Only A Public Option Can Make Decisions in Patient's Best Interest

By Maggie Mahar, Health Beat. Posted July 1, 2009.

But, for the sake of argument let’s assume that under health care reform, both private insurers and their shareholders experienced a change of heart. Patients still won’t accept limits imposed by for-profit managed care companies. They don’t trust them. They know that the law says that a corporation must put its shareholders’ interests first. Patients—and doctors—will always suspect that when insurers try to limit the number of services patients receive, they are just trying to save money.  They are not physician organizations. They are not medical ethicists. They are not even elected officials. Put simply, private insurers have neither the scientific expertise nor the moral standing to set the nation’s healthcare priorities.

Should For-Profit Corporations Make Such Important Social Decisions?

Some insurers understand this. “We find ourselves [becoming] private regulators and making public policy by HMO,” Alan Hoops, then chief executive officer of Pacificare told the Los Angeles Times in 1998. “We in the business of constantly passing judgment on the societal value of a given protocol.”  If the insurer agrees to cover more treatments, we all pay for them, in the form of higher premiums. Often the judgments raise questions of medical ethics. “How much reconstructive surgery is truly needed for children with severe facial disfigurement?” the LA Times asked. “Surgeons could simply restore normal functions or do more elaborate, and more costly work that would dramatically improve patients’ lives. ‘Do we reconstruct the entire face or simply improve it?’ asked John Golenski, a medical ethicist and executive director of George Mark Children’s House in San Leandro, California. “How to draw those lines in not clear in any insurance organization I’ve ever worked with.”

The LA Times zeroed in on the central question: “As health care is increasingly dominated by large, publicly traded corporations intent on maximizing profits for shareholders, should insurers be taking the lead on issues of such importance to society? Can the competitive marketplace handle these issues in a way that society will find acceptable?”

Probably not. I can only imagine the headlines if Wellpoint decided thatm  for a child  born with a hole in her face where a nose should be, surgery that ensured that she could breathe easily would be sufficient. Many of us might well feel that federal regulators should insist that private insurers cover full plastic surgery for children born with physical  deformities. Many of us might feel that they should pay for the PSA testing for early-stage prostate cancer that many urologists still recommend—even though there is no evidence that it either saves or prolongs lives. Others might argue that MRI breast scans should be available for average-risk women, even though the reseach reveals that, by detecting "pseudo-disease," the scans do more harm than good.  The list is endless.

Yet, Jaffe is right, we must reduce the volume of health care services we provide. In some cases we can “pay less” for certain drugs, devices and procedures that are over-priced. But we also need to “pay more” for certain vital services such as primary care, chronic disease management, and palliative care.

We need to pay Medicaid providers more. We need to reward hospitals that invest in systems that reduce errors and infections.  We need to fully fund Medicare and Medicaid so that they can ferret out fraud. (One reason Medicare’s administrative costs are so low is because it doesn’t do what it should to find and prosecute healthcare providers who are bilking the system.)

While we pay more for some treatments, we need to eliminate those that are ineffective. We have ample evidence that one-third of our healthcare dollars are squandered on products, procedures and hospitalizations that are exposing patients to risks without benefit. If we want better outcomes, we have to learn to “do less.” We know that more conservative medicine leads to better outcomes. .  

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Maggie Mahar is a fellow at the Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006).

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