we in a health care crisis?
know, we are in an incredibly turbulent transition time. We have
gone from, let's say even as recently as 10 to 15 years ago, an
approach in which basically money was no object, where the rule
of thumb was if something might help and it wouldn't hurt, do it.
That's all that our criteria was. And at this point all of a sudden
costs have been infused into the conversation and we are literally
reinventing medicine from the ground up. That's made things awfully
complicated because ten years ago, research was basically focused
on wonderful new drugs, new devices, new procedures, great headline-making
things. And we still have a lot of that, but at that time we did
not have a lot of research that showed us about ordinary care, how
to stretch our dollars. And now, all of a sudden, we have to stretch
dollars, but we don't have the research to do it. And we don't know,
among a lot of things that physicians have been doing for years
and years -- we really don't know which ones are very good and effective.
about what you call
Americans' entitlement mentality.
entitlement mentality that I'm thinking about here is connected
to the fact that we are terribly insulated from our cost of care
as individuals. Health care generally is so expensive almost nobody
can afford to pay out of pocket, but, indeed, even though we do
pay for our own premiums, most of us, we don't even think that we
pay our own premiums because we think our employers do it. We don't
see the money. And so we tend to think of our health care benefits
as "This free thing that I get once I sign up for my job," and many
of have fairly low out-of-pocket co-payments, especially if we're
in an HMO. And once we have this health care and we think it's free,
we think we're entitled to everything under the sun. And another
thing is that most health care contracts are based on the concept
of medical necessity, as it's called. Now some health plans define
"medical necessity" in a fairly narrow way. They'll say, "Well,
it has to be absolutely mandatory to cure disease," or some such
thing. But most health plans define "medical necessity" by saying
it either has to be shown to be safe and effective or at least that
it has to be accepted by physicians. Now when you add those two
together and translate 'em into English, what it means is that medically
necessary services are everything that works, or everything that
physicians even think might work. Well, that is a pretty big entitlement
if you think about your health plan and you say, "Well, I get everything
that works or that doctors think might work." Then you're entitled
to a great deal.
are the shortcomings of managed care?
think it might be useful to talk about the ethical hazards
of managed care on a couple of levels. Patients worry about
being denied access to things that they really need. Physicians
worry about not being paid for very important services that
they have provided. Those are important things. I think those
are very important worries, but I think to some extent that's
transitional because we're in this incredibly turbulent time
when we are upending medicine, just upending it. And we're
trying to pick our way through and find out what works and
what doesn't. And in the process a lot of crude things are
being done. Some of the gatekeeper things, some of the utilization
review procedures, some of the very crude financial incentives,
these are transient products of turbulence and they are fading.
care isn't a thing; it's just a whole lot of different efforts to
bring rationality and a bit of fiscal conservatism to our health
care system. But in the process I think some of the deeper issues
that we're up against have to do with the best interest of each
individual versus the best interest of populations of people. And
we really do have clashes of, in a certain instance, some very wonderful,
but extremely expensive, treatment that really does work for somebody.
There's, for example, a disease called Gauchets disease, and there's
a drug that at least a couple of years ago was quoted to cost up
to $400,000 a year per patient, depending on the patient, depending
on his or her needs. And that's a lot of money, but the problem
is it really works! It actually works for people who really need
it. So that's one kind of problem. Another kind of problem that
I think is much bigger, more widespread, is what do we do regarding
treatments that really haven't been proved, that are just sort of
theoretically promising and they are then quickly offered to people
who have no other hope? I think those are very important issues,
because the more money we spend on those, the less money is left
for people who have much more ordinary, less glamorous needs.
do you decide which treatment is
effective or not effective?
I'll tell you how we don't decide. We don't decide it in courts,
which is one way we have been deciding it. Kind of a classic example
has been bone marrow transplants for breast cancer, particularly
for women with advanced breast cancer. And the situation is tragic
because these are women who really don't have many other hopes,
if any. And so for along time doctors have been suggesting, "Well,
gosh, let's try bone marrow transplant," because what's essentially
involved is high dose chemotherapy to the point where you're wiping
out the bone marrow and then you reinfuse bone marrow, which is
necessary -- it's not surgical operation, it's a salvage procedure.
And this became actually quite common before we had any evidence
science, randomized controlled trials, that it ever did any good.
And women who were very desperate were told by their physicians,
"This is your only hope. I think it's a good idea," and the women
would say, "Then I'll try it." And they would ask their health plan
and health plan would say, "There's no evidence that this works."
And some health plans said no, some said yes, but a lot of women
went to court because it was their only hope and because a lot of
doctors accepted it at that time. But now, during the past year,
we finally have some research results. Five studies came out. Four
or them suggested strongly that there was no benefit to this compared
to standard chemo.
this is why managed care draws limits?
does managed care limit services? Well, to begin with, because we
can't possibly afford everything we want to do for everybody. There's
a necessity of drawing some limits. And beyond that, once you draw
limits, you have to actually enforce them. Everybody, I think, agrees
that we need to draw limits and you betcha no -- you know, we can
not as a society afford everything for everybody. But our problem
is, you know, it's kind of that Rule of Rescue thing. As soon as
we find actual person being deprived of something that might help
and probably won't hurt, it's very hard for us to say, "No, you
can't have it. Yeah, it would help and, no, you still can't have
it." We really can't do that very easily. And one of the things
that we have created, ah, in terms of creating managed care -- in
a sense, we've kind of created out own ogre so we can stick pins
in it even while it's doing something that we need for it to do
are healthcare costs rising?
several reasons. One is for several years actually a lot of health
insurance premiums did not keep pace with inflation. For another
thing we've got an aging population, and that drives costs higher
to some extent. We also have a lot of wonderful new treatments that
are in the pipe lines that are coming out, new drugs, new devices,
new genetic treatments. And every time we get a new break-through,
we get exciting headlines about it, people say, "Oh, my goodness,
we've got to have that," and how dare we deny this wonderful new
thing to this poor soul who needs it. Meanwhile, even though our
economy is in great shape right now, employers are not going to
be wildly enthusiastic about the idea of paying more for health
care in the future.
ethics play a role in health care policy?
can't not play a role, because ethics concerns whatever is the most
important in the way that human beings treat each other. And so
since health is a very important part of human life, we can't not
have ethics in health care. I guess the other ingredient, is that
our resources for it are limited. And it's not just that the resources
are limited, it's that the obligations of citizens to help one another
are not infinite. We saw in the collapse of the Soviet Union and
the East Bloc that the idea of a society based on coerced altruism
doesn't last. We certainly have got to have some altruism in this
society, and we have obligations to help our fellow citizens, but
they aren't unlimited. There's a certain point at which I get to
keep a certain amount of what I have earned and worked for.
of this turbulence and transition time has been lots of horror stories
about what awful things are happening as managed care companies
do terrible things and deny necessary and much needed care from
people. And so our news media -- economics in managed care is one
area where we are not seeing a lot of sophistication from the news
media. So that what we're seeing is all these horror stories about
the evil HMOs that denied some terribly important, utterly clearly
necessary treatment from this person without necessarily showing
that it really is necessary. But I've never seen a story yet about
how a patient was making a perfectly silly, frivolous demand and
how an HMO virtuously said no. And yet there are plenty of such
cases. Talk to anybody who works in an emergency room and they will
tell you about people who show up because "Oh, I ran out of Tylenol,"
or in New York City I heard last summer during the encephalitis
scare, a lot of people were showing up at ERs with a mosquito bite.
And I'm sure that they were afraid, "Gee, I've got this mosquito
bite. I know mosquitoes transmit this infection and so I'm scared
to death. Do I have encephalitis
doctors sort of double agents at this point?
physicians are under serious challenges from the double agency factor,
because they are more obviously now being expected to, on the one
hand, continue to look out for the best interest of their patients,
but they are also at the crossroads between the money and the medicine.
And they are asked to look out for the best interest of the health
plan. In the olden days with the artesian well of money, it was
easy to be altruistic when you had unlimited amounts of other people's
money to spend. And now we don't have that. And part of the problem
is figuring out what is going to be the physician's role. On the
one hand, the physician wants clinical autonomy at the very least
to adapt guidelines suitable for populations to the individual patient,
because there are many cases where the guidelines don't fit the
patient, and vice-versa. So the physician needs clinical autonomy,
but the more autonomy and control the physician has over the resources,
the more likely it is that the physician is going to be personally
at risk, financially or professionally, for how he or she uses those
resources. I mean there are basically two ways to contain the cost,
controls or incentives. Either you play Mother May I, which is this
annoying, intrusive utilization review from the outside, or you
shift the control to the physician, but only in the presence of
something to remind the physicians on an ongoing basis that this
patient right here is not the only concern.
should we be going in health care?
golly. You know, I'm really mixed here, because I think traumatic
as it has been, there's been a good bit of value to this turbulent
period of muddling through, because we're learning a lot right now
about ways in which health care has not been so good all along,
after all. Fee-for-service was not an ideal system. Enormous amounts
of money were wasted, a lot of medicine was practiced purely on
the basis of anecdote and guess and hunch.
thing for the future -- we really do need to cover those other 44-1/2
million people who have not been broad on board yet. It really is
important, and not just because it's the decent thing to do in an
affluent society, but also because that many people without good
access to health care creates economic quirkiness in the marketplace.
A lot to strange economic dynamics when you have that many people
who don't have access to health care and everybody else is scrambling
to try and avoid being hit with the bills indirectly for those people's
second thing I think we need to do is to learn that we have to say
no. We have got to be willing to say no to identified individuals
and make it stick. We have to say no in very careful ways and have
very good reasons for saying no, but if we're going to draw limits,
we have to actually enforce them. And that means enforcing them
when it affects a real person who's right here in front of us and
who would benefit if we made an exception.
keeping us from getting to
where we need to go?
we certainly have many examples of reasonable people coming together
in a room and putting forth a reasonable plan. The problem is actually
getting the rest of the people to agree that it is a good plan,
because any approach is going to have major trade-offs and major
down sides, whether in the total cost or questions about denials
of care and things like that. I think part of the problem right
now that is stopping us from enacting universality of health care
is this concept of medical necessity the is defined as "everything
that works" or "everything that doctors think is promising." To
institute medical necessary for another 45 million would, I think,
be economically prohibitive. Everything that works, we can not sustain