Consider This

As health reform boils, a stirring concern has been whether choice will be curtailed. A survey in the New York Time (scroll to p. 13) charts this. Of those polled, 43% believe that "access to medical care and treatment would be limited."

Fears about rationing are greatly exaggerated. Opponents to reform present rationing as the undermining of choice, the inevitable, evil outcome of reigning in costs leading to withholding therapies. Images of long lines, delayed treatment, faceless government bureaucrats (the kind we otherwise encounter at insurance companies), and unnecessary deaths. The cause, says the right, will come from government crushing private insurance.

Nonsense. The surest way to sabotage health reform is to leave financing in place using a private, for-profit market, making exactly the kinds of decisions people fear most. It has a track record based on non-competitive choice. Make no mistake, insurance is a form of rationing as certain as any other, but beneficiaries sit in corporate boardrooms where they weigh decisions based on profit and monitor daily stock market ticks.

If we''re talking about insurance companies rationing, their stepping stone to greater profit comes from denying service. Too often a denial comes with the explanation that it is "not medically indicated." That means the company has decided to save. We shouldn't let them get away with the myth that this is based on free choice, evidence-based clinical treatments, or the benefit of the entire society. It is the few for the many.

Currently there are several forms of rationing. The government favors the very young (SCHIP) and the very old (Medicare), although both are threatened in the midst of congressional deal-making. In the work force, full versus part-time employment dictates rationing because it is an avenue to the least expensive form of insurance. People working in companies employing 50 people, versus those in smaller mom-and-pop outfits benefit from rationing on behalf of large businesses. Employment alone is not a gold standard, but the unemployed, or the underemployed fare worst of all currently.

The risk-aversive, open market place usually works against people with a "pre-existing" condition. This can be anything from someone with freckles who later develops skin cancer, to a child who is considered at risk for later mental illness because of a consultation with a psychologist.

Princeton's bio-ethicist Peter Singer recently described how rationing has existed, and will continue in an environment of finite resources. Then, he says, "we can ask, 'What is the best way to do it'?"

Rationing in the mental health system
For those with a mental illness or addictive disorder, rationing is reality now and has been since the Medicare law passed in 1965. Until recently, Medicare co-payments for mental health treatment amounted to 50% out of pocket compared to 20% paid by people for other medical problems. The disparity lasted until last year when Democrats ended a Republican filibuster, helped by the arrival of an ailing Sen. Ted Kennedy, to vote a new Medicare reform bill.

HMOs followed similar patterns with fewer services and restrictions in therapies and reduced payment for providers. Insurance has denied inpatient hospitalizations and limited outpatient consultations for mental health and addictive disorders. This has resulted in high rates of hospital readmissionss, and more costly visits to emergency rooms. The consequence for an individual can be devastating. For society it leads to waste.

Another example of rationing comes from access to medications. A good example is the drug clozapine, a costly drug in the United States (much less so in Europe), and one that Medicaid curtailed. The medicine and the mandatory blood tests in the US were priced ten times more than cheaper medications. They were also much more effective and a whole lot less than hospital care. A study in the New England Journal of Medicine notes:

"Several nonexperimental studies have suggested that the additional cost of clozapine treatment may be more than offset by the consequent reduction in hospital costs, and one controlled trial showed reduced rates of readmission and fewer days in the hospital with clozapine.

Of the 200,000 patients in the U.S. who might have benefited, only 8,400 were taking clozapine in 1991 writes Mark Hurwitz in the Columbia Law Review.

Meanwhile, advocacy organizations sued to make this patented medicine available to people with schizophrenia and states tried best they could. Pennsylvania offered a lottery to select 200 people who could receive the drug. Massachusetts agreed to pay for 15 patients. In 1990, the Omnibus Spending Law contained a provision, writes Hurwitz, "intended to apply specifically to Clozaril. The provision amends the federal Medicaid law to allow states to exclude, or otherwise restrict coverage of drugs" associated with monitoring services.

The substitution of generics for brand names provides a major opportunity to save. But here is where rationing requires judgment, and a balancing act mediated by FDA standards for the bio-equivalence of a generic. The controversy over a patented and a generic antidepressant, Wellbutrin XL 300 versus Budeprion XL 300, is a case in point. Many patients hardly noticed a difference when the generic Budeprion was substituted. But those who did experience a return of symptoms complained that insurance denied coverage of a medicine that worked. The less expensive generic, not the outcome, was the reason.

Dr. Nada Stotland, former president of the American Psychiatric Association, told MIWatch the challenge in prescribing psychiatric medications is finding the one that works. Three may be available for a given diagnosis, but evidence confirms not all patients respond to the same drug. Rationing that reduces medical choice in these instances is counterproductive. Hence decisions must be coupled with evidence not arbitrary criteria.

Rationing is inevitable
Is the argument over rationing a three-dollar bill? Clearly unlimited access is impossible. But if we are to save money and improve health simultaneously, we must recognize how profit margins have overridden a multitude of evidence-based treatments promoting recovery for people with a mental illness. The question we face is how to guarantee health reform does not perpetuate traditional, time-tested rationing, penalizing people with mental illness or addictive disorder on a false currency of choice within the status quo.

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Phyllis Vine

Consider This

by Phyllis Vine

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