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E. Havvi Morreim, PhD

E. Haavi Morreim, PhD
E. Haavi Morreim, PhD
ProfessorDept. of Human Values and Ethics
College of Medicine University of Tennessee

Are we in a health care crisis?

You 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.

Talk about what you call
Americans' entitlement mentality.

The 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.

What are the shortcomings of managed care?

I 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.

Managed 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.

How do you decide which treatment is
effective or not effective?

Well, 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.

So this is why managed care draws limits?

Why 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

Why are healthcare costs rising?

For 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.

Should ethics play a role in health care policy?

Ethics 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.

Part 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

Are doctors sort of double agents at this point?

I think 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.

Where should we be going in health care?

Good 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.

One 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 care.

The 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.

What's keeping us from getting to
where we need to go?

Well, 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 for everybody.

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