The myth of no limits
Koller, Christopher F.
THE MYTH OF NO LIMITS CHRISTOPHER F. KOLLER ALL HEALTH CARE IS TEMPORARY he "request for coverage" has reached the senior management of the insurance company. A thirtyeightyear-old patient...
...We will struggle to save the life of a lowbirthweight baby but neglect the culture of hopelessness that caused the premature birth...
...Child and family advocacy groups have criticized the approach as immoral since it supposedly limited care available to Medicaid recipients, and in one highly publicized case a child died from liver failure in the midst of fund-raising efforts to pay for a transplant denied by Medicaid since it was determined to be a lowfunding priority...
...Health-care economists point out that consumption of complex medical technologies is a function of neither resource supply nor patient demand but of physician availability: limit the number of specialists certified in a given field and presumably 10: 27 March 1992 Commonweal unnecessary consumption would decrease...
...In the past, health insurance paid for "generally accepted" medical procedures, and research institutions and the federal government picked up the tab for "experimental" or "investigational" procedures...
...Unfortunately, this process often fails the needs of both patients and society...
...For the remaining 10 percent and those who do not detect the disease early, however, breast cancer is likely to be fatal...
...We are limited not only in our choices, but in our life...
...She is driven as much by fear, uncertainty, and the hope of seeing her children grow as by a careful calculation of the risks and benefits of various treatment options...
...New Medicare reimbursement guidelines scheduled to take effect this year address this in a back-handed way...
...We avoid explicitly saying no to the woman who wants AUBMR or sorting out conditions for a "yes" decision (yes, if lymphatic involvement only, and no if further metastases...
...Those which deliver and distribute health care represent how we care for our sick and vulnerable, our selves...
...This traditional differentiation between experimental and accepted procedures—more of a spectrum than a dichotomy—is collapsing under the weight of patient demand for treatment (consider the case of AIDS treatments), public sentiment in highly publicized cases, court rulings that have generally overturned denials of coverage, and the profusion of research centers and new medical technologies competing for a shrinking pool of federal research funds...
...Senate race in Pennsylvania, have seized national health-care reform as the mouthpiece of their lost populist voice...
...A war story for beleaguered insurance companies involves a health maintenance organization which agreed to cover AUBMR for a patient with breast cancer, provided she went to one of five premier research institutions with which the company had existing relations...
...It also apparently works for carefully selected patients...
...We cannot expect more from this woman with breast cancer, a supererogatory sacrifice of any hope of survival for the sake of social good and nameless victims...
...We generate thousands of dollars and newspaper column inches for a single child undergoing multiple organ transplants to preserve her hopes and our own...
...Disenchantment with the U.S...
...There are more comprehensive steps that can be taken to ration health care...
...However, they have yet to adequately recognize that any legitimate attempt to address these issues must come to grips with the allocation of limited resources among seemingly limitless treatment and diagnostic technologies...
...The 35 million people who are uninsured have limited access to the procedure, as do the millions more on state and federal insurance programs, and the large and growing numbers of "underinsured...
...We bear a great cost for this system of allocating resource-intensive care...
...While the mantle of "victim" rests uneasily on the muscular shoulders of the insurance industry, the case of AUBMR indicates how in the U.S...
...by implicitly saying no to thousands of pregnant mothers who receive their only care in the hospital emergency room...
...Perhaps we as a society tolerate the U.S...
...health-care system can be broadly categorized as involving its cost, its inequitable distribution, and its increasing depersonalization of care (in the form of greater specialization, administrative processes, and fragmentation of services...
...patients were selected on the basis of access to the centers and their researchers...
...We can expect more from ourselves: institutions which do not hide the fear of the body's diminishment and death but support principles of dignity and comfort, and which face up to the difficult task of setting priorities and distributing limited resources...
...The patient will receive the procedure only if the insurance company agrees to it...
...The ultimate, and perhaps unavoidable, form of rationing in a health-care system is an explicit prioritization of technologies and procedures for reimbursement, one that tries to compare AUBMR to prenatal visits and screening mammographies...
...system because it reinforces the important cultural myth of limitlessness, in which each of us is free to choose whatever we need from an ever expanding array of options to preserve our immortality...
...To ration health-care technology is to limit our own individual choices and hopes by submitting to an imperfect government-imposed system...
...Often, it is done through incremental policy making, affecting the supply of a certain technology...
...It is a radical intervention in the body, a manipulation of a life pushed to death by the disease and the cure...
...Some of the incentive for physicians to specialize is eliminated by reducing compensation for technical procedures (for example, traditional Medicare gravy trains such as the treatment of cataracts and prostatectomies) and increasing reimbursement for "cognitive" procedures such as primary-care office visits...
...We will die—and this gives us pause...
...We shortchange the voiceless among us, the growing numbers who can't afford the admission fee of comprehensive medical care and wait outside for handouts...
...As a result of these pressures, availability of the technology proliferates faster than experience or consensus on its appropriate use, and more patients and their physicians are demanding access to a broader range of complex, resource-intensive procedures for which somebody—no longer solely the government—must decide criteria for selection and funding...
...A free-market-based resource allocation system has proven reasonably effective at delivering shirts and bread for those who need it, while still producing diamonds and caviar for those who can afford them...
...As efficacy was clinically demonstrated, for example, in the case of heart transplants, the procedure entered the medical mainstream as "accepted" or "standard" practice...
...some institution has to decide at what point one AUBMR is not worth the three thousand prenatal visits which could be funded instead, or a similar number of screening mammographies which could detect perhaps five additional cases of breast cancer before serious complications...
...Concurrence by five separate authorities is as close to consensus as medicine can manufacture: Was the woman still entitled to the procedure...
...All five medical centers turned her down as an inappropriate candidate, but the patient then found a center just starting its program which was willing to take her on...
...All health care is temporary...
...Institutions and their captains, anxious to generate streams of funding and prestige, develop research trials for "hot" medical technologies...
...anywhere from 5 to 20 percent of those undergoing the procedure succumb to the toxicity of the drugs or resulting infections...
...A national policy that controls the number of facilities approved for experimentation with a new treatment or procedure would both limit its availability and create fewer but larger experimental trials...
...But, as Daniel Callahan has pointed out, most of health care's research innovations have shifted from the broad-based and epidemiological, such as vaccines, to individual patient interventions, such as AUBMR for breast cancer, which produce much smaller incremental gains...
...CHRISTOPHER F. KOLLER lives in Buffalo, New York, where he works for a health-maintenance organization, AUBMR is logically simple and technically dazzling...
...This response reinforces cultural traditions of human rights, personal autonomy, and benign neglect on questions of resource allocation...
...we encourage one another to cheapen what it means to be alive to mere physical survival...
...More importantly, who decides...
...AUBMR is expensive...
...Language of "rights" or "autonomy" fails in a realm of limited resources...
...Finally "global budgeting" as practiced in Canada attempts to set prospective limits on federal and provincial spending for health care and then negotiates accepted procedures and reimbursement rates to meet those limits...
...Incidence rates for breast cancer are sufficiently high that widespread application and acceptance could mean significant additional expenses...
...today...
...A thirtyeightyear-old patient diagnosed with metastatic breast cancer and her physician are requesting the carrier pay for an Autologous Bone Marrow Rescue (AUBMR) for the woman—her "last best hope for survival," the request maintains...
...Rationing of care, or more politely the allocation of resources, in any explicit way is a pill the U.S...
...Technology is no solace for tragedy...
...A free-market attitude toward health-care research and development has evolved in the U.S...
...Prices quoted by institutions for the treatment, hospitalization, and physicians' fees range from $85,000 to $150,000...
...Clearly, however, not everyone who wants AUBMR for breast cancer can receive it in the U.S...
...Tight certificate-of-need requirements for the acquisition of new equipment by medical centers also limit their dispersion...
...system and its way of resolving the dilemmas of allocation because it protects us from the responsibility that comes with autonomy, making difficult decisions about others and ourselves...
...Very early clinical trials report disease-free rates at five years of 80 percent for breast cancer patients with lymphatic involvement and 30 percent for patients with metastases to other organs (compared to 50 and 10 percent for conCommonweal 27 March 1992: 9 ventional treatment...
...Less calculable but more costly is the potential for bad press generated by a widely publicized denial-of-coverage decision and any subsequent legal appeal...
...Institutions represent our collective choices...
...In the U.S., we leverage that hope by distributing it in a fragmented, inequitable way...
...Technology notwithstanding, "we know not the hour" and at some point technology's primary value ceases to be curative and becomes instead illusory, offering hope against hope...
...Medical care in the U.S...
...The Democrats, emboldened by last November's U.S...
...The most publicized attempt to do this has been in Oregon, where an elaborate methodology has tried to determine cost-benefit figures for the treatment of hundreds of clinical conditions and then integrate them with patient preferences gleaned from numerous town meetings...
...Long-term (five-year) survival rates dip to 50 percent if detection occurs after the cancer has spread to adjacent lymph nodes, and to 10 percent if other organs are affected...
...If AUBMR and other new and expensive medical technologies are not luxuries, health care's Rolls Royces and Ferraris, their allocation should not rest with laissez-faire principles of benign neglect or unrepresentative institutions...
...Perhaps we as a society tolerate the U.S...
...Limiting the number of centers performing a procedure creates a rationing by queuing, in theory the long wait weeding out the less needy...
...here is another component to health-care technology which makes its distribution problematic: it provides hope, however slim, for a prolonged life...
...It is dangerous...
...It is also perhaps the best example of a host of high technology, resource-intensive procedures available in the U.S...
...We shortchange individuals who are deluded about the inevitability of decline and death...
...Applications of the technology for virtually every other type of cancer are being investigated in North America and Western Europe...
...ho should receive AUBMR for breast cancer...
...which raise questions about their appropriate use and application in a society with limited resources to spend on medical care...
...Breast cancer will strike one in ten women...
...Among the arsenal of high technology medical procedure, AUBMR strikes particular fear into insurance companies' hearts for two reasons...
...Each individual case we encounter ("the identifiable victim") presents a challenge to this myth and we will struggle to defend it...
...The results have been controversial...
...The pharmaceutical and medical-devices industries look for new "markets" of sick patients for new products, creating demand by courting patients and physicians...
...The "untimely" death—whether by cancer, failed organs, or an accident—only heightens technology's capacity to delude and alienate patients and their families...
...Compared to it, a heart transplant appears merely to be complicated plumbing...
...As a society, we desperately want to say "anyone who needs a medical procedure, gets it...
...The role of health-care-rationing agent is a new one for private insurance companies...
...These new technologies were generally limited to a few major research institutions...
...It is a false hope, a false comfort for real fears, alienating one from an integrated view of human life which includes a place for aging and physical decline...
...Anything to stay that fear, such as medical technology, offers hope...
...How would such allocation be made...
...They should be rooted in the experiences of frailty and limitation, as well as strength and pride...
...Since the effectiveness of chemotherapy is limited by its destructive effects on the recipient's white blood cells, researchers have devised methods of "harvesting" the patient's bone marrow prior to chemotherapy, blitzing the cancer (and the patient) with lethal doses of anticancer drugs, and then reinfusing the bone marrow to "rescue" the patient...
...Considerations range from the principled, clinical efficacy and patient condition, to the pragmatic, prior payment decisions, legal precedent, risks of lawsuits, and adverse publicity...
...There is a final frontier to physical life beyond which technology cannot push...
...Moreover, no system of health-care delivery, the besieged U.S...
...model or its ballyhooed Canadian cousin, can deliver everything to everybody who wants it...
...Ninety percent or more of patients with breast cancer detected and treated in its early stages can expect to experience no recurrence of the disease...
...patient may still not be ready to swallow, calls for "national health care" notwithstanding...
...now involves two decisions: "appropriateness," what is best for the patient, and "coverage," what is agreed to in the patient's insurance policy contract...
...And technology has delivered on that promise—yesterday's death-dealing smallpox is today's vaccine—resulting in unimaginable reductions in human suffering and misery...
...Medical care competes with many other goods—housing, food, clothing, defense—for a limited pool of resources: money, people, time...
...This is how we decide who receives medical care in the U.S.: a casebased ad hoc allocation process biased toward technology-intensive procedures and identifiable, insured, very sick patients...
...fragments of society that do not represent the whole are being forced to answer fundamental questions of resource allocation which affect all...
...q Commonweal 27 March 1992: 11...
...In our efforts to preserve individual hopes, we have failed to provide a remotely similar range of aspirations...
...Early detection techniques, such as mammography and breast self-examination, and treatment advances involving surgery, radiation, and chemotherapy, have made the prognosis for the disease quite good...
...Autologous Bone Marrow Rescue (AUBMR) represents one of medical science's newest and most powerful weapons to improve survival rates for this and other cancers...
...Federal regulation of new technologies consists of reviews of patient safety only...
Vol. 119 • March 1992 • No. 6
