Health Insurance and Public Policy: Risk, Allocation, and Equity

By Miriam K. Mills; Robert H. Blank | Go to book overview

many young people initially into medicine was the aura of omniscience attributed to the profession and the combination of power of position and the ability to make major changes in relief of human suffering. Cost constraint was not taught within medical schools (although doubtless this will now become incorporated within curricula). Inexorably, the physician becomes a deliverer of care according to formula. Similar to completing one's very own oil painting with the numbers, giving even the most untalented a sense of "creativity," so too the physician's area of independence becomes steadily more circumscribed. Those who monitor the performance become as vital, if not more so, to the hospital stability as those who provide the treatment.


CONCLUSION

Oregon health officials have overhauled the rankings and produced a list that is far more reflective of popular sentiment, a kind of health care by democracy. Medicaid, the federal-state health care program for the poor, will finance treatments only for those procedures in the upper part of the list. "The money saved by eliminating costly procedures at the bottom will be used to provide treatment for many more people. To spread the money around to every Oregonian who is without health insurance, fewer options for treatment would be available to the 190,000 who are receiving Medicaid now" ( Egan, 1991).

Included among the highest benefits are several types of pneumonia, tuberculosis, peritonitis, appendicitis. Listed among the lowest are terminal HIV disease, chronic pancreatitis, superficial wounds, and encephaly where a child is born without a brain. The cutoff--the line below which no public financing would be provided--will be after actuaries determine the full cost of the operations in the budget. Representative Henry Waxman, the California Democrat who is chairman of the House Health and Environment Committee, said the plan set up a two-tier medical system--one for those with access to costly miracles and modern medicine and one for those without. Some see this as a model for a national health care system. The existing system already amounted to health care rationing by default, because it deprived so many of any health insurance.

This plan is an example of the ultimate implication of a DRG approach. In addition, there has been the activity of health evaluation services that review physicians' treatment plans. Many doctors do not like these. About 10 percent of all proposed tests or operations reviewed proved clearly unnecessary when subjected to careful scrutiny. The year-long study on the efficacy found that 34 percent of the cases failed the first screening. After a further investigation, a total of 11 percent of the cases reviewed were deemed inappropriate. In some cases, the doctors agree not to perform procedures after talking with reviewers. In others, they go ahead anyway.

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