Medicine's Rising Costs Put Hippocratic Oath At Risk : NPR

Medicine's Rising Costs Put Hippocratic Oath At Risk : NPR

In most medical schools, students recite the Hippocratic Oath together to mark the start of their professional careers. The soon-to-be physicians swear to uphold the ethical standards of the medical profession and promise to stand for their patients without compromise.

Though the oath has been rewritten over the centuries, the essence of it has remained the same: "In each house I go, I go only for the good of my patients."

But the principles of the oath, says Dr. Gregg Bloche, are under an "unprecedented threat." In The Hippocratic Myth, Bloche details how doctors are under constant pressure to compromise or ration their care in order to please lawmakers, lawyers and insurance companies.

Bloche says that doctors are increasingly expected to decide which expensive tests and treatments they can and cannot provide for their patients. Their duel role as examiner and cost-cutter can then potentially compromise patients' care, he says, particularly when insurers and hospital administrators urge physicians to only perform "medically necessary" treatment.

"The average person thinks that 'medically necessary' care means all care that might potentially be beneficial," he says. "But the reality is that it's a wide-open term."

Care may be denied, says Bloche, for a variety of reasons, including whether patients have consented to cheaper treatment options through their health insurance plans. What that means, he says, is that doctors who ration care on behalf of insurance providers may simply be following their patients' wishes — even if patients are not aware that they're receiving subpar treatment.

"In the real world, the choices aren't made clear in the employee benefits office," he says. "In the real world, the cheap health plan and the expensive health plan both promise you 'medically necessary' care and you don't really know what that means. So you sign up for this care and you think, 'Aha! This one's cheaper than the other. And it's promising medically necessary care. You don't really know that one car is a Lexus and one car is a Chevy. These two plans are being presented to you as Lexuses. And so you say, 'I'll buy it.' But in fact, in terms of the care it makes available, it's cheap because it's a Chevy, not a Lexus."

Talking about potential tradeoffs in care is a conversation that doctors and policymakers need to have, says Bloche, because it's inevitable that our health care system will need to find ways to set limits on care.

Interview Highlights

On the rationale of withholding care:

"The rationale there is that the doctor who stints on care three years later when you get really sick is acting in accordance with your preferences as you expressed them in the employee benefits office three years before," says Bloche. "And therefore, the doctor is not violating the Hippocratic Oath. The doctor is merely complying with your preferences when you rolled the dice in the employee benefits office."

On insurers not being required to reveal their criteria to providers for what claims they'll pay:

"This is a walk on the wild side. I've taken on some of these cases for people that I know, and one thing about it, if you know the system's hypocrisies, then you can beat the system. One of the hypocrisies is that the companies take the position that their guidelines for what they will and will not pay for are trade secrets — that they're proprietary. Now imagine a legal system in which the laws were considered trade secrets and their lawyers weren't allowed to know the laws in advance because that would mean they could game the system. That doesn't fit with our legal values, our due-process values — but that is what happens for many, not all, health plans. They take the position that they're not going to reveal in advance the rules for what they'll pay for and won't pay for because that would enable doctors and patients to game the system."

On randomized clinical trials:

"What's amazing is that probably only 10 to 20 percent of the treatments that doctors use today have been tested [in] randomized clinical trials. Even when a treatment is shown to work really well for the sample that's studied in the clinical trial, in the real world patients are all different. [They] vary hugely. So we're never going to be able to have solid science that can tell us for sure whether the treatment is going to work or not. So let's do the research but let's be realistic and pragmatic about the limits of that research."

"We cannot afford anything like what we're spending on health care today, and we're certainly not going to be able to afford what we're projected to spend in the future," he says. "We spend almost a fifth of our national income today on medical care. And within 25 years, unless we change dramatically, we're going to be spending a third of our national income on medical care. And we're doing that by borrowing from our kids."

Related articles

• Ethical gray zones put the Hippocratic ideal in jeopardy (boston.com)

Health Care and the Campaign - NYTimes.com

Health Care and the Campaign - NYTimes.com

Republican candidates and deep-pocketed special interests are spreading so many distortions and outright lies about health care reform that it is little wonder if voters are anxious and confused.

Here are a few basic facts that Americans need to keep in mind before they go to the polls, and afterward. First, most aspects of the reform do not go into effect until 2014. Second, things are indeed bad out there: The costs of medical care and insurance premiums are (still) rising, and some employers are (still) dropping coverage. But for that, you should blame the long-standing health care crisis and the current bad economy. Health reform is supposed to help with these problems.

Here is a look at the claims being made on the campaign trail — and the distortions they contain:

PURE NONSENSE: John Raese, the Republican candidate for the Senate in West Virginia, is claiming that the law will require patients to go through a bureaucrat or panel to reach a doctor. That is flat out untrue. You will still choose your own doctor or insurance plan without interference. Nor, despite other claims, will the law provide subsidized insurance to illegal immigrants. They are precluded from using even their own money to buy policies on new exchanges.

The Obama administration will not be compiling a federal health record on all citizens, including each individual’s body mass index, as Ann Marie Buerkle, a Republican running for a House seat in upstate New York, has claimed on her Web site. The administration is offering incentives to doctors to record various vital statistics in electronic medical records and report the data in the aggregate, to help understand national health trends.

WE CALL THAT CAPITALISM: Republican politicians never tire of denouncing health care reform as a “government takeover” — or socialism. What is true is that the law relies heavily on private insurers and employers to provide coverage. It also strengthens regulation of those insurers and provides government subsidies to help low- and middle-income people buy private insurance on the exchanges.

Those exchanges will promote greater competition among insurers and a better deal for consumers, which last time we checked was a fundamental of capitalism.

WHAT ABOUT MCDONALD’S? Conservative commentators pounced after the fast food chain and several other large employers that provide skimpy, low-cost policies to their workers warned that they might drop their health plans entirely if forced to comply with the new law. They particularly objected to a requirement that they begin raising the low annual limits on what their plans are willing to pay for health care.

In response, the administration has granted some 30 waivers for one year (Rush Limbaugh promptly accused the administration of allowing these employers to “break the law”) and has signaled willingness to smooth out other bumps on the road toward full reform. In 2014, all plans will have to meet minimal standards and large employers will have to provide coverage or pay a stiff fine.

WHAT ABOUT MY PREMIUMS? Some Republicans are also claiming that health reform is driving up premiums. There have been sharp increases in some states, primarily in response to soaring medical costs. Some insurers may also be trying to increase their profits before the reform law holds them in check. A few very welcome provisions that take effect early, like requiring insurers to cover preventive care without cost-sharing, will play a minor role in premium increases for next year.

Reform has also energized federal officials and many state regulators to challenge and force down big increases sought by insurers. The Justice Department just filed suit against Blue Cross and Blue Shield of Michigan for allegedly using its market power to drive up costs for its competitors and its own subscribers.

More...

Related articles

• Correcting The Lies About Health Care Reform (alan.com)
• Health reform's benefits kick in (politico.com)

Harry Reid, Sharon Angle Debate -Angle Is Opposed To Any Insurance Company Mandates And She Is Opposed To Unemployment Insurance

Most Americans are unaware of how bad our healthcare system is in comparison to the rest of the developed world. I know, I lived more than two years in South Korea which, like every other developed country save America, has a single payer, national health insurance system which every workers pays into. I payed approximately $60.00 per month into this system during my stay working in South korea.. I am a 57 year old man with a preexisting hypertension condition which is treated with maintenance drugs.
In May of 2008, as a result of ever work and fatigue, my American prescribed blood pressure medicines stopped working. I collapsed in a subway station and was rushed to a hospital by ambulance with dangerously high blood pressure. I received emergency treatment ans spent a large part of the night in the hospital. I had a complete physical, blood work and electrocardiogram. The cost was $64.00. That's it. This included the ambulance and hospital treatment, all tests and medications.
Subsequent to the aforementioned incident I was required to see a doctor on a weekly basis for two months and then on a monthly basis until August of 2009. My doctors visits were $5.00 each. I was prescribed new medications. My medications, six drugs, totaled $45.00 per month. I had my doctor's cell phone number and email address. I was told by him to call him whenever I needed. We text messaged each other and I contacted him with questions by email quite often.
A fair question is who pays for this? Everyone in South Korea is required to pay for a government run health care system. You chose your own doctor, any doctor in the country. I changed doctors because my first doctor was very impatient. My second doctor was the best doctor I have ever had. She referred me to her husband who is a specialist. I saw him and paid him $6.00 once. Afterwards we spoke by phone, and contacted each other regularly by text message and email.
These two doctors took a personal interest in me and brought me back to full health. Healthcare and hospitals in Busan South Korea and in Daejeon South Korea, where I lived, are at least as good as in the Atlanta area in the United States. As I said my second doctor and her husband were the best doctors I have ever had.
Americans need to realize that American healthcare lags behind many countries in the developed world in almost every objective, statistical area. This includes enfant mortality, lifespan as well as other discriptors of medical care. We pay a lot more for our healthcare and receive less. Why, the middlemen insurance companies drive up the costs while providing no actual benefits to the American people. We need a single payer system. The recent healthcare reforms are a small step in the right direction. We have a long way to go. Insurance companies make huge profits as middlemen. They are free to attack healthcare reform with misleading and scary advertisements. They have the money to pay lobbyists as well as to donate to candidates and proxy organizations which support their continued control of American healthcare. Human beings are fearful of change. America really needs a change in our healthcare system. We have taken a small first step. We have a long road ahead of us filled with the potholes of greed, self interest and fear.
John H. Armwood