use different technique if the disease were not local–though the CAT scans already showed several suspicious lesions away from the original tumor site.

It should be noted that PET scans often miss small metastatic lesions and if positive require biopsy confirmation. So a negative PET showing no spread would have a good chance of being incorrect. And a postive PET would require some confirmation to act on it. All this in an 80 year old with non-resectable lung cancer.

That decision to do a PET scan costs about $4000 in our institution. The range of cost around the country is between $3000 and $6000.

In no other endeavor involving individuals are such expenses incurred, with so little consideration of expense and in this case with so little expectation of a successful outcome. It’s one of the reasons our healthcare costs in the last year of life are excessive.

In the woman’s case above it could be reasonably argued that the chance that this tumor was local was virtually nil and that she should be palliated with local irradiation to relieve the tumor related respiratory symptoms and then treated symptomatically.

In my view she has no chance of cure whether she has the PET scan or not.

Can we afford such testing? Where do guidelines end and physician judgment begin? Don’t we pay physicians to excercise judgment and don’t they need to include cost efficacy in their patient care decisions?

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