Medical Best Practices. Best For Whom?

Here’s a disquieting little news tidbit. Wellpoint, the country’s second largest heath insurance company, is rolling out a program that will pay cancer doctors a $350 bounty per patient to treat their disease according to Wellpoint’s idea of best practices.

It doesn’t take a feat of memory to recall when the Republicans were warning that a single-payer system or even the compromise of Obamacare would put a government bureaucrat between you and your doctor. Death panels and all that.

But ever since we quit paying the local doctor with eggs and got health insurance somebody else has been between our doctors and us — the insurance company. You remember them. The people who raise your premiums every year, restrict coverage when they aren’t denying it outright, and dictate which doctors, medicines and procedures they will pay for.

The notoriously thuggish Harry Cohn, head of Columbia Pictures for many years, was fond of saying to his writers, directors, actors — anyone who tried to dispute his idea of how to make a picture — “Who eats my bread, sings my tune.”

This is a little blunt, but it has always been true. Whoever picks up the tab calls the shots. When it comes to health care, it is either you, the government, or the insurance company. And since you probably can’t actually afford to self-insure unless you’re a Trump or Koch or Gates, it is one of the other two. So the whole debate ought to come down to this: Who do you distrust the least?

You want the best care possible. It’s your life. But the other two payers have different priorities. They want the cheapest health care possible. Or in the case of the insurers, they want to keep the costs low enough to make a hefty profit and to keep winning the business from the people who actually have to pay the tab — individuals, employers or the government.

And keeping costs in check gets harder and harder. As the population gets older and therefore more in need of expensive care, as medicine becomes more high tech, drugs more specialized, even personalized, the costs rise faster than per capita income and tax revenues. So all the payers feel the squeeze and pass it on to insurers, demanding less expensive premiums. Loath to shrink their profit margins, the insurers cover less or pay less for what they cover.

So we have the creation of best practices, restricted formularies, restricted networks to hold down costs. Doctors are reluctant to turn over their power (or their own profits) to non-doctors so Wellpoint is bribing them to follow their rules, to sing their tune. The insurers claim their practices are best. For whom? Call me cynical, but better for them than for me comes to mind.

The government is really not a health care provider or decision-maker in most cases. It is just a fund-raising mechanism that decides which insurers it will allow in the game. But it is still the doctors and insurers who make most of the decisions about care. To the credit of Obamacare, it is at least trying to insist the decisions on best practices be based on data rather than on habit or profitability. That has provoked howls of protest. This is America, what’s more important, patients or profits? What are you, a socialist humanist?

One should never forget that the insurers are raking off 10 or 15 or 20 percent of the proceeds. Eliminating that seems like a big cost saving and helps account for how much cheaper health care is in single-payer systems. But there is still rationing, it’s just the government rather than the insurers in change of the rationing. In either case, restrictions are in place. You aren’t necessarily getting what’s best for you, but what the system can afford to provide. There is still a system and resources are still finite.

Medicine presupposes the interest of the patient always comes first, but the delightful cynic (or realist) La Rochefoucauld long ago taught that the most powerful motivating force on earth is self-interest. Doctors heed it, hospital managers heed it, insurers heed it, government bureaucrats heed it.

So the real question becomes whose self-interest is most closely aligned with that of the patient? Who would you prefer to trust with the decisions about how to treat your cancer? Profit hungry doctors, hospitals and insurers like Wellpoint? Or a government single-payer, such as in Canada, at least answerable to voters rather than shareholders.

That looks easy, but not so fast. We are living in an era that celebrates self-interest over community interest, so voters are just as liable as greedy insurers to throw granny to the wolves rather than accept a tax increase. Good luck.


Medical Best Practices. Best For Whom? — 1 Comment

  1. Thank you, Keith. Another monumental
    plea for sanity. We need you in DC. Run
    and you’ll have my vote and all I can steal.