health care

My question for Ron Paul: Autonomy and health care

R. Horton

Earlier this year at the Tea Party debate, Wolf Blitzer asked Ron Paul if a person who chose not to buy health care should be left to die. Paul responded that this person’s friends and community could support him and pay his bills. Many in the audience seemed to be all right with letting this person die.

Conservatives and libertarians both express a strong commitment to autonomy, which they sometimes refer to as freedom. The new health care law is unacceptable they say, because it requires individuals to purchase insurance. People should not be required to purchase insurance, but they should be responsible for the consequences if they do not have insurance. Of course, this scenario is rarely a problem for anyone, and Blitzer asked the wrong question.

I would want to ask a different question. I want to know about the person who has worked all her life and been successful. After 20 or 30 years, she decides to expand her opportunities by starting her own business. Remarkably, her business is profitable in its first year. She can afford to buy insurance, but she cannot buy adequate coverage because she has preexisting conditions that every major insurance carrier refuses to cover. When she contracts a serious illness, she is driven into bankruptcy because of medical bills that are astronomical but quite common. Should our country let her die? Should she be permitted to slide into bankruptcy?

Autonomy is not quite as simple a question as it apparently seems to Republicans and libertarians. Philosopher Isaiah Berlin described two types of liberty: one is negative and the other is positive. For conservatives, it is imperative that individuals not be forced to do something they may not want to do and no government intrusion is acceptable. This is negative liberty. For liberals, such liberty is meaningless if one is unable to make the choices he or she desires, which is positive liberty.

Describing the liberal view of positive liberty, Berlin says,

“It is true that to offer political rights, or safeguards, against intervention by the state, to men who are half-naked, illiterate, underfed, and diseased is to mock their condition; they need medical help or education before they can understand, or make use of, an increase in their freedom. ”

While conservatives will not force someone to purchase insurance, liberals want to ensure that everyone has the option to have health care. Everyone who needs health care and cannot obtain it becomes a liberal in an instant.

The number of uninsured in the United States is said to be around 50 million, but many more than that have inadequate insurance. Unfortunately, most people do not realize they are underinsured until it is too late. Many people only learn that their treatment will not be covered by insurance after they have received the treatment. What kind of autonomy is this? What is the value of liberty if it leaves one with no options to avoid bankruptcy, untreated illness, and death? Is this really what we want to be?

The Ethics of Medication

R. Horton2 Comments

Yesterday, I went to the doctor, and he prescribed medication for reflux disease. When I went to pick up my prescription, the cashier told me the pharmacy could not fill it until they received authorization from the doctor. I asked whether the doctor’s prescription was not authorization. It turns out, according to the pharmacist, that the insurance company will not pay for the medication without a written justification from the doctor.

Rather than needing doctor’s authorization, the insurance company was rejecting his authorization. So, I get no treatment for my reflux, which hardly seems fair, but the situation is exasperatingly complicated.

It could be that my doctor, under the influence of pharmaceutical reps, prescribed an expensive medication that is no more effective than cheaper alternatives. If so, it may be in the best interest of everyone, except the doctor and pharmaceutical company, to reject payment for an expensive medication that offers no additional benefits over other medications. Praise to the insurance company for holding the line on costs.

It may be that the doctor knows that the new and expensive medication is more effective and has fewer side effects than alternatives. He may have prescribed what he feels will promote my health and healing better than any other treatment available. In this case, all thanks go to my doctor, and the insurance company is really quite evil.

Or, it could be that the insurance company rejects any expensive treatment with the hope that patients will give up and find cheaper treatments or go without treatment. This, of course, might save money in the short run, although rejecting claims costs money in itself. Sometimes, rejecting a claim is more costly than simply paying it. the amount of staff time and resources tied up on this one prescription is enough to give one pause. The pharmacy says the insurance company won’t pay for the prescription, but I did not press them on how they know this. It is possible they simply consulted a list of preferred medications. It may be that they checked a computer database. Or, they may have actually made a phone call. Any of these options require employee time.

After determining that the drug was not a “preferred” drug, the pharmacy faxed a form to my doctor. If things go as planned, a member of the doctor’s staff will obtain a statement and signature from him before completing the form and faxing it back to the pharmacy. This is an inefficient system at best.

In this case, the patient, me, is going without treatment for reflux, which is causing real problems and can lead, if untreated, to serious problems such as esophageal cancer, which frequently terminates in death. So, who is to blame for the suffering of the patient? Greedy pharmaceutical companies? Doctors under the influence of greedy pharmaceutical companies? Greedy private insurance companies? Or pharmacists who raise problems when there is no problem? I really don’t know the answer.

Is health care better when you pay more?

R. Horton1 Comment

In a New York Times article today, Reed Abelson makes the bold statement that a new hospital study provides “stark evidence” that higher payments do not translate to better medical care. He is citing a Pennsylvania government study of the 60 hospitals in Pennsylvania that perform heart bypass surgery. Two of the highest paid hospitals also had the highest death rates. This could be for many reasons. These hospitals might take the most difficult cases or the most costly. Either example would cause higher costs and poorer results.

So, the study is too narrow to make sweeping generalizations about health care costs, but it does raise some questions. Noting that this particular study does not prove much, Abelson goes on to say, “Still, the Pennsylvania findings support a growing national consensus that as consumers, insurers and employers pay more for care, they are not necessarily getting better care. Expensive medicine may, in fact, be poor medicine.”

Implied in the article is a call to adopt a pay-for-performance model for health care. The idea is that physicians and hospitals with better outcomes would receive higher pay. On the surface, this seems like a good idea, but there are potential problems. One way to improve outcomes is to deny service to high-risk patients. Abelson’s article notes that Geisinger Health Care is offering a 30-day warranty on its cardiac surgery. Private hospitals are able to choose the best candidates for surgery and have a much better chance of making good on the warranty.

Public hospitals face other dilemmas. Hahnemann University Hospital now says that its record keeping probably did not give an accurate picture of how sick its patients were before coming for surgery. Public hospitals and teaching hospitals take all patients and do their best to save them. Those with the sickest patients are likely to have the worst outcomes. This is not proof of poor care.

The question of how to compare care at different facilities or among different doctors is not one easily answered. Most will agree that better performance should be rewarded, but getting an accurate picture of care quality will require more than counting deaths and dollars. Dr. Richard Snyder of Independence Blue Cross, is quoted as saying, “Philosophically, you’re not going to get an argument from us. We believe we should pay more for high quality than poor quality.” Implicit in his statement is frustration over how to measure quality. Recognizing the complexity of the question is the first step to formulating possible answers.