Tuesday, September 8, 2009
The Serious Medicine Test: The Challenges To Health Insurance--And The Promise of Serious Medicine
"I've got a question for all those folks: What are you going to do? What's your answer? What's your solution?"--That was Barack Obama, speaking yesterday at a Labor Day rally in Cincinnati.
The story was right there on the front page of The Washington Post, and perhaps that's as it should be, even if Obama didn't really say anything new. But in the meantime, it's a shame that a story about the Serious Medicine that saved the life of a little girl is consigned to page E1 of the same edition of The Washington Post, tucked away in the low-profile "Health" section. It's a strange commentary on our priorities that non-news "news" of "health care policy" politicking is seen as more important than lessons about saving lives.
But okay, politics first. Obama asked some questions that are on the public's mind: "What are you going to do? What's your answer? What's your solution?" he said to Obamacare opponents.
Obama doesn't seem to have a very satisfactory answer of his own, but his opponents will need a better answer than defending the sorts of private-sector practices--insurance company rescissions--also headlined on the front page of The Washington Post this morning.
The WaPo header was tough: "When Your Insurer Says You're No Longer Covered/Firms Defend 'Rescissions' as Fraud Control" And while anecdotes--folks losing their coverage on what would seem to be flimsy, even fraudulent, rationales--can be minimized, it's harder to minimize reams of data that make the same point. For example, these data are in Karl Vick's WP story:
In the past 18 months, California's five largest insurers paid almost $19 million in fines for marooning policyholders who had fallen ill. That includes a $1 million fine against Health Net, which admitted offering bonuses to employees for finding reasons to cancel policies, according to company documents released in court.
"This is probably the most egregious of examples of health insurers using their power and their resources to deny benefits to people who are most in need of care," said Gerald Kominski, associate director of the Center for Health Policy Research at the University of California at Los Angeles. "It's really a horrendous activity on the part of the insurers."
In their defense, the insurance companies argue that they are merely fighting fraud, which by some estimates totals $100 billion a year. But surely there's a better way to fight fraud--better than leaving sick people high and dry and bankrupt.
The even larger policy issue, however, is the fate of the private insurance market. As more people stay out of the insurance pool--especially the young and healthy, who don't think that they need coverage--the people left in the pool will tend to be older and less healthy. That is to say, much more expensive to cover. And so from a purely business point of view, the insurance companies have to look for ways to cut expenditures. And what better way to cut expenditures than simply booting policy holders who file expensive claims?
OK, it's not nice, not ethical, and probably not even legal, but business has to survive. Right? The private insurers are making plenty of money right now, but the business model is in something of a death spiral, as customers game the system, and companies game the customers right back, using computers and data-mining--and plain old ruthlessness--to eliminate "cost centers." If present trends continue, health insurance companies will be doing something else in the future.
But the political consequences of the rescission issue will be drastic: Even Republicans, skeptical of state power as they are, are moving toward various kinds of plans that call for forcing insurance companies to sell insurance to everyone, or to create a special tax-subsidized pool for costly customers. (And, we can presume,forcing the insurance companies to pay claims, although the definition of "pay" will no doubt be lobbied and litigated ad infinitum.)
Yet one might step back from all this political to-ing and fro-ing, important as it is, and ask "What about medicine? And cures? And life?
It's important that we keep in mind the real purpose of medicine--healing people. And so another article in the Washington Post this morning commands our attention, starting with the headline: "A Frightful Week for A Little Girl." As Sandra G. Boodman describes it, 4-year old Brooke Dawn was feverish and in severe pain; she was soon hospitalized. Doctors at first thought it was an infection of some sort, and were treating her accordingly--and wrongly.
But eventually they realized that Brooke was suffering from Kawasaki Disease, an inflammation of the blood vessels. As Boodman explains, it took Serious Medicine to solve this problem:
There is a narrow window for treatment to prevent cardiac complications -- within 10 days of the initial illness -- and eight days had already elapsed. Doctors began intravenously administering a blood product called IVIG, which has been shown to reduce heart attacks, coronary aneurysms and sudden death in Kawasaki patients. Without treatment, the disease may disappear on its own, but 25 percent of its victims will eventually suffer sometimes fatal heart attacks and aneurysms, often in adolescence.
Named after the Japanese physician Tomisaku Kawasaki, who first described it in 1967, Kawasaki disease is a severe inflammation of the blood vessels; its cause is unclear. It is most common among children of Asian, especially Japanese, ancestry; more than 2,000 cases are diagnosed annually in the United States. Among them was John Travolta's 16-year-old son, Jett, who died last year after suffering a seizure; he had received a Kawasaki diagnosis as a toddler.
So in addition to the doctors who made the correct diagnosis, the hero of this story would appear to be the drug IVIG. That's intravenous immunoglobulin, and for people suffering from a wide variety of illnesses--not just Kawasaki, but also dermato/polymyositis, idiopathic thrombocytopenic purpura (ITP), Guillain-Barre syndrome, polyneuropathy, some viral diseases, and some forms of immune deficiency--it's a life-saver.
IVIG is Serious Medicine. Fortunately for us, there are at least 10 different brands of IVIG on the market. None of them are inexpensive, and to the extent that they have become less expensive than they once were, that's because mass production and improved efficiencies have brought the cost down so that many more can be healed. (And yes, there are legal/patent issues, too, but nothing can go off patent until it is first patented--there's no way around spending money somewhere along the chain.)
So let's take stock here. The politicians are arguing about health insurance. Meanwhile doctors are using Serious Medicine to save lives. Both activities have their place, but which should have a higher place?
So a useful question for Serious Medicine Strategists might be, "Will the new health care plan--any of them, from either party--make it more or less likely that more Serious Medicine will come into existence and be made available?"
We can call that the Serious Medicine Test. And it should be a critical question for anyone who worries about illness and incapacitation and death.
Posted by James P. Pinkerton at 8:26 AM