Cost Containment

(Also see Oregon and Health Care Reform)

“Insulin’s steep price leads to deadly rationing”
(Modern Healthcare — September 10, 2018)
Diabetic ketoacidosis is a terrible way to die.  It’s what happens when you don’t have enough insulin….Nicole Smith-Holt lost her son to diabetic ketoacidosis three days before his payday, because he couldn’t afford his insulin.

“How a push to cut costs and boost profits at surgery centers led to a trail of death”
(USA Today — March 2, 2018)
“The surgery went fine.  Her doctors left for the day… By the time an ambulance delivered Tam to the emergency room the 58-yearold mother of three was lifeless….Dr. Nancy Epstein, chief of neurosurgical and spine care at New York University Winthrop Hospital, said surgery centers doing delicate work near the spinal cord, windpipe and esophagus in a same-day procedure is ‘pretty revolting.’ But she said the centers are making so much money — ‘reeling it in hand over fist’ that the potential dangers are being ignored.        ………..

Preauthorization — What does it mean?
“Preauthorization” — sometimes called “prior authorization” — is a decision by a health care insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.  Your health insurance or plan may require preauthorization before you can receive them.
When presenting a program about new advances in treating heart failure, a physician found the answer.

“Who Actually Is Reviewing All Those Preauthorization Requests?”
(Medpage Today — November 8, 2017)
Nearly all of the physicians in attendance were in their 70s and 80s.  All were retired, and none were actively involved in patient care.  Most of the attendees were employed by insurance companies to do preauthorizations for drugs and medical procedures.
The presenter asked if they had heard of the new treatments before.  They responded that they had but that they did not authorize them.
When asked, “If the drugs will help people, how can you say no?” they responded:
“You see, if it weren’t for us, the system would go broke.  Every time we say yes,
healthcare becomes more expensive, and that isn’t a good thing. …  Plus, if I
approve too many expensive drugs, I won’t get my bonus at the end of the month.”

“How the Medicaid Debate Affects Long-Term Care Insurance Decisions”
(New York Times — July 14, 2017)
Susan Flanders, a retired Episcopal priest who watched her father die slowly while in the throes of Alzheimer’s, believes that the aid-in-dying movement will eventually catch up to the desire of many people to make plans in advance to end their lives, should their minds permanently falter in a severe fashion.
She’s also utterly unafraid to mix money into the conversation…”It’s hundreds of dollars each day that could go towards their grandchildren’s education or care for people who could get well…”. How soon will the federal and state governments come around….

“Abusing assisted suicide laws”
(Washington Times — June 7, 2017)
With the passage of assisted-suicide laws, there are new reports that health insurance companies are refusing to cover lifesaving medical care and are offering to pay patients to kill themselves instead…..Allowing insurance company bureaucrats to overrule how a doctor will treat a patient at any point is absurd, but in an age when some states are legalizing assisted suicide, it can be downright deadly.

“Cost analysis of medical assistance in dying in Canada”
(Canadian Medical Association Journal — January 23, 2017)
Medical assistance in dying could reduce annual health care spending across Canada by between $34.7 million and $138.8 million…
[Note: It’s hardly surprising that ending patients’ lives, rather than providing them with health care, saves money.]
More on Canada

“Assisted-suicide law prompts insurance company to deny coverage to terminally ill California woman”
(Washington Times — October 20, 2016)
[Stephanie Packer] said she called her insurance company to find out why her coverage had been denied.  On the call, she also asked whether suicide pills were covered under her plan. “And she says, ‘Yes, we do provide that to our patients, and you would only have to pay $1.20 for the medication,'” Ms. Packer said.
More on California

Comments from the past:
“[I]n the final analysis, economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable practice.”
(Derek Humphry and Mary Clement, Freedom to Die, St. Martin’s Press (New York, 1998), page 313).  Humphry is the co-founder of the Hemlock Society, now known as Compassion & Choices.

In 2008, then candidate Barack Obama was asked what he thought of Oregon’s assisted-suicide law.  He responded, “I’m mindful of the legitimate interests of states to prevent a slide from palliative treatments into euthanasia. On the other hand, I think that the people of Oregon did a service for the country in recognizing that as the population gets older we’ve got to think about issues of end-of-life care.”
(Source: Mail Tribune, Medford, Oregon — March 23, 2008)



“Assisted-suicide law prompts insurance company to deny coverage to terminally ill California woman”
(Washington Times — October 20, 2016)
[Stephanie Packer] said she called her insurance company to find out why her coverage had been denied.  On the call, she also asked whether suicide pills were covered under her plan. “And she says, ‘Yes, we do provide that to our patients, and you would only have to pay $1.20 for the medication,'” Ms. Packer said.
More on California

Who’s really hurt by assisted suicide?
(Source:  CNN — November 4, 2014)
The idea of mixing a cost-cutting “treatment” such as assisted suicide into a broken, cost-conscious health care system that’s poorly designed to meet dying patients’ needs is dangerous to the thousands of people whose health care costs the most — mainly people living with a disability, the elderly and chronically ill….When you look at assisted suicide based on one individual, it often looks acceptable. But when you examine how legalization affects the vast majority of us — especially the most vulnerable — the dangers to the many far outweigh any alleged benefits to a few.

“Blumenauer Pushes for End-of-Life Conversations Again”
(Oregon Publish Broadcasting — October 22, 2014)
Congressman Earl Blumenauer is working to try to allow doctors to bill health insurance companies for end-of-life conversations….Blumenauer is pushing the Obama administration to include his bill in its rulemaking authority, due out by the end of the month.  He tried to include similar legislation in the Affordable Care Act, but it was taken out after a furor erupted over so-called “death panels.”
[Note:  Blumenauer is a strong supported of Oregon’s assisted suicide law.]

“Dr. Emanuel’s resolve to die at 75 is no prescription for rest of us”
(Salem News — October 12, 2014)
He is one of the chief architects of Obamacare….He warns of a “tsunami of dementia” among elders still taking up expensive space beyond their sell-by date…. It is important to note that this is the way fundamental and sometimes transformational shifts in societies begin — with an engaging “conversation” that seeks to mask the endgame. …What does he think will happen if America’s leaders adopt his thinking, that health care past age 75 is a waste of the country’s resources”
More on Obamacare

“Coverage for End-of-Life Talks Gaining Ground”
(New York Times — August 30, 2014)
Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 60 million Americans on medicare as early as next year.

“Operator? Business, Insurer Take On End-of-Life Issues by Phone”
(Source: Kaiser Health News — August 27, 2014)
Imagine you’re at home….You have cancer. You just had another round of chemo, and the phone rings.  “My name is Kate, I’m a health care counselor.”  After sending a letter, counselors essentially cold-call to offer what they describe as “nondirected” end-of-life counseling….It is paid for by insurers and federal privacy rules permit this for business purposes.

“You’re on the clock: Doctors rush patients out the door”
(USA Today — April 20, 2014)
“Doctors have one eye on the patient, and one eye on the clock,” said David Rothman, who studies the history of medicine at Columbia University’s College of Physicians and Surgeons….No one knows exactly why 15 minutes became the norm….”  “We’re all sort of like lemmings,” Lickerman said. [Alex Lickerman is an internist who has taught medical students at the University of Chicago.] “We’ve seen that everyone else is doing it so it must be the right thing to do.”

“Cost of Treatment May Influence Doctors”
(New York Times — April 17, 2014)
In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing…..They [the cardiology societies] plan to rate the value of treatments based on cost per quality-adjusted life-year, or QALY– a method used in Britain and by many health economists.

“Mark Halperin’s epic fail: Actually, nuclear option will save Medicare”
(Salon — November 27, 2013)
“We do need to do some of that [rationing] in this country because we can’t afford to spend so much on end-of-life care,” Halperin said.
Halperin got into a little bit of trouble Tuesday, because his comments inadvertently confirmed the premise of a question about the coming “death panels.”

“Assisted suicide fraught with consequences”
(Source: Sacramento Bee — July 14, 2013)
Cost is always a concern. As the health care industry evolves, cost of care is becoming an increasingly prominent decision point, which in turn prompts more attempts by cost-minded administrators and HMOs to cut these costs however they can.

“Care home boss: let people choose how to die”
(The Telegraph — July 9, 2013)
The documents should also encompass how, where and when a patient wants to die… This could eventually lead to clinics like Dignitas operating in Switzerland to end their life, Dr. Chai Patel said. Dr. Patel said the argument for the right to die should come strictly from an “ethical and human perspective” but acknowledged that it could also have a financial impact.

“How Much For An MRI?”
A health care reporter tires to solve the mystery of her migraines with a doctor-recommended imaging test but trying to find out the real cost of that test induces headaches of its own.
(Kaiser Health News — December 9, 2012)

“NPR Audience Wants End of Life Care Rationed for the Elderly”
(Source: National Review — October 18, 2012)
Recently, NPR held a debate with utilitarian philosopher Peter Singer and an ER doctor named Arthur Kellerman arguing yes, and Christian lawyer Ken Connor and head of Pacific Research Institute Sally Pipes, arguing no.
First, note the stacked question to be debated:
“Yes or no to this statement: End-of-life care, we can’t afford to keep every elderly person alive, so we’re going to have to ration it.”

“Death panels on steroids”
(Daily Caller — July 25, 2012)
If you want to see what direction health care is going, just read the July 12 issue of the New England Journal of Medicine….[T]he patient should be able to pick up the lethal drugs from a government-authorized, all-purpose location where a government bureaucrat would determine the patient’s eligibility for a death prescription…..Do we really think that a government that is constantly looking for ways to contain health care costs will be likely to deny death eligibility? Do we think that government death-control officials will do the right thing– or the cheap thing?

“It’s expensive to support the disabled — suicide kits are $39.95”
(Winnepeg Free Press — July 21, 2012)
Arthur Schafer’s portrayal of comments on the merits of physician-assisted need challenging….Schafer, like many supports of physician-assisted suicide (also known as “doctor-prescribed death”), does not seem to have considered the wider issues facing Canadians with disabilities.

“Oregon awarded $1.9 billion federal funding pact, new flexibility for health care reforms”
(Oregonian — July 9, 2012)
The federal government has formally approved reforms to the Oregon Health Plan…State officials today announced that the federal Health and Human Services has granted more flexibility by amending a waiver for Oregon’s transformation initiative, intended to cut costs….

“The Coming Medical Ethics Crisis”
(Source: Reason — March 15, 2012)
For the past several yeaars, the medical profession has been undergoing a disturbing transformation. The process was begun by the Centers for Medicare and Medicaid Services (CMS) in an effort to control exploding Medicare costs, and was accelerated by the passage of the Patient Protection and Affordable Care Act of 2010.  As a surgeon in practice for over 30 years, I have witnessed this transformation firsthand.  I fear that my profession will soon abandon its traditional code of ethics and adopt one more suited to veterinarians.

“Aging Out of Health Care”
(Chicago Tribune — November 30, 2011)
Bioethicists Daniel Callahan and Sherwin Nuland say the amount of money spent on Medicare is unsustainable. With senior citizens the fastest growing age group in the country, they say the only way to control the ballooning costs is to try to bring the entire population up to a life expectancy of 80 and stop using most expensive technologies and medicines to extend life beyond that, even if some people will die.

“More states limiting Medicaid hospital stays”
(USA Today — October 24, 2011)
Some to cut Medicaid coverage to 10 days.
A growing number of states are sharply limiting hospital stays under Medicaid to as few as 10 days a year to control rising costs of the health insurance program for the poor and disabled.

“Death and Budgets”
(New York Times — July 14, 2011)
Dudley Clendinen has concluded that “When the music stops, when I can’t tie my bow tie, tell a funny story…I’ll know that Life is over. It’s time to be gone.”
Obviously, we are never going to cut off Alzheimer’s patients and leave them out on a hillside. We are never coercively going to give up on the old and ailing. But it is hard to see us reducing health care inflation seriously unless people and their families are willing to do what Clenendin is going — confront death and their obligations to the living.

 Assisted Suicide and Cost Containment

by Rita L. Marker

Of all public controversies in recent years, assisted suicide is perhaps the one that is surrounded by the greatest degree of misunderstanding. For example, one often hears it referred to as the “right to die.” Yet assisted suicide has nothing to do with letting someone die. Neither the law nor medical ethics requires that a person be kept alive by being subjected to unwanted medical treatment.

Furthermore, the debate isn’t about the tragic personal act of suicide. Nor is it about attempted suicide. Neither suicide nor attempted suicide is considered a criminal act.

Instead, the current debate is over whether public policy should be changed in a way that will transform prescriptions for poison into “medical treatment.”

Oregon is the only place in the world with a specific law permitting assisted suicide. (Although widely practiced in the Netherlands, euthanasia and assisted suicide remain technically illegal there.) Unfortunately there is no way to know of abuses, or even the number of deaths, occurring under the Oregon law since failure to adhere to its reporting requirements is not penalized.

But we do know that, in Oregon, a doctor can write a prescription for drugs that are intended to kill the patient. When the prescription is filled, the pharmacist doesn’t give the usual instructions about how to safely take it. Instead, a patient is more likely to hear, “Be sure to take all of these pills at one time — with a light snack or alcohol — to induce death.” Directions center around making certain that the patient dies after taking the prescription.

The lethal drugs are covered by some Oregon health insurance plans. They are paid for by the state Medicaid program under a funding category called “comfort care.” (This certainly gives meaning to the statement, “All social engineering is preceded by verbal engineering.”)

Even though Oregon stands alone in approving such “comfort care,” there is a full court press to expand its legalization to every state. Already Hawaii’s governor has vowed to propose legalization of both euthanasia and assisted suicide. A court challenge to Alaska’s law prohibiting assisted suicide has been filed. Attempts to place the issue on the ballot have begun in several states. And, in virtually every state, there is a lawmaker who is drafting an assisted suicide proposal.

Assisted suicide activists expect many of these efforts to fail initially but count on their providing the opportunity for publicity. This publicity follows a rarely altered pattern.

First, a “hard case” is spotlighted. This is accompanied by the assertion that assisted suicide was a necessary last resort. Assurances are made that the method and timing of death were freely chosen by the person (who is, conveniently, dead and thus unable to refute these claims). Finally, accusations are made that anyone who dares raise questions about such a demise lacks compassion and merely wants to force others to suffer.

It should be noted that many advocates of assisted suicide seriously believe that what they’re proposing is a compassionate choice that should be available. However, despite their sincerity and good intent, it is the content, not the intent, of the policies and laws they espouse that will ultimately affect each and every person.

Whether other states embrace Oregon-style “comfort care” will depend upon a willingness to carefully examine what is truly at stake in this debate. This is, above all, a debate over public policy.

No matter what one’s views may be about the concept of assisted suicide, it’s necessary to reflect on the context in which it would be carried out. This reflection necessarily includes consideration of contemporary economic forces affecting health care.

As acting solicitor general Walter Dellinger said during his 1997 argument against assisted suicide before the U.S. Supreme Court, “The least costly treatment for any illness is lethal medication.”

He was, of course, correct. A prescription for a deadly overdose runs about $35. Once taken, the patient won’t consume any more health care dollars.

Cost containment could well become the engine that pulls the legislative train along the track to death on demand. Those who advocate dismantling the barriers that now protect patients from assisted suicide recognize the power of cost containment. For example, Hemlock Society co-founder Derek Humphry recently explained his belief that, in the final analysis, economics will drive assisted suicide to the plateau of acceptable practice.

There’s no question that economic considerations have always played a role in decisions about health care.

Most of us can recall a time not long ago when patients were routinely subjected to unneeded tests and treatments. And we know now that money fueled these abuses. Then, health providers were reimbursed for everything they did to or for a patient.

Fortunately, patients and families became more aware of their rights to reject unwanted and unnecessary interventions. But the end to overtreatment didn’t stem primarily from a respect for patients’ rights. Instead, it grew out of changes in the way health care is reimbursed.

No longer do doctors and hospitals get paid for all they do. Instead their incomes often depend upon how little they provide. And now, not surprisingly, the pendulum has swung to the other extreme where more and more people (insured and uninsured alike) find it difficult, if not impossible, to get needed and wanted health care. Again, the fuel for change is money. The catalyst has been managed care.

Managed care has dominated health care delivery is recent years. A significant number of health maintenance organizations (HMOs) are “for-profit” enterprises where stockholder benefit, not patient well-being, is the bottom line. Gatekeepers operate to protect resources by delaying or denying authorization for services.

Some programs have what are called “gag rules” which prohibit doctors from telling patients the whole truth about interventions that might be helpful. The stark words, “There’s nothing that can be done” may really mean, “There’s nothing more we’ll pay for.” But patients may not know that.

Imagine the patient who is in pain and is given the “nothing can be done” routine. Pain control is definitely given short shrift by many health plans. Some plans don’t provide coverage for chronic pain except in very limited circumstances. Others put an unreasonably low cap on the amount paid for hospice care. (One Oregon insurer limits payment for hospice care to a $1000 maximum.)

Navigating the murky health insurance waters — of services not covered, services not approved and the complex methods of co-payments — is particularly difficult for patients who are seriously ill and/or in pain. They have precious little energy to deal with a system that seems impenetrable.

Few people pay much attention to the particulars of their health insurance coverage until they are ill. By then it may be too late.

Assisted suicide advocates assure us that a physician would only prescribe the lethal overdose after careful discussion with the patient.

To make this assertion represents the height of naiveté, if not disingenuousness. It’s a presumption made by those relatively few people who have the luxury of a personal family physician who may also be a golfing or bridge partner. Having a physician friend who would talk over a planned assisted suicide before prescribing a lethal dose is nothing more than a fantasy for the vast majority of Americans.

Today most people are fortunate if they see the same doctor from visit to visit and, even when they do, time constraints exist.

For example, some managed care programs expect physicians to limit new patient visits to 20 minutes and are told to devote no more than 10 minutes to a returning patient.

Do we really believe that health plans that now limit doctors’ time in this manner would let doctors spend hours discussing the pros and cons of assisted suicide before prescribing the fatal overdose?

Conflicts of interest also should be recognized. An obvious concern is the possibility that a physician could persuasively “offer” the option of assisted suicide to a patient whom the physician knows may pose the threat of a malpractice case. But there are more subtle, more likely, types of competing interests between physicians and patients.

For instance, some health programs provide financial bonuses to doctors who conserve economic resources by withholding time or care from patients. It’s reasonable to point out that this has the potential for conflict of interest between patients and physicians.

Add to this the results of a survey published in 1998 in the Archives of Internal Medicine. It found that doctors who are the most “thrifty” when it comes to medical expenses would be six times more likely than their counterparts to provide a lethal prescription. These same doctors would be diagnosing, screening and counseling patients — and prescribing lethal drugs for assisted suicide.

Even in light of such concerns, activists favoring assisted suicide contend that the choice of assisted suicide should be available.

Choice is meaningless, however, if there is only one affordable option. True, advocates of assisted suicide insist that every person , prior to receiving assisted suicide, would be offered all options. This appears protective. But there is a vast difference between anoffer of something and the ability to accept that offer.

This difference was acknowledged at a conference where assisted suicide guidelines, drafted by a San Francisco ethics committee, were under discussion. The guidelines stated that physicians had to offer palliative care (pain and symptom management) to patients before providing assisted suicide. However, when asked if there was also a mandate that patients have actual access to this care before being given a lethal prescription, the ethics committee spokesperson replied that there was no such requirement.

Thus the offer of all options is grossly misleading. It creates the illusion that all options would be available to people when, in fact, they would not. In theory, offering the choices between unaffordable palliative care and an affordable drug overdose is one thing. In practice, it takes little imagination to figure out which “choice” is really available.

As attorney and consumer advocate Wesley Smith has said, “The last people to receive medical care will be the first to receive assisted suicide.”

If we embrace assisted suicide as medical treatment, it will return our embrace — with a death grip that is cold, cruel and anything but compassionate.

Rita L. Marker is an attorney and executive director of the Patients Rights Council. She is the author of Deadly Compassion (William Morrow and Co., 1993).

This article first appeared in Insight magazine (March 8, 1999).