Listening to a @NPR story of a woman who was diagnosed with cancer. insurance denied the medication that would save her life. Her doctor wrote a “compassion letter” to the drug maker asking for mercy.
— Abshir Omar (@AbshirMSP) December 5, 2019
I’m in my car screaming!
Why in 2019 are we begging to live? #Medicare4All
I just encountered another of those audience-grabbing stories about insurance companies failing to provide medical coverage. The bean counters apparently denied somebody’s necessary life-saving medical care. I understand the outrage this story causes, because we all imagine ourselves, with years ahead of us, suddenly facing mortality because an actuary somewhere said “no.” Putting ourselves in those shoes, the prospect seems horrific.
Is it, though? Princeton economic historian Jerry Z. Muller writes that, while medical metrics are frequently overused in ways that undermine doctors’ autonomy, that isn’t always bad. It certainly can be, when insurance executives who don’t understand medicine overrule a doctor’s opinions based on shoddy math. But throughout medical history, Muller says, hospitals have hosted tension between doctors who want to take heroic life-saving actions, and accountants who tally the costs.
Generations of TV medical dramas have convinced laypeople that medicine consists of earnest, energetic professionals making split-second decisions while lives hang in the balance. This might make sense in Emergency Room conditions, where people come in broken and bleeding, staving off burst appendixes and suppurating aneurysms. But most medical care is slow, deliberative, and costly. Asking whether continued costly treatment will have meaningful outcomes isn’t always unreasonable.
The model we’ve all seen in stories like House M.D. looks exciting, dangerous, and fun. Somebody enters the hospital with a twitching thigh muscle, and the glamorous doctors, who have only one case, piece together clues proving how an aortic dissection threw a clot to the brain, resulting in testicular obstructions: medicine as logic puzzle. I might’ve paid better attention in middle-grade biology had I thought I’d get jobs like that.
But an NPR human-interest story broadcast at the peak of that show’s popularity traced the costs of just one episode, landing on a $300,000 price tag—and that’s a conservative number, because I added up their annotated costs and got something far higher. And that’s nearly ten years ago; advancing technology and added administrative bureaucracy probably mean it’s far higher now. Even under the best circumstances, medicine is expensive.
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| The early-seasons core cast of House M.D. |
Let me interrupt myself here and note: I don’t mean accountants should be more active in scaling back costs and denying medical care. A good friend recently received a medical diagnosis that mercifully ties all her disparate symptoms together. She should’ve received this diagnosis twenty years ago, but overworked, underfunded doctors made hasty short-term determinations, almost certainly rushed along by bean-counters. A little more time and money could’ve saved years.
So yes, I acknowledge that there’s no simple, arithmetic formula to strike a balance between the accountants and the doctors, whose desires often conflict. And the arena of that conflict is a patient’s body. The outcome, as seen in the tweet quoted above, can be tragic for individuals—but downright mandatory for the medical economy overall. Anybody hoping to solve this problem concisely should also wish for a pony, because it’ll do as much good.
Because, let’s be honest, when people complain about private insurance’s interference in medical decisions, their solution is often to nationalize medical care, to a greater or lesser degree. As America’s political Left wants to institute Medicare For All, Britain’s political Right is actively considering privatizing the NHS, which American progressives often brandish as a model of more efficient medical template. Which they want because the NHS isn’t much better.
British medical journalist Dennis Campbell, writing in the Guardian, a newspaper with undisguised Leftist allegiance, notes that NHS bureaucrats regularly overrule doctors’ opinions. Campbell cites a panoply of reasons bureaucrats to this, but buried in this list, he names “resources”—a weasel word meaning “money.” So the NHS, like America’s private insurers, overrules doctors’ wishes to keep costs down and funnel money where it’ll do the most good.
If we expect a constant stream of on-demand, high-tech medical treatment, we’ll inevitably run into the impediment that all resources, including money, are finite. Somebody needs to make decisions about who gets costly, invasive treatment. That “somebody” will inescapably be a bureaucratic goat whose official functions, whether funded by the state or private capital, will conflict with life-saving desires. Somebody’s live will take priority over another.
The system is heartless to individuals. I’m sure that woman whose life-saving cancer treatment got denied is suffering greatly. But trading corporate bureaucrats for state bureaucrats won’t solve anything. Unless we abjure high-tech medicine, which will never happen, we’ll always have to make finite resources cover infinite needs. That’s what bureaucracy does. Sometimes, that means making painful decisions and letting human lives go.
See also: Doctors vs. Accountants©: Part II
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