Sunday, October 25, 2009

Oregon Offers Terminal Patients Doctor-Assisted Suicide Instead of Medical Care

In July of 2009, RedState put up a story about Randy Stroup, a 53-year-old man with metastatic prostate cancer who applied to Oregon’s government-run Health Plan to pay for his treatment. The Plan refused to pay for the treatment but offered to pay for physician-assisted suicide. This, RedState tells us, is a look at “The Future in ... Barack Obama’s America”.

Well, not exactly. The RedState article lacked some important context. First, it did not explain that Oregon refused to pay for Mr. Stroup’s chemotherapy because:

Oregon doesn't cover life-prolonging treatment unless there is better than a 5 percent chance it will help the patients live for five more years

Back in the early 90s the State of Oregon established a tax-funded health plan to help the uninsured. This State health plan was intended to work within an established and limited budget while providing health care to as many needy people as possible. In order to do this the State figured out how much of the taxpayers’ money it was willing to spend on health care for the poor and uninsured. It then produced a list of treatments ordered by effectiveness. It determined how much each treatment would cost and estimated how many of each treatment it would have to provide. It calculated an extended price for each treatment on the ordered list, kept a running total, and drew a line when the total equaled the amount of money it had to spend. Everything above the list would be covered; everything below would not. It’s not clear that this approach succeeded: political pressures seem to have resulted in a rather small list of disallowed procedures and made the attempt to live within a set budget ineffective. One restriction that does survive is that the Oregon Health Plan will not pay for cancer treatment when there is less than 5% five-year survival rate. This is why Mr. Stroup’s treatment was not covered. (pdf; Prioritized List of Health Services, pp. 17-61)

There is another point about Mr. Stroup’s experience that was not made clear at RedState or at the Fox story RedState linked. The Oregon Health Plan does not offer terminally ill patients a choice between no medical care and State-paid physician-assisted suicide. Rather it offers terminally ill patients “comfort/palliative care” and - despite the title of my post (taken from the Fox story) - comfort/palliative care is medical care. Specifically, here’s what comfort and palliative care means under the Oregon Health Plan (same pdf; see page 93):


It is the intent of the Commission that comfort/palliative care treatments for patients with an illness with <5% expected 5 year survival be a covered service. Comfort/palliative care includes the provision of services or items that give comfort to and/or relieve symptoms for such patients. There is no intent to limit comfort/palliative care services according to the expected length of life (e.g., six months) for such patients, except as specified by Oregon Administrative Rules.

It is the intent of the Commission to not cover diagnostic or curative care for the primary illness or care focused on active treatment of the primary illness which are intended to prolong life or alter disease progression for patients with <5% expected 5 year survival.

Examples of comfort/palliative care include:
1) Medication for symptom control and/or pain relief;
2) In-home, day care services, and hospice services as defined by DMAP;
3) Medical equipment (such as wheelchairs or walkers) determined to be medically appropriate for completion of basic activities of daily living;
4) Medical supplies (such as bandages and catheters) determined to be medically appropriate for management of symptomatic complications or as required for symptom control; and
5) Services under ORS 127.800-127.897 (Oregon Death with Dignity Act), to include but not be limited to the attending physician visits, consulting physician confirmation, mental health evaluation and counseling, and prescription medications.

Examples of services which are not intended to be covered as comfort/palliative care include:
1) Chemotherapy or surgical interventions with the primary intent to prolong life or alter disease progression; and
2) Medical equipment or supplies which will not benefit the patient for a reasonable length of time.

Physician-assisted suicide is legal in Oregon and the State’s Health Plan offers it as one of a range of palliative options. Personally, I think legalizing physician-assisted suicide is a terrible idea; Ezekiel Emanuel’s 1997 Atlantic article makes the dangers inherent in such a policy quite clear. However the voters in Oregon have decided they want terminally ill people to have that option and since it is legal it is offered as one of the comfort and palliative care options. It is not, however, the only care option available to Mr. Stroup under Oregon’s Health Plan. The Plan is also willing to pay for Mr. Stroup to enter a hospice when his disease becomes more serious. If he prefers to die at home the Oregon Health Plan will pay for him to receive hospice care at home. The Plan will pay for him to receive pain medications. If he needs a wheelchair the Plan will pay for that. Mr. Stroup can choose from the full range of medical care usually consider comfort/palliative care.

The Oregon Health Plan is attempting to conserve a scarce resource: tax dollars available to fund health care for the poor and uninsured. The government of Oregon realizes that if agrees to pay for very expensive treatments with very little chance of success it will have to do one of two things: provide care to fewer poor and uninsured people or raise more money for the Health Plan through higher taxes. By focusing on physician-assisted suicide and failing to consider the broader offer of palliative care, the RedState story insures that anyone who reads Mr. Stroup’s story will insist the State should have paid for Mr. Stroup’s chemotherapy - and that their failure to do so is a condemnation of government-run health insurance.

Yet this formulation obscures the issue that is really at the heart of this story: are we willing to spend whatever amount of money it takes to make sure that everyone gets every possible treatment? Surely there must be cases like this under government programs where physician-assisted suicide is not an option, where the government has refused to pay for an expensive treatment that is likely to prove futile while offering to pay for all necessary comfort and palliative care. If we remove the option of physician-assisted suicide from our thinking, are we still prepared to argue that the government should have paid for Mr. Stroup’s chemotherapy? Are we prepared to argue that so long as there is any chance whatsoever that a treatment might save someone - or might prolong his life for a few months or might make his last few months more comfortable - we will pay whatever amount of money is required to provide him with that treatment?

If our answer is “Yes” then must understand what that means: higher taxes for all of us. If we are not willing to write a blank check for a government-run insurance plan then we need rules that tell the government how much we’re willing to spend and how we want that spending allocated. The Oregon Health Plan was designed to have a limited budget and allocates spending by covering some treatments and not others. If you flinch from this and believe everyone like Mr. Stroup should be given every possible treatment then we’re back to unlimited spending on health care and higher taxes. There is no magical third option.

Yes, you say, that’s a problem with government-run health insurance; people with private insurance don’t encounter the same problem.* Actually people with private insurance encounter exactly the same problem. In as nice a bit of sleight of hand as I’ve seen lately, ABC managed to report on the physician-assisted suicide issue in Oregon and turn it into a condemnation of insurance companies.

The ABC story begins with Barbara Wagner who also had metastatic cancer and who also was denied treatment by the Oregon Health Plan due to her poor prognosis. It took ABC eleven paragraphs of references to Ms. Wagner’s “insurance company” before it explained that the “insurance company” was actually “state-run”. After presenting Ms. Wagner’s case; briefly mentioning Mr. Stroup’s case; discussing the (undeniably) incredibly insensitive letter the Oregon Health Plan uses to deny care to the terminally ill**; and warning of the dangers of physician-assisted suicide in a cost-cutting setting, ABC goes on to discuss an executive who is fighting his insurance company to force them to pay for Sutent to treat his liver cancer. The executive is no different from Mr. Stroup except that the executive has a private insurer instead of a government one. But the private insurer faces the same dilemma as Oregon’s State-run Health Plan: the more extremely expensive treatments it covers the more premiums are going to rise. This will mean some people who could have afforded health insurance are not going to be able to do so and will become uninsured and -presumably - receive worse care. Just as is the case with Oregon’s government-run Health Plan, paying for every costly treatment available means either higher costs for everyone or fewer people covered or both.

The ABC story contains two quotes that make it clear people are unable or unwilling to see this reality. The first quote comes from the executive who wants his private insurance company to pay for Sutent:

Most of my objections are that some second rate guy on the staff of the insurance company is second-guessing one of the foremost authorities and trumping his judgment[.]

I’m pretty sure the guy on on the staff of the insurance company isn’t second-guessing the executive’s doctor’s medical judgment. I imagine that guy - whatever rate he is - believes absolutely what the executive’s foremost authority is saying: Sutent will cost $54,000 and might - might - extend the executive’s life by six months. However the insurance company guy also knows two other things: paying for Sutent was not something the insurance company included in its calculations when it set the executive’s premiums and if it starts paying for Sutent - and other drugs like Sutent - premiums are going to have to go up for everyone. It’s not the facts about what the drug might do that are in question; it’s whether the drug is worth the money it will cost. Understandably it’s worth any amount of money to the executive; if he had the money to pay for it himself he would. Equally understandably it’s not worth what it costs to the insurance company - and it may not be worth what it costs to the insurance company’s other policyholders.

The other quote that demonstrates an unwillingness to face the reality of the connection between more care and more money is this:

"[Ms. Wagner’s] case is hardly unique," said Michigan lawyer Geoffrey Fieger, who defended Dr. Jack Kevorkian's crusade to legalize physician-assisted deaths. "In the rest of the country insurance companies are making these decisions and are not paying for suicide," Fieger told "Involuntary choices are foisted on people all the time by virtue of denials."

"I am surprised there hasn't been a revolt in this country," he said. "It happens every day and people are helpless."

Let’s give Fieger the benefit of the doubt and assume he’s not suggesting revolt because insurance companies won’t pay for suicide. Then we have to ask: what would be the goal of his revolt? To force insurance companies to pay for every possible treatment? That doesn’t require a revolt; it just requires that subscribers be willing to pay higher premiums. To turn health insurance over to the government? That would simply transfer the problem from insurance companies denying treatment to the government denying treatment. And if we aren’t happy with that then we can force the government to pay for every possible treatment - so long as we’re willing to pay higher taxes instead of higher premiums. A revolt is not going to change the fact that if you want more care you have to pay more for it.

Like the dilemma of pre-existing conditions the conflict between our desire for all possible care and our desire to not bankrupt ourselves paying for it is a conflict inherent in the nature of health insurance. It is not an issue that arises only with private insurance companies or only with government-run health insurance. If we want private insurance and all possible care then we have to be prepared to pay higher premiums. If we want government health insurance and all possible care then we have to be prepared to pay higher taxes. If we’re not willing to pay higher sums to either private insurers or the government then we have to accept that someone, somewhere is going to have the power to decide that the treatment your doctor tells you might prolong your life, tells you might - if combined with a miracle - save your life, is simply not worth the money to your fellow taxpayers or your fellow subscribers.

I understand that most people want every possible chance at every possible moment of life. I stood where Ms. Wagner, Mr. Stroup, and that unnamed executive stood. My doctors went to bat for me and my private insurance company paid for me to get that less than 5% chance. That was ten years ago which means I got very, very lucky. If we as taxpayers or we as premium payers decide that we want everyone to have the chance I had, that’s our decision to make. But we have to realize the cost. And we have to stop kidding ourselves that if only we had private insurance instead of government-run or government-run insurance instead of private, the reality that more care costs more money would magically disappear. It won’t. Reality is stubborn that way.


* It’s a charming bit of irony that a Right-leaning Website like RedState is up in arms over the Oregon Health Plan being unwilling to treat Sam when - as their own post makes clear - Sam was “Uninsured and unable to pay for expensive chemotherapy”. In other words, Oregon was at least willing to pay for comfort/palliative care for Sam; the private market was unwilling to pay for so much as an aspirin.

** The ABC story quoted an Oregon Health Plan official as saying the Plan intends to increase sensitivity by having someone from the Plan phone patients to deny them treatment and suggest comfort/palliative care. I cannot imagine anyone staying in that job for more than a week.



I have written about Randy Stroup and Barbara Wagner in the present tense. However both the Fox story about Mr. Stroup and the ABC story about Ms. Wagner appeared in the Summer of 2008 - more than a year ago. As the Fox story makes clear, the Oregon Health Plan eventually agreed to pay for Mr. Stroup’s chemotherapy. Although it made an exception for Mr. Stroup, Oregon apparently was not willing to make an exception for Ms. Wagner. However Ms. Wagner’s doctor appealed to Genentech, the pharmaceutical company that makes the medication she needed. Genentech agreed to supply a year’s worth of the drug free of charge.

Randy Stroup died July 16 of this year. He was 54. I have also read that Barbara Wagner died although the blog that reported this did not provide a source. I am terribly sorry that neither Mr. Stroup nor Ms. Wagner shared my luck.


brosty said...

oh ok -- not death panels -- just "hey will help you slip away comfortable and cheaply"

again -- thank you Massachusetts

Elise said...

Ya know, you pretty much missed the whole point of my post. And the link to your Website doesn't work.