The Land of the Free
And I thought that in the United States we didn’t ration health care:
An insurance company that initially refused to pay for a liver transplant for a 17-year-old Northridge girl who died in a hospital should face criminal charges and pay civil damages, an attorney for the girl’s family said Friday.
In the real world, it’s not possible to have an insurance program that will pay for just anything. A private insurance plan will try to find reasons to avoid paying for anything that’s expensive. And it’s natural inclination to do this will be checked by the sloppy method of public outrage and lawsuits. A public program, by contrast, could operate according to an explicit budget constraint, with elected officials and the voters who vote for them in a position to make a choice about how much resources they want to dedicate to health care services rather than to other things. In either case, people with the means and inclination could step outside the insurance circle and purchase additional services.
49 Responses to “The Land of the Free”
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July 31st, 2009 at 4:06 pm
If anyone finds out how a few words from Yglesias makes rationing different from government and private sector, let me know. Both are using the price mechanism.
July 31st, 2009 at 4:09 pm
While it is certainly true that the Sarkisyan case is a case of rationing in our system, there are other cases which are more reflective of how our system rations care. The cases of Denise Prosser, Mark Windsor and Nikki White are more reflective of how our health care system rations care than Sarkisyan’s case. In short, when you get sick, you lose your job, get kicked off coverage and are left in the cold.
July 31st, 2009 at 4:10 pm
Motivation makes a difference. The insurance company has a legal responsibility to maximize shareholder value. This means increasing revenue and decreasing costs. Medical treatments are costs.
Say what you will about government health care, but at least they wouldn’t have the same incentive to limit coverage in order to make their numbers that quarter.
July 31st, 2009 at 4:20 pm
“In either case, people with the means and inclination could step outside the insurance circle and purchase additional services.”
Perfect. Then it will work just like education. Rich kids go to Phillips Exeter Academy, poor kids go to PS182. Presto. Justice. Can’t imagine anyone complaining. Unless we get in a situation where PS182 ends up spending a gargantuan amount of money to educate a bunch of adversely selected kids, thereby always underperforming. And being completely held hostage by the political process, union heavies, etc.
But luckily, that hasn’t happened at all. And the process by which we provide a good publicly and let rich people opt out is working fine. And on the cheap.
Wait…
July 31st, 2009 at 4:23 pm
This is rationing too, from my friend Greg Peters, a brilliant Louisiana political cartoonist and graphic designer
July 31st, 2009 at 4:23 pm
What do the CIGNA people tell themselves to rationalize this?
July 31st, 2009 at 4:34 pm
Note that CIGNA was immune to lawsuit damages in this case, since the insurance was provided through the workplace and damages were preempted by ERISA. Even allowing insurance companies to be sued would be a step forward.
July 31st, 2009 at 4:36 pm
OTOH if rich people opt out, while still paying taxes, I would think you’d be happy. That’s fewer people using up resources for the uninsured.
Or are you just suffering from knee-jerk bigotry and prejudice toward rich people?
Tsk.
July 31st, 2009 at 4:39 pm
I’m for mandatory coverage and a public option and most of the features of the more progressive plans. But “sure the government might deny this poor child the transplant, too, but at least it’s a transparent public process not guided by the profit motive” is not what you would call a slam-dunk argument for reform.
July 31st, 2009 at 4:39 pm
Ignoring the ridiculous strawman that he uses to start the post, once again Yglesias completely ignores reality to make a cheap point. It was an experimental procedure without much experience to prove it would be effective.
http://articles.latimes.com/2007/dec/22/business/fi-transplant22?pg=1
As heart-breaking as the story may be, there will be plenty more of these in the future no matter who is paying for health care, because we’re going to have to make some tough choices to keep health care spending from bankrupting us. People like Matt and Ezra Klein love to point to things like CER as a way of controlling costs and making these decisions, but it’s highly likely that in this case CER or a QALY approach would have come to the same conclusion as Cigna did and said it was not covered.
I also really enjoyed how the only part of the story Matt quotes is a paraphrase of the attorney, and he doesn’t even mention any of the relevant facts of the case. Does Matt think a public plan would or should have paid for the transplant in this case? If not wanting to lose money is really the cause of this and is a shameful reason to deny care, isn’t the hospital partially to blame as well? I do not mean to completely exonerate Cigna here, without more information (much of which is not available due to medical privacy laws) none of us can say for sure whether or not the transplant should have been performed, but the issue is not so black and white like Matt would have you believe. It’s way too easy to just assume there is a villain at work rather than look objectively at the tough cases like this.
July 31st, 2009 at 4:44 pm
And it’s natural inclination to do this will be checked by the sloppy method of public outrage and lawsuits. A public program, by contrast, could operate according to an explicit budget constraint, with elected officials and the voters who vote for them in a position to make a choice about how much resources they want to dedicate to health care services rather than to other things.
And in other news, Nataline’s family is not at all outraged that the government refused to pay for her liver transplant because they realize the government program is subject to an explicit budget constraint and that elected officials and the voters who vote for them made a choice about how much resources they wanted to dedicate to health care services rather than to other things.
You have got to be kidding.
July 31st, 2009 at 4:51 pm
Well, looks like Law and Order has one episode already ready to go for next season.
July 31st, 2009 at 4:52 pm
It wasn’t that long ago that liver transplants were an experimental procedure. I think we can get costs under control, and move forward with experimental procedures. The only reason anyone can get a liver transplant, is because the state has subsidized many guinea pigs and patients for practice. The hospital in which one is most likely to have a successful transplant, has a team that has performed 13 transplants.
This girl’s case is sad, though. Whether or not the insurance company’s decision rested on the doctors’ decision is where the issue lies. If it’s true that the doctor refused, then it’s understandable.
July 31st, 2009 at 5:00 pm
“Or are you just suffering from knee-jerk bigotry and prejudice toward rich people?”
No. Just pointing out that the idea of having a public good that the rich can opt out of doesn’t really seem to work all that well. Because everybody want the rich-person version of the good. Which is why just about every state university in existence tries to be the “Harvard of the ________.”
Just keep in mind that, using this model, someone is going to have to go to the PS182 version of the heart doctor, the PS182 version of the OB/GYN and, most unlikely, the PS182 of the pediatrician.
Is that a sustainable model? I suspect not. I suspect that everyone else suspects not, too.
Instead, what we will get is everyone demanding every treatment gets paid for. Which is impossible and unsustainable. (Which politician is going to tell the 17-year-old in the post, “Sorry, you die of liver failure.”?)
So what we will get is some agency somewhere acting like the heavy. That agency will have to decide who dies.
So… we will have politicians making healthcare decisions. Which is exactly what people opposed to the plan are saying.
Look, right now we get heartless corporate goons making these decisions. And maybe a bureaucrat would be an improvement. But when people on the Right say, “This will lead to bureeaucrats rationing care…” they just so happen to be correct.
July 31st, 2009 at 5:13 pm
In the real world, it’s not possible to have an insurance program that will pay for just anything. A private insurance plan will try to find reasons to avoid paying for anything that’s expensive. And it’s natural inclination to do this will be checked by the sloppy method of public outrage and lawsuits. A public program, by contrast, could operate according to an explicit budget constraint, with elected officials and the voters who vote for them in a position to make a choice…
This from a guy who has spent the past three months railing about how ignorant politicians are and how flawed the American political process is. Please. Yes, insurance companies are corrupt and profit seeking. But, politicians are corrupt and vote seeking. This isn’t to say there aren’t better ways of running health care, but if you operate from the assumption that “explicit budget constraints” (HAH!) and “voters” act as any kind of rational system to general good policy outcomes, you haven’t been reading Matt Yglesias’s blog for the past three months.
July 31st, 2009 at 5:27 pm
Yes, I remember this case of poor Miss Sarkisyan from when it was all over the local news, with mass Armenian protests against the insurance company. You don’t mess with an Armenian in Southern California with impunity.
On the facts, though, it sounded utterly hopeless for poor Miss Sarkisyan. A transplant would have likely been a complete waste of a large amount of money. Thus, she would be the perfect poster child for exactly whom Obama and Orszag would agree must die for the common good of cost saving.
But, frankly, are the politicians really going to withstand the heat that, say, the 100 member Congressional Armenian Caucus will bring when a beautiful Armenian teenager is dying? (Only one Congressman is an actual Armenian, but Armenian ethnic solidarity and enterprise makes them formidable players in American politics for such a tiny group.)
July 31st, 2009 at 5:35 pm
The argument isn’t that rationing doesn’t happen now; it does. It’s that a government run program will simply centralize the rationing. As I’ve said before, this plan is all about trading one set of naysayers for a different set.
July 31st, 2009 at 5:40 pm
All this carping about hypothetical costs is making me nuts. Look: either we commit to covering everyone and then make it work (as all the other major democracies have done–plenty of observable examples there of how to handle cost issues, transplant issues, etc., IF we care to learn from them) or we get lost in weedy discussions that are interesting as intellectual exercises but don’t really resolve anything.
One thing about government bureaucrats everybody forgets: they manage public resources for the good of the PUBLIC: Not the CEO’s already exorbitant bonus, not the stockholders’ dividends. I’d much rather have a government bureaucrat making program decisions (or even transplant decisions, although the physician should be the one who makes that call) than a health-insurance stooge whose job is to say “no” as often as possible.
July 31st, 2009 at 5:42 pm
If a public health care regional office has $100 million to spend by the end of the fiscal year, its employees will strive to make sure that they spend every penny of it giving people health care.
If a private HMO has a budget of $100 million for the rest of the fiscal year, its employees will strive to spend as little money as they can giving people health care. If they can deny enough claims so that they end up spending $80 million instead of $100 million, everybody gets a big bonus. If they spend all $100 million, people are going to get fired or demoted.
Quick, which office would you rather have review the claim form that your doctor sends in?
July 31st, 2009 at 5:58 pm
Rationing is totally inevitable and necessary, but the political system is totally unable to cope with the white-hot emotions it creates.
The best kind of health care reform, in my view, would be to eliminate ALL state mandates and create a rigorous disclosure regime so that everyone knows exactly what his insurance covers and is aware ex ante that it is his decision how much more or less of each kind of coverage to buy. It also makes sense to legally demand that everyone purchase a certain amount of coverage to minimize the externalities from mandatory ER care. Eliminate the tax treatment of employer coverage to get rid of all the dead-weight loss it creates. Ultimately the only way to take care of rationing is to make people be and feel like masters of their own destiny when it comes to insurance. They’ll be much more willing to forego last-six-months care if they remember that they chose not to enroll in the outrageously expensive last-six-months insurance plan.
Then we can handle the problem of poor people not having enough coverage as explicit rather than implicit welfare.
Totally infeasible as a political matter, of course, which is why every possible system that we end up with will be a complete, demoralizing clusterfuck and Congress will be putting out existential financial crises related to health care forever.
July 31st, 2009 at 6:17 pm
I don’t normally agree with Sailer, but in this case…
That poor little girl. But deciding not to perform an expensive procedure like a liver transplant on a kid who probably was going to die anyway is the kind of rationing we ought to be doing, whether in a public plan or a private plan.
Moreover, it’s the kind of rationing that’s going to be unpopular, whether in a private or a public plan.
I don’t see how Pender’s plan would work. I can’t imagine looking at an exhaustive list of what would and wouldn’t be covered in my potential health care plans, and figuring out which plsn to pick. I don’t know enough about what treatments are reasonable and cost-effective.
July 31st, 2009 at 6:30 pm
“A public program, by contrast, could operate according to an explicit budget constraint, with elected officials and the voters who vote for them in a position to make a choice about how much resources they want to dedicate to health care services rather than to other things”.
This is the theory which brought us ehtanol subsidies, DOD budgeting by how many defense projects can be spread out over how many Congressional Districts, a “stimulus” plan whose major goal is to pay off favored constituencies, etc.,etc., ad nauseum.
July 31st, 2009 at 6:44 pm
…because, as we all know, individual health care expenditures will be voted on by Congress.
July 31st, 2009 at 6:52 pm
If what Pender suggests is that everyone individually, or as a family or workplace, picks individual services, or groups of services, then you will be stratifying care by financial means to the extreme.
July 31st, 2009 at 6:59 pm
Pender: I do not see Canada, Great Britain, France, Holland, etc. etc. as giant clusterfucks. (unless you’re expressing a certainty that monied interests, who own our political system, will do everything the can to turn health reform into a giant cf. There, I might be with you.)
But what you propose, Pender, is exactly like “empowering people to become masters of their own destiny” in regard to….let’s say…. police protection. “Sorry, Mr. X, you’re not enrolled in our Preferred Protection Plus plan, so we won’t handle your burglary compaint. Too bad!”
“Sorry, Miss A, we can only send one firefighter to deal with your house fire, you’re only enrolled in the bottom grade Fire Utility Forget-About-It plan!”
I do not want to live in the world you seem to hope for.
July 31st, 2009 at 7:36 pm
@ Sam M: What’s with this PS182 analogy? Poor schools suck mainly because they serve a population that “sucks”. Don’t get me wrong – they mean well, but it’s a cycle of larger social neglect, ignorance and concentrated poverty. Anyway, star teachers &/or administrators can do wonders, but just like star athletes – they are always the exception. And the average PS182 will do it’s best (everyone stressed, kids failing) while society shits on it.
Healthcare, however, is completely different. The variables are actually controllable. Instead of basically being responsible of leading a kid to success despite absurd odds, all you have to worry about is delivering quality care at a reasonable cost. If we treated doctors like we treat teachers, you’d have ER’s across the country being held accountable for not being able to send every patient away in perfect health!
July 31st, 2009 at 7:40 pm
cardinalFang said
I can. I can imagine a giant standardized box with large type like on credit card forms that spells out exactly the categories of coverage and exactly the caps in coverage amounts. Give common examples next to each one. Make the customer initial every single one of ten or so categories before he is enrolled. Hell, make him take a short quiz at the end to make sure he understands the plan, sort of like what is done with student loan exit counseling. Force the insurance companies to disclose the common unpleasant scenarios from each plan in a standardized way so that people know the extent of their coverage. Having everyone get a complete in-the-Matrix level of understanding of your plan isn’t feasible, but government regulation can do wonders to enable transparent disclosure. Health insurance is not rocket science, and we can definitely make people grasp the basic contours of their plan and its limitations and how much it would cost to eliminate those limitations before they sign.
dougR, police and firefighting don’t involve life-and-death rationing to nearly the extent that health care does, so they’re inapt analogies. The point is that when the system inevitably has to condemn some people to die, it’s better that people feel like they made the decision themselves. If they blame the government, then you get creeping coverage mandates and creeping costs and the system isn’t sustainable. I’m not an expert on the health care of the countries you listed, but how do people in, e.g., Britain react when NICE says “sorry, we could save your wife’s life with this cancer drug, but it costs $60,000 per year and that’s $9,000 too much so we have to let her die”? Do they just not know that those drugs exist? Or are they in the process of dismantling the viability of their system by demanding that NICE provide more and more expensive treatments? The reports I’ve read suggest that the latter is slowly but surely underway, but I’m sure the former plays a large role, and neither is particularly admirable.
modernovidius: Yes, but health care is already stratified by financial means to the extreme. And why not? Is it a matter of social injustice that Bill Gates has a nicer car than you? If not, why it a matter of social injustice that he can pay for better health care than you? Are you going to make it illegal for him to spend more on cancer treatments than you can afford? Again, if you want to ensure a certain floor level of coverage for everyone, pass out sufficient welfare that people can buy at least that basic level of coverage.
The ultimate point is that it is a terrible weakness of government that it is forever at the mercy of small and highly-motivated groups. That’s why we have agricultural subsidies, and F-22 bombers, and bridges to nowhere, and sweetheart tax exemptions for every goddamn industry under the sun. That kind of creeping accommodationism creates a ton of waste. And rationing of health care, particularly in cases of life and death, is going to be the most fertile ground for this bullshit that we’ve ever seen. It already is, and that’s why states create so many insurance mandates, and that’s why so many people can’t afford health insurance!
July 31st, 2009 at 8:36 pm
“If it’s true that the doctor refused, then it’s understandable.”
I’d guess the doctor didn’t refuse. Mom mom had a very similar case that actually went a little farther. My mom wanted a bone marrow transplant that the doctor thought was very unwise. But he didn’t want to be the guy to say no. He assumed the insurance company would refuse, so he pushed it off on them. But they approved it for some really stupid reason. So then doctor figured that there wasn’t really any chance of her finding a donor in time, so he’d go ahead with the process. My mom then found a donor the next day. The doctor still didn’t want to tell my mom that the procedure was really a waste, so he scheduled a transplant surgery for three weeks later. My mom died in two. But it never should have gone that far. The transplant process would probably have killed her anyway, and she was already beyond hope. A simple NO! at the beginning would have been better for everyone.
And this is the problem with the current rationing system. It’s not based on any rational medical policy. It’s based on arbitrary decisions made by random and usually unqualified people. Some patients get too much care, and some patients don’t get enough. It has nothing to do with their health, but everything to do with the mood of some randomly selected accountant at the insurance company. If you need treatment, you’d better hope the guy making the decision got laid last night. Because that’s really what it’s going to come down to. The advantage of a government system of rationing is that it can be based on medical need applied equally to everyone. The current system is just random selection. People who don’t deserve treatment get rationed in, and people who’d be helped get rationed out. Add in a payoff or two, and you can change your odds. So when we talk about rationing, we need to talk about the criteria we use to decide on the rationing. In the current system, there really aren’t any criteria.
July 31st, 2009 at 8:36 pm
A perfect example of what’s wrong with modern politics.
Remember all those posts about France and Germany and the UK and Japan and Canada and so on, and how great their health care systems are? Well, in those countries there’s no chance that this girl would have gotten a transplant. Wouldn’t have happened.
But in this country, idiots like Matt take this two year old case and say it shows the problems with our system, and the public at large says, well, that doesn’t sound right, I want the girl to live, and if changing systems would mean she lives, I’m in favor of that.
But it’s just a Big Lie. If we change systems, she’s still not going to get the transplant.
Matt knows that, so he tells a variety of little lies as well. That’s why he suggests that the insurance company, which didn’t have any money at risk here, since it was simply an administrator for a large company which had self-insured these costs, was making a decision with its eye on the bottom line. And why he suggests that an American public health insurance program wouldn’t be motivated to try to avoid paying for things
July 31st, 2009 at 8:59 pm
“But it’s just a Big Lie. If we change systems, she’s still not going to get the transplant.”
That is absolutely true. And the people on the other side are being just as disingenuous when they say there is no rationing in the current system. In the end, this girl probably should have died, so the system got lucky and made the right decision. But if we are going to make these decisions (and we must), let’s base them on real medical criteria, not whatever mood some accountant is in that day.
This comes down to the basic difference between liberals and conservatives. Liberals think decisions should be made by people who are qualified in the field in question. Conservatives think that all decisions should be made by accountants.
July 31st, 2009 at 9:00 pm
Re: Just pointing out that the idea of having a public good that the rich can opt out of doesn’t really seem to work all that well.
Why not? The rich get to hire their own security guards while the rest of us must rely on the police (something which can also be a life and death matter). Has anyone suggested banning private security?
Re: Just keep in mind that, using this model, someone is going to have to go to the PS182 version of the heart doctor, the PS182 version of the OB/GYN and, most unlikely, the PS182 of the pediatrician.
This is already true. The rich can afford the best doctors on the planet. Meanwhile the poor may be stuck with a guy who graduated bottom of his class from WhatsaMattaU in some Third World country.
Re: So what we will get is some agency somewhere acting like the heavy.
Been there, done that. For every healthplan in existence, whteher public or private, there is some mechanism in existence to determine what procedures will be covered and whether patient X in situation Y should get that treatment.
Re: The best kind of health care reform, in my view, would be to eliminate ALL state mandates and create a rigorous disclosure regime so that everyone knows exactly what his insurance covers and is aware ex ante that it is his decision how much more or less of each kind of coverage to buy.
And would you also be OK with some sort of enforcement mechanism to make sure that insurance companies really do cover what they purport to cover? Because right now they are quite good at finding all sorts of little loopholes to get out of paying for things they are supposed to cover.
July 31st, 2009 at 9:05 pm
The argument isn’t that rationing doesn’t happen now; it does — just not to me, and if it ever does, then I’ll give a shit.
Fixed your typo there, J-Rob.
Pender: it’s well documented that people are especially bad judges of medical needs, whether on a short-term diagnostic basis or a long-term one. That’s what doctors are meant to be for. Giving them a dozen yes/no checkboxes isn’t going to change that.
It’s bad enough right now with the menu of plans that offset lower premiums against higher out-of-pocket costs. Spend a year on the top tier, and only see the doc for your annual physical? Should you decide to tempt fate and renew at the bottom tier for next year?
It’s probably unworkable, too. Bodies don’t work like a car, where you can get a warranty for different bits. But I suppose it’s an entertaining glibertarian fantasy for people who consider themselves masters of their own domains.
July 31st, 2009 at 9:05 pm
One thing I think people don’t realize is that not only could you pay for additional procedures above and beyond what a government plan covers, if there are enough people like you who want these kinds of “extra” services, you could have a secondary insurance market that would cover them.
July 31st, 2009 at 9:09 pm
Fuck the policy.
July 31st, 2009 at 9:21 pm
“The best kind of health care reform, in my view, would be to eliminate ALL state mandates and create a rigorous disclosure regime so that everyone knows exactly what his insurance covers and is aware ex ante that it is his decision how much more or less of each kind of coverage to buy.”
I’m all for that. But there isn’t an insurance company in America that would ever be willing to say up front what they will cover and what they won’t. They want to promise you the moon and give you a meteorite. Misrepresentation and lawsuits are what keep the system going. Take that away, and the insurance industry will go into a new business. An honest insurance system just isn’t profitable enough. That’s why nobody talks about the Japanese system, which is similar to that proposal (but with an individual mandate). But American insurers see how much more money they make compared to their Japanese counterparts, and they don’t want to go there.
July 31st, 2009 at 9:48 pm
Rationing health care is a bet you make that the victim won’t be someone you care about. It sounds so very reasonable and necessary until it’s you, your kid, one of your parents, or your spouse who needs a rare, expensive, or experimental treatment.
Socialize the entire system, ban private insurance, and appropriate whatever resources are necessary to cover everything for everybody.
Or, don’t. I’m sure that your grieving process will be enriched by the knowledge that your loved one died to save profits and tax money.
July 31st, 2009 at 10:07 pm
fostert, it is not “accountants” making those decisions, it is doctors, so until you actually know what the hell you’re talking about you should stop spouting off such utter nonsense. But I guess it’s easier to just avoid reality and pretend there is a villain who can be blamed for everything.
July 31st, 2009 at 10:17 pm
“It sounds so very reasonable and necessary until it’s you, your kid, one of your parents, or your spouse who needs a rare, expensive, or experimental treatment.”
Actually it sounded very reasonable to me when my mother needed rare, experimental treatment. She spent a million dollars (Blue Cross’s, of course) to add three months of pain and misery to her life. That million dollars could have saved a lot of poor kids who died because they didn’t have money. My mother’s three extra months certainly didn’t outweigh what could have been. And I did think that at the time. I was just shocked at what she was getting. Six units of single-donor platlelets every day? That’s like eight month’s of what an adult human male can safely donate. She blows through that every single day. That’s just insane. And this was after the Richter’s transformation which is always fatal. Sometimes, it’s just time to give up. Life is inherently a fatal condition, and at some point, it’s just not worth it.
July 31st, 2009 at 10:27 pm
No, Fostert, Mark’s exactly right. Let’s get everybody COVERED, at least, to put an end to people dying broke, in debt, untreated, or otherwise burdened by the misery our current “system” visits on far too many. And then yeah, let’s bitch about this kind of decision (I have a feeling it’s going to become pretty pressing too). (And as I suggested in an earlier post, we can certainly look to the more successful and cheaper systems abroad for ways to approach things like this, as well as ways to approach cost containment, physician compensation, and the rest of it.)
July 31st, 2009 at 10:31 pm
“fostert, it is not “accountants” making those decisions, it is doctors, so until you actually know what the hell you’re talking about you should stop spouting off such utter nonsense.”
Well, I have a friend who used to work for an insurance company to deny coverage to people. He was a business major working on his CPA and had no medical degree. He received bonuses for every claim he denied. And in his group, there was not a single medical doctor. And these were situations where the policyholder was recommended by their actual doctor for the treatment. So if a doctor recommends a treatment but the patient doesn’t get it because an accountant (or less) said he couldn’t have it, who made the decision? A doctor or an accountant (or less)? You obviously never worked in the medical field. I have, so don’t tell me I don’t know what I’m talking about. You obviously think insurance companies are manned mostly by medical doctors and that doctors really would rather work the phones for $12 per hour than practice medicine. How insane is that? If you can show me one single example of a doctor with a license to practice medicine who works the phones for an insurance company for crappy wages, I’ll grant that you might have a case. But I know damn well you can’t produce that doctor.
July 31st, 2009 at 10:37 pm
“No, Fostert, Mark’s exactly right. Let’s get everybody COVERED”
Whoah there, I wasn’t disagreeing with Mark, I was just noting that some of us are comfortable with the difficult rationing that should occur at the end of life. For me, it was reasonable even when my mom’s life was at stake. I think a realistic discussion of rationing is possible. It will sure make people queezy, but it’s possible.
July 31st, 2009 at 11:35 pm
I see no reason to reduce it to a zero-sum game. There will be people who will surely die from their condition, and there will be far more people who could become healthy and active again with proper medical care. My client who had a liver transplant that wasn’t entirely successful, is getting ready to go to a four year college with the associates’ he’s earned since his operation, and a lot of scholarship money because he’s phi theta kappa. He’ll probably get to see his daughter graduate from high school, and go on to college. He is sometimes frail and vulnerable to infection, but he is well taken care of and takes good care of himself.
His condition was no fault of his own, and he survived an amazing six years on the waiting list, with excellent care from his doctors and myself (as a 24/7 caregiver). He has survived the Bush years, and things are looking up.
If the government can negotiate better drug prices, he just might eventually pay for it all indirectly. He’s certainly a good parent, good citizen, and good worker.
More improvements in home-care, and transplants candidates and recipients will live longer and be healthier. Right now, one of the greater problems with liver transplantation is that so many donor livers are too fatty, or already shot from toxins.
August 1st, 2009 at 2:39 am
Seriously, how do you become the CEO of Cigna. What does it take? How many ethical lines do you have to cross on the way up?
Ever since I was a little kid I lived in dread fear of succumbing to “ladder climbing syndrome.” I mean, by the time you are 10 or 11 your are aware; in order to fight your way up the ladder of evil and become the head of say, a large heath insurance company, you must always be the most complete asshole in the room. If you make it to the top, you must accept that you will forever be known as a complete asshole by all decent people, and even more egregiously, you will be acknowledged as the quintessential asshole by all the other asshole wannabes that surround you, day and night.
August 1st, 2009 at 8:14 am
Re: He received bonuses for every claim he denied. And in his group, there was not a single medical doctor.
I worked at an insurance admin company (we processed claims, etc., but did not underwrite anything ourselves). People certainly did not get bonuses for denying claims! The claims people in fact were allowed to have no more than a two percent error rate. More than that and they were out the door. Denying claims (other than for errors, which just means the claimant should correct the claim and resubmit) creates hassles and at he extreme legal appeals. This costs money and can lead to a state audit and, possibly, fines. As for the precert and authorization process this is done by people with RN degrees, who are medically savvy. We also had a doctor on staff part-time to advise. I would be surprised if it’s any different anywhere else.
August 1st, 2009 at 9:33 am
Thomas writes:
From Matt’s post:
Matt explicitly states that any system is gong to deny certain procedures, and offers a fairly thoughtful discussion of different decision-making processes.
Yes, this is what’s wrong with our politics – conservatives are dishonest idiots.
August 1st, 2009 at 10:38 am
Yes, this is what’s wrong with our politics – conservatives are dishonest idiots.
It’s not just the conservatives – it’s also the dimwitted “libertarians,” cranks, and general fuckwits that whine about the use of government power for anything other than mass murder. Why they think the government is always right when it goes about committing terrorist acts against innocents but couldn’t possibly do the right thing for healthcare is one of those mysterious things that is probably just a side effect of their diseased minds.
August 1st, 2009 at 10:59 am
Re: it’s also the dimwitted “libertarians,” cranks, and general fuckwits that whine about the use of government power for anything other than mass murder.
Libertarians tend to be rather young and inexperenced: they have not yet learned that life is under no obligation to follow the models in the econ 101 textbooks. Thank goodness there’s no “libertarian physics” practiced by engineers designing things according to the Intro to Physics texts or we’d be lurching from one design flaw disaster to the next.
August 1st, 2009 at 9:52 pm
Ah fostert, the old “I have a friend” bit, that’s very helpful. It sounds very sinister and terrible, your third party account of how insurance companies are run and how they deny claims, but it is not accurate. I work in this industry (which I guess in some people’s eyes makes me the enemy and someone to be dismissed, Nancy Pelosi did say I am a villain), and I can tell you that is not how companies deny claims. If there are things not covered by a contract you might have non-medical people making the decision, but in the cases we are talking about it is a medical doctor making the decision on whether the treatment is necessary. I don’t know where you get this $12/hour working the phones nonsense, because those are not the people making these decisions, and yes I can give you plenty of examples of doctors with licenses to practice medicine who work for insurance companies reviewing claims. That you would dispute these most basic facts and make claims that are so ludicrous really disqualifies you from even speaking about this, I really can’t stress enough just how wrong you are about the way the claim denial process works in the health insurance industry.
August 1st, 2009 at 9:57 pm
And I see that JonF already beat me to it, using those tricky things called facts and actual first-hand knowledge to dismiss fostert’s “my friend told me Aetna buys you a Porsche if you can deny chemo for a 5 year old with leukemia, no experience needed!” story.