We Won't Pay For You To Live, But We Will Pay For You To Die

[realtraveller]

That was the news that an Oregon cancer patient got.

Drug company supplies cancer drug Oregon Health Plan won't | StatesmanJournal.com | Statesman Journal

The Oregon Health Plan sent a letter to this lady informing her that the chemo prescribed by her physician would not be covered by the Oregon Health Plan. The letter added that physician-assisted suicide would be covered, however.

Nice. Anyone remember Logan's Run?

[theworm[$]]

so the company is provided the drug at no charge. That's Great!

[frazzledspice]

The article said that the Oregon Health Plan (which is apparently a euphemism for Medicaid) covers only hospice-style care for cancer patients whose anticipated 5 year survival rate is 5% or less.

I think that we have health care rationing now. It is rationed by what we can afford.

The difference is that Oregon Medicaid is rationing its chemotherapy benefits to exclude those who have less than a 5% five year survival rate.

With affordability rationing, there are uninsured and underinsured Americans who could have 75% five year survival rates who aren't getting chemotherapy because they can't afford it. Which is fairer?

My husband's aunt died of cancer a few years ago at age 61. She and her husband were self-employed and hardworking. Being self-employed, their insurance options weren't that good (and, while they earned a middle-class income, they were far from affluent.) The routine colonoscopies that everyone else gets over 50 were probably unaffordable for her. By the time she got care it was too late to save her.

If you think that Oregon Medicaid's policies are too strict, then perhaps they should change it to 4% survival rate over 5 years, or 3% survival rate over 5 years. But please don't use this as a platform to prove to us that the current system is better for America as a whole.

[jgibson2[$]]

MaryAnne,
Don't you think it's at least a little cold to send the "we'll pay for assisted suicide" in the same letter with the refusal of chemo?

Also, 5 year survival statistics are, of necessity, based on technology which is more than 5 years old. This medication isn't that old. Nobody really KNOWS what this woman's chance of being alive in 5 years is. That, of course, is why the drug company is willing to cover her costs. They believe their medication will offer her significant benefit and they're willing to pay to prove it. If they cover enough of the bills medicaid and insurance companies won't and prove their point, they can get reimbursement in the long run.

The drug company wouldn't be ponying up if she had extensive metastatic disease, because that wouldn't help their statistics. I hope she's around in 10 years to lobby for coverage for people in her category.

We do need to change the system. It's broken, but this doesn't convince ME that any kind of single-payer system will work for everyone -- or even for that group of uninsured/underinsured.

Oh, and I have a colonoscopy every 1-2 years, so I know what they cost. Money isn't the deciding factor for someone with a middle-class income, regardless of insurance. My insurance company gets billed less than $2000 for the procedure. That's not cheap, but brown-bagging lunch and making your own coffee would pay for anything not covered by insurance. Low-risk people only need it done once every 10 years and I'm sure most GI docs would be willing to come up with a payment plan. I'm very sorry that your husband's aunt wasn't aware of the risks. I'd bet that taking time from the family business was much more a factor than money, because they'd both have had to take a day off. In the end, the cancer cost far more than any number of colonoscopies (my surgery and treatment cost well over $100,000) and took far more time from the business.

I work with enough high-risk and sometimes symptomatic NURSES who give the stupidest reasons for not getting scoped. My own brother put his off for nearly 8 years after my cancer diagnosis and 7 years after my moms. Money wasn't the deciding factor for him, time off from work was his excuse -- and fortunately his polyps were still benign when he finally quit making excuses. All the siblings who lived close enough to witness my experience had theirs done within a year of my diagnosis. The real issue for middle class folks is the mistaken belief that colonscopy is a grueling experience and/or that it's already too late (those with symptoms) or they're not really at risk.

[frazzledspice]

I don't believe in assisted suicide, period, and I would certainly put it on the list of "non-covered" items in insurance policies--right alongside cosmetic surgery.

My husband's aunt's business was a mom and pop operation. During their busiest times (the holidays) they'd work seven days a week, at least twelve hours a day. They never had help. I am sure that time and expense both played a part in her not getting that test.

I've had two so far, three polyps the first time, and one the second. Other than having to drink that awful stuff the day before, there was absolutely no pain or discomfort with the procedure, and I was relieved the second time to see that the amount of fluid I had to drink was only half as much.

[jgibson2[$]]

I don't believe in assisted suicide either, but it's the law in Oregon. IMHO, this sort of response is what you get when assisted suicide is the law. In another state, they might or might not refuse the chemo, but at least it wouldn't come with an offer to kill her -- which I think was Kathy's point in the first place. NOT appropriate to offer to further shorten someone's life when you've just refused the only treatment that has a chance of lengthening it.

[theworm[$]]

I do believe in physician assisted suicide, but I think it's unconscionable that it would be posted in the letter refusing treatment.

I think that there are a lot of issues for discussion in the story. I love the fact that the drug company is paying for this woman to get treatment.

Whether the Oregon policy is right or wrong is a topic, but I think the bigger topic is in general about rationing. We pay for insurance and should receive comprehensive care. Rationing, though , is something that we all live with whether we like it or not. The system can't pay for all possible treatments. Now, is the Oregon criteria fare or reasonable? I don't know, and I don't know how those decisions are made. I wouldn't want to be on the receiving end of a letter telling me that I won't get life-saving treatment, and I feel for this woman and everyone else in her position.

The fact that the letter offered a suicide option is horrible. I don't see a lot of need for discussion there - I think everyone would agree that was tasteless.

How we all feel about assisted-suicide is a topic of discussion, but I think the big one is rationing. We would love to have no rationing, but is that possible? I don't think so.

[brian_igo]

Crassness aside, if you have a 95% chance of dying from your cancer in the next five years, end-of-life options should be on the table.

Anyone want to go back to the days where doctors would hide a terminal diagnosis to spare the patient?

[conradd]

The Oregon Health Plan does have flaws but there is no question that it allows a greater number of people access to preventative health care. Before OHP was instituted in 1994, we had traditional Medicaid. This meant that pregnant women, babies, and senior citizens had very good health care with almost unlimited access. However, as soon as the women delivered and babies reached a certain age, they were no longer eligible. Seniors had to reach age 65 before they became eligible for coverage, then they had unlimited access to the health care system. This ended up with uncovered people putting off seeking medical care for minor conditions until they ended up in an emergency room. Since they were often unable to pay for the care they received, it resulted in a spiral of higher health care costs. Conversely, there was no oversight of medical care provided once people became eligible and Medicaid patients could (and did) see as many physicians as they wished. You can imagine the problems this caused with different prescribed medicines.

At that time, the president of the Oregon senate was a physician. He co-authored the Oregon Health Plan which took the Medicaid monies available to Oregon and made the sum available to a wider range of citizens through enrollment in managed care plans. Through a series of public meetings held throughout the state, the following guidelines were agreed upon as a guiding force for health care in Oregon:

• All citizens should have universal access to a basic level of care

• Society is responsible for financing care for poor people

• There must be a process to define a “basic” level of care

• The process must be based on criteria that are publicly debated, reflect a consensus of social values, and consider the good of society as a whole

• The health care delivery system must encourage use of services and procedures which are effective and appropriate, and discourage over-treatment

• Health care is one important factor affecting health; funding for health care must be balanced with other programs which also affect health

• Funding must be explicit and economically sustainable

• There must be clear accountability for allocating resources and for the human consequences of funding decisions


I worked on the start up phase, overseeing a team of enrollment counselors. We went to the homes of senior citizens who were currently enrolled in Medicaid to explain their options (loosely worded - while they did not have the option of remaining on their previous Medicaid plan, they could choose their managed care plan). Additionally, they were now covered for dental care. I will never forget one woman who had been pulling her own teeth because she couldn't afford dental care. I helped her find a dentist who fitted her with a full set of dentures. Another woman had a 6 foot dining room table that was covered with different prescriptions. She had been seeing a number of doctors and had a different pharmacy for each doctor. I helped her gather up all her prescriptions for a visit to her new managing care doctor. It took 2 shopping bags.

Yes, OHP is a rationing plan. However, the focus on preventative care allows many more people to be enrolled and receive a basic set of health care services under the eye of a primary care doctor who serves as gatekeeper to additional services. It's far more efficient that the previous system.

“The letter said doctor-assisted suicide would be covered. To say to someone, `we’ll pay for you to die, but not pay for you to live,’ it’s cruel,” she said. “I get angry. Who do they think they are?”

Dr. John Sattenspiel, senior medical director for LIPA, said that at some level doctor-assisted suicide could be considered as a palliative or comfort care measure. “We had no intent to upset her, but we do need to point out the options available to her under the Oregon Health Plan,” he said

Wagner, 64, lives in a low-income apartment in Springfield with her dachshund, Chachi. She’s a divorced mother, grandmother and great-grandmother, retired from driving a school bus and waiting tables.

She quit smoking when she was diagnosed about two years ago. Her oncologist, Dr. Jae Lee, treated the cancer with chemotherapy and radiation, and it went into remission, she said.

Brian's point is well taken. She may not want to hear about assisted suicide but it is an option, should the chemo fail. I'm not a fan, but it's legal.

So, should have the OHP paid for her treatment? $4,000 each month is a lot of money. That could provide preventative care for quite a few people.

Here's a list of services currently listed by the OHP:

What is covered?
The following services are examples of what may be covered by your benefit package:

* Diagnosis (services to find out what is wrong)
* Physician services
* Check-ups (medical and dental)
* Family planning services
* Maternity, prenatal, and newborn care
* Prescription services
* Hospital services
* Comfort care and hospice
* Dental services
* Alcohol/drug treatment
* Mental health services

What is not covered?
* Treatment for conditions that get better on their own, like colds
* Conditions that have no useful treatment
* Treatments that are not generally effective
* Cosmetic surgeries
* Gender changes
* Services to help you get pregnant
* Weight loss programs

Furthermore, out of 680 listed and prioritized conditions, the first 503 on the list are currently covered (down from 530 in the last biennium). By prioritizing diagnoses, the state is able to move the dividing line between covered and non-covered services up and down depending on available funding.

“The letter said doctor-assisted suicide would be covered. To say to someone, `we’ll pay for you to die, but not pay for you to live,’ it’s cruel,” she said. “I get angry. Who do they think they are?”

Dr. John Sattenspiel, senior medical director for LIPA, said that at some level doctor-assisted suicide could be considered as a palliative or comfort care measure. “We had no intent to upset her, but we do need to point out the options available to her under the Oregon Health Plan,” he said

Wagner, 64, lives in a low-income apartment in Springfield with her dachshund, Chachi. She’s a divorced mother, grandmother and great-grandmother, retired from driving a school bus and waiting tables.

She quit smoking when she was diagnosed about two years ago. Her oncologist, Dr. Jae Lee, treated the cancer with chemotherapy and radiation, and it went into remission, she said.

What hasn't been said is that at the age of diagnosis, she would not have been eligible for Medicaid. Under OHP, she's received medical care from an oncologist - chemo and radiation - and lived two years in remission before the cancer returned. Under the old plan, she would have had to live three years with cancer before eligibility for Medicaid and she most likely would have been dead before then.

It's a horrible choice, to decide based on efficacy of treatment and prognosis for recovery, who is covered and who is not. However, when taxpayers are footing the tab for treatment, government has an obligation to use resources wisely. OHP isn't perfect but it's far better than the previous system for many more people.

[jgibson2[$]]

brian_igo said

Crassness aside, if you have a 95% chance of dying from your cancer in the next five years, end-of-life options should be on the table.

Anyone want to go back to the days where doctors would hide a terminal diagnosis to spare the patient?

Unfortunately, we haven't gotten entirely away from hiding a terminal diagnosis to spare the patient. Sometimes it's family choice, sometimes it's physician discomfort.

In this case, the woman's physician believes she has a better than 5% chance of surviving with the new medication. The Oregon Health Plan chose to go with the old statistics, since the new medication hasn't been around for 5 years to have a track record. I can't really argue against their choice, given the expense of the medication. I do believe it's appropriate for the drug company to pony up if they want to prove that their new medication offers new hope. She looks like a poster child for that and if she, and others they choose, do well on the new regimen, OHP will have to change their reimbursement policy -- for a select group of patients.

[realtraveller]

I've been away but coming back to this thread. My point was that it was really cold for the state to send this letter. In effect it says, we have other more important priorities than the slim chance to save your life. However, the state will pay for your suicide because it costs us very little and saves us the cost of your last hospitalization. A very nice way for the state to add to this woman's emotional distress.