So Little, So Late

Article

"Everyone's entitled to free care" does not mean everyone gets everything. Sometimes the incentives are poorly aligned.

In “Too Little Too Late?” posted Monday, May 19, 2008 we discussed CIGNA’s belated reversal of a liver transplant denial (in other words, they really didn't want to pay for that transplant and thier dragging thier feet may have been the proximate cause for Nataline Sarkisyan’s death; she was a 17 year old, 3 year leukemia survivor with a reoccurrence. Without the new liver, the doctors estimated she had only a 35% chance of living 6 months; with it she had a 65% chance to live 6 months--Same difference? Not emotionally!

Some of the comments we received said, blatantly, that CIGNA allowed the patient to die over money. But, did the transplant surgeons at UCLA turn the other way over money, as well?

One person wrote in that “Come the revolution, when insurance companies are mouldering in their graves, and everyone is entitled to free care because they paid for it with their taxes, things may be different.” He later added, “I think FFS Medicare, as an example, generally does a good job deciding what should be covered and what should not. Indeed, ‘Medicare-for-All’ wouldn't be terrible as long its funding mechanism isn't a Ponzi scheme.” Another commentator, however, lamented: “When taxes pay for all this care, the same issues will arise as in England--If you're over 55 years of age, you may die for want of a liver.”

Sometimes the incentives are perverse, Indeed, "everyone's entitled to free care" does not mean everyone gets everything. Sometimes the incentives are poorly aligned: one person reacted “I don't want physicians and hospitals making medical decisions, especially life-sustaining ones, when they have to weigh if it's to their own economic advantage.” And in this context, one may ask what will happen is that the politicians will over promise on benefits, under fund in taxes, and leave the providers stuck in the middle?

Below, some reader responses:

Reggie J.

Date: June 6, 2008 5:06 PM EST

An equal pox on both CIGNA and those physicians. Nevertheless, let's say you're right and the parents sue CIGNA and win big. What next?

We are reaching the point where the Boomer Generation is wearing out, some parts faster than others. Many of us are dying, one part at a time--a knee, hip or organ here, there. What's the big deal? Can't all of our livers, lungs, kidneys, hearts be replaced? Unless we 'buy the farm' fast it pretty much is a sure thing that, for most of us, we're not going to live pain-free forever. Is there a different protocol for deciding about catastrophic surgery for a 17 year old verses someone 55? How about 75? What's an acceptable probability for cure, survival, or amelioration for any condition or procedure? I'm not taking the side of insurance companies, but there's a lot that needs clarification here. Any other legitimate business would have the right to cut its losses, but apparently not insurers. We don't have consensus on what is a good risk-is it based on living a healthy lifestyle (i.e., not making adverse lifestyle choices)? Having good insurance or money in the bank? Who you know? If society can only raise so much in taxes, what draconian measure will be required to cut health care costs--rationing?

So again who pays? Even if your revolution comes, the taxpayers will be our children and grandchildren and who will be paying for their heath needs, especially if we use up those tax dollars faster then they accumulate?

Whether we see one government (single) payer or one conglomerate of private insurers, what will those contracts include in the future?

Will major organ transplants continue to be covered, or will we begin to see exclusions? Will there be life time caps or caps per episode of care?

From: Harvey (MD, PhD, JD)

Date: June 6, 2008 5:41 PM EST

As now, I expect there would be different levels of coverage. "Ya pays yer money and takes yer choices."

I see nothing absurd in a society in which the majority of its assets are devoted to preserving the population in hearty health, as opposed to the one we have now, where most assets are devoted to fast cars, fancy electronics, mindless entertainment, and making war. Further, rational, universal health care seems to work pretty well in many European countries, so it's hardly a pipe-dream.

Getting back to the 17 year-old, I'm still waiting to hear HOW CIGNA was in a better position to make a decision about a transplant than the doctors on the case.

My response: Although you have both a medical and a law degree, I think you are speaking more as a lawyer than as a physician: It's not about the greater competency of the UCLA transplant surgeon over the HMO bean counters (as absurd as that sounds); nor is it about medical directors practicing medicine in their role as administrators. The patient was in a persistently vegetative state and apparently very debilitated, otherwise one would assume they, not just the protestors outside their buildings, would have been fighting for an immediate transplant. That is, doing a transplant in a very weakened condition might reasonably be called "experimental."

Was a transplant ever appropriate and if so, did they delay for business or for medical reasons?

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