Survival of the Compassionless
posted by Frank Pasquale
If you’re interested in the logical endpoints of an unregulated health care marketplace, two recent stories are a good place to start. In John Carreyrou’s Medical Maze, a breast cancer patient gets bounced from clinic to clinic because she failed to get diagnosed at a federal cancer-detection program. And after managing to cripple New York state’s efforts to expand health care to low-to-middle income children, the Bush Administration is targeting more marginal groups :
Under a limited provision of Medicaid . . . the federal government permits emergency coverage for illegal immigrants and other noncitizens. But the Bush administration has been more closely scrutinizing and increasingly denying state claims for federal payment for some emergency services, Medicaid experts said.
Some states are defying the administration. If they fail, consider the consequences for the health care marketplace.
In response to the administration’s efforts to restrict emergency care,
New York City public hospitals, which serve 400,000 uninsured patients a year, among them illegal immigrants, would continue to provide the cancer treatment no matter what, said officials from the Health and Hospitals Corporation. But if there is no reimbursement from Medicaid, they said, they will have to look elsewhere for financial support.
Now consider the competitors of such hospitals–ones that will insist on only treating the insured.
In Carreyrou’s piece, they are reported to have developed several innovative market-driven strategies for avoiding very sick uninsured patients:
Ms. Loewe called M.D. Anderson [Hospital] but was told she needed a referral from her oncologist. She asked Dr. Duncan for the referral, but he refused, Mrs. Day says. Dr. Duncan says he knew from experience that M.D. Anderson didn’t take charity-case referrals unless the patient’s diagnosis was unusual and the treatment couldn’t be handled locally.
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Ms. Loewe phoned in tears because the county indigent clinic suspended its assistance, alleging she had ramped up her working hours . . . .[An advocacy group] intervened and got her reinstated. A supervisor at the county clinic says there’s no record of Ms. Loewe being dropped from the county welfare rolls during that time.
***
After four months of chemotherapy, Ms. Loewe’s tumor had shrunk by half but wouldn’t get any smaller. Her doctors decided it was time for a mastectomy. Dr. Cook’s office repeatedly asked Ms. Loewe how the operation would be paid for, according to Mrs. Day and Ms. Burhansstipanov. He finally scheduled the surgery in early November 2003 after receiving a consent fax from the county saying it would cover the costs.
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[After her mother developed brain cancer,] Mrs. Ferguson found a neurosurgeon, J.D. Day, who was willing to operate on her mother free. But the hospital where Dr. Day performed his surgeries, Swedish Medical Center, refused to make its facilities available unless Ms. Loewe or her family paid $90,000 up front, Mrs. Ferguson says. Mrs. Ferguson and her husband, who is also a nurse, had only a few thousand dollars in the bank.
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[Loewe's daughter] then contacted the University of Colorado Hospital and argued that her mother’s case was an emergency. She says the university hospital told her it was under no obligation to admit Ms. Loewe because her brain tumor resulted from a pre-existing condition — breast cancer — and therefore didn’t qualify as an “emergency medical condition.”
Now consider what would happen to any of these entities if they had decided to give charity care to Loewe. In a market-driven health field, that’s a loss. That means they have less money to invest in the types of advertising, innovation, and other competitive strategies necessary to distinguish themselves from competitors. You might also expect such a hospital to start losing on the ratings scores so beloved by advocates of consumer-directed health care–taking on “difficult cases” like Loewe’s is likely to raise the mortality level at the hospital.
Another query for consumer-directed health care advocates: let’s say that “$90,000 or no surgery” ultimatum was really the end of the line for Loewe. How would financing institutions work here? Would you like to give Loewe’s daughter the “freedom” to, say, mortgage her house to pay for her mother’s health care? And if she had no equity, maybe a health care loan that, with a few tweaks to the bankruptcy laws, could be nondischargeable debt to be garnished from her wages for the rest of her life? What are the racial implications of regularizing collateral-backed care when “63% of black households have no financial assets, more than twice the rate of whites”?
All this leads me to one sad conclusion about the debate over consumer-directed health care. Certainly for small medical problems and procedures, we should be encouraging people to be cost-conscious. But we should be under no illusions about the brutal consequences for the poor of better-calibrating care in general to patient purchasing power. In the cold calculus of money-directed health care, botox injections may prove a far more lucrative opportunity for a surgeon than excising a growing cancer. As a prolix Janis Joplin might conclude, freedom to direct one’s own care may turn out be just another word for the right to be outbid by others.
September 22, 2007 at 10:59 am
Posted in: Health Law
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Responses (1)
J - September 24, 2007 at 2:19 pm
I’m not a “consumer-directed healthcare advocate,” but I am confused about how two stories about problems explicitly related to federal law and regulations demonstrate “the logical endpoints of an unregulated healthcare marketplace.”
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