Accountability for Reasonable
Limits to Care
CAN WE MEET THE CHALLENGES?
All health systems, whether public or private or rich or poor, limit access to medical care. Occasionally, this limit setting takes the form of a public melodrama focused on the “heartless” denial by an “evil” insurer or bureaucrat of a “last-chance” treatment for a dying patient. Such drama leaves little room for the limit setter to claim moral authority. For example, when Medicaid denied coverage for a bone marrow transplant to young Coby Howard in Oregon, the script of the public drama barely mentioned the fact that he was not in remission from his leukemia and therefore was not even eligible for a transplant.
The backlash against this case propelled the state to evaluate its Medicaid coverage through a process that attracted international attention. Yet most lightning-rod cases yield no such positive, if unintended, side effects. In Fox v. Health Net (Sup. Ct. 219692 ), for example, a California jury decided that a private insurer's initial denial of an unproven bone marrow transplant contributed to the patient's death. The resulting $89 million judgment, combined with lobbying by interest groups, helped make bone marrow transplant the standard of care for advanced breast cancer—delaying discovery that such treatment was ineffective.
Public melodramas generally mislead people about efforts to set limits on health care, for most such efforts do not involve last-chance rescues. Avoiding these dramas—and viewing extreme situations more critically and dispassionately— requires that we learn how to set limits fairly and well in more typical settings.
Consider a case that entailed more established treatments and no life-saving rescue. When Massachusetts Medicaid recently faced cuts owing to steep declines in state revenue, the high cost of psychiatric drugs became a target (Sabin and Daniels 2003a). The agency established a process through which key stakeholders would develop a cost-reducing coverage policy acceptable to psychiatrists and patient advocates. Despite opposition by the American Psychiatric Association (APA) to limits on drug coverage, including requirements that providers obtain prior approval, the decision-making process secured acceptance of the plan among local psychiatrists and patient advocates.