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A pediatric cardiologist in Texas reported to Commissioner Gary Glenn of Boise, ID, that an HMO is using ultrasound to detect fetal heart lesions. "Parents of affected babies are reportedly offered a free abortion but told that if they choose to carry the child to term, any medical expenses related to the heart defect would not be covered by the HMO."
Reading: "Is This Forced Abortion?", AAPS News, 11/96, p. 3
A similar story appeared on the front page of the April 12-14, 1996, weekend issue of USA Today. In this case an HMO refused to provide care for an unborn child with a gene for cystic fibrosis. It offered instead to pay for an abortion.1
I recall the many reassurances I have read and heard from those in the right-to-die camp that "assisted death" will not be forced on anyone should it be legalized. But can it be avoided in a burgeoning industry in which doctors are paid not to provide but to deny care?
If promoting the deaths of inconvenient and costly infants seems too far afield, one need not look far to find inconvenient adults whose deaths resulted when a managed care company deemed them too expensive to treat. An AP report on April 16, 1996, revealed the death in 1994 of a 33-year-old man who died of suffocation on the floor of his bathroom while over a period of 17 minutes his wife twice begged their HMO's physician-gatekeeper for permission to call an ambulance and was turned down.1
Many are the tales of cancer deaths caused by treatment delayed while a patient parleyed with an HMO over an expensive test. One such is the story, printed in U.S. New and World Report, of Joyce Ching. Joyce developed abdominal pain and rectal bleeding shortly after giving birth to her second child. After three office visits her symptoms remained unexplained. Her husband intervened and insisted on a definitive test. A barium enema ($261) was inconclusive. After three months of office visits, her allotted funds for the year were used up. Joyce Ching died several months later of colon cancer at the age of 32. A jury determined that it was the delay of a sigmoidoscopy (which would have been diagnostic but which cost $450) and the denial of referral to a specialist which cost Joyce her life.1
Then there is the New York Post report of the case of a man who repeatedly went to his HMO for constant chest pain. Though he failed many heart tests given him (which is well documented) he was refused hospital admission and was treated only with medication, despite asking several times for heart bypass surgery. Once he was told to take Tylenol for his chest pain. He was finally admitted to the intensive care unit of a hospital where he suffered a heart attack shortly after admission. After receiving the heart bypass surgery he had needed all along, this man, unlike many others less fortunate, recovered.1
It has been demonstrated in independent studies published in two medical journals2 that the death rate is lower for stroke and heart attack patients treated promptly by specialists than for those cared for immediately afterward by a family physician. The authors of both studies raise the concern that, in view of the rising use of HMO's, lives may be lost in the effort of managed care to limit access to specialists. This does not appear to be idle speculation. A Robert Woods Johnson Foundation study found that persons in HMOs were 40% more likely than those in fee-for-service plans to report trouble obtaining needed medical treatment.3
The Canadian experience reveals what happens when the attempt is made to hold down health care costs by limiting health care services. Our neighbors to the north have long had a single-payer health scheme in which, similar to our HMO system, health care is rationed. Contrary to expectations, availability of health care services has decreased, while costs have increased. A 1992 study found that patients waited an average of five weeks to see a specialist and 14 weeks for surgery. By the early '90s costs escalated to $8,600 per year for a family of four, and the government has progressively reduced financial funding due to short falls. Advanced equipment is often unavailable, hospital staffs have been reduced, and thousands of hospital beds have been cut. Health care facilities have been forced to cut back expenditures to the point where physicians must send patients needing specialized treatment to other countries, most notably the U.S. Many physicians themselves have forsaken their country for the purpose of continuing their medical practice elsewhere.4
In 1993, dogs at a hospital in Toronto were able to get CAT scans immediately while people were put on a waiting list. The reason? Dog owners were allowed to pay out of their own pockets. Because the hospital was forced to treat nonpaying patients, CAT scans became so expensive that the scanner could be operated for only a few hours a day, while the fees paid by dog owners allowed the machine to operate longer, thus covering usage by humans. When this information became public, the government acted to equalize treatment made available to people as compared to dogs: they outlawed the use of CAT scanners for animals!4
Neither governments nor HMOs can reduce demand by limiting supply. Simple economics should make that apparent. And common sense should make it apparent that when cost is the bottom line in health care, as it is in our managed care system, there will inevitably arise the need to cut costs by cutting expensive treatments. It does not tax the imagination to envision some future time when a patient is offered this option: die cheap or live without medical care. It's already happening to babies.
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Posted 9 Sep 2000
Copyright 1997 by P J King.
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