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Medicine's Rising Costs Put Hippocratic Oath At Risk

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Medicine's Rising Costs Put Hippocratic Oath At Risk

Health Care

Medicine's Rising Costs Put Hippocratic Oath At Risk

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This is FRESH AIR. I'm Dave Davies, filling in for Terry Gross.

When health care policy is debated, some warn that a greater role for government means bureaucrats will be rationing care. Others counter that insurance companies are already doing that.

Our guest, Gregg Bloche, is a health policy analyst who says doctors themselves increasingly have to decide which patients will get expensive tests and treatments and which ones won't. In his new book, Bloche argues that modern medicine forces doctors to disregard the Hippocratic Oath, which obliges them to put their patients' interests above all else.

He says society needs to rethink the relationship between physician and patient and be more honest about the choices that are made in providing health care. Gregg Bloche is a graduate of both Yale Law School and the Yale Medical School, and he completed a residency in psychiatry at the Columbia Presbyterian Medical Center.

H: Why Doctors Are Under Pressure to Ration Care, Practice Politics, and Compromise their Promise to Heal"

Well, Gregg Bloche, welcome to FRESH AIR. Now, you write in the book that under the health care system we have now, doctors are often put in the position of rationing care and, you know, withholding or denying some treatments or tests, sometimes without even really being aware of it. Give us an example of how this works.

GREGG BLOCHE: Yeah, let me tell you about Sara(ph).

Sara was an 82-year-old grandma who was visiting her daughter, and she suffers a massive heart attack. Paramedics rush her to the hospital, she's quickly taken to the intensive care unit and put on all manner of monitors with fancy chemicals dripping into her body through all sorts of tubes, and this is costing tens of thousands of dollars just to keep her alive for a few days.

The doctors come to a conclusion that her prognosis is dismal. They think she almost certainly is not going to make it, and in their minds, understandably, almost certainly becomes certainly.

And they tell Sara and her daughter that things look really dismal and that they'd better start making plans, end-of-life plans, and that it didn't make sense to continue aggressive treatment.

And only later does a doctor come in, say something really tactless about how much it costs to provide all this treatment. The reference to cost causes the daughter to flip out, become enraged and to demand all aggressive treatment. And the doctors, afraid of the daughter, go ahead and treat Sara really aggressively. And within a couple of weeks, Sara walks out of the hospital on her own power, and she lives for another year or so.

And for the doctors, this was a shock because the tiny, tiny chance that Sara could make it became in their minds a zero chance. The fact that she made it shows that there was a chance. But the reality was that these doctors were under tremendous pressure to set limits on behalf of their health plan; tremendous pressure not to spend tens of thousands of dollars on Sara when they were pretty sure that she wasn't going to make it.

DAVIES: Yeah, we ration care. We ration care every day.

And so sometimes are aware of it, and sometimes they're not because it's so at odds with the Hippocratic ideal that they kind of push it to the back of their mind and then out of their mind.

DAVIES: And what was that tactless thing that the doctor said to Sara's daughter?

BLOCHE: Well, one of the doctors comes into the intensive care unit while Sara's daughter is sitting by the bedside and says: Well, have you ever stayed in a really expensive hotel? And Sara says: Yeah, I guess so. And the doctor says: Well, you know, how much do you think an expensive hotel costs? Sara says maybe: $600, $800. And the doctor says: Well, this room costs $10,000.

And of course, the message there is you are wasting the public's money by being here. You are wasting the public's money by continuing to breathe, and it was that moment that led Sara's daughter to flip out, to become furious; that moment of loss of trust.

And what are the lessons that the doctors, the other doctors took from that? Well, not that covert rationing is a bad thing but rather we've got to do better at keeping the relationship intact because we can't afford to provide Sara that room in that really expensive hotel.

DAVIES: Now, help us understand what it is doctors are thinking about when they, you know, deny a treatment that might be beneficial but is expensive. Is it because they have rules from a medical director above them? Do they get a cash incentive for saving money? How does it actually work?

BLOCHE: Increasingly, we're seeing financial incentives to be frugal. In fact, actually, in the health reform bill, one provision that's troubling in a law that, for the most part, I think is a wonderful moral advance for our country, one provision that's troubling is the creation of so-called accountable care organizations that might well have Medicare in the business of giving doctors incentives covertly to skimp on care.

I think we'll be seeing more of this. We also certainly have rules being set by medical directors in large medical group practices, rules that lay out policies for limit setting.

What we don't have, Dave, what we don't have, and this is really a troubling thing, what we don't have is candor in health insurance contracts and in the laws and regulations that govern Medicare and other public programs, candor about the balances to be struck between costs and benefits.

DAVIES: Now, you write that insurers typically promise to pay for any treatment that is, quote, "medically necessary," unquote, right?

BLOCHE: Exactly.

DAVIES: Now what - that sounds pretty clear: You've got to do what you need to do. Why does it leave wiggle room?

BLOCHE: Well, the average person thinks that medically necessary care means all care that might potentially be beneficial. But the reality is it's a wide- open term. It typically gets construed by courts and administrative agencies to mean the care that most doctors provide. And so doctors get to set the standards.

But patients and the public expect that it means all necessary care. And so when we find examples of covert rationing, when we find examples of potentially beneficial care being denied, we tend to get really angry.

DAVIES: And I'm sure a number of cases have gone to court on this. What do the courts say about the legality of rationing care based on cost, on saving money?

BLOCHE: Well, the courts have been all over the map on this issue. The U.S. Supreme Court, 11 years ago in a unanimous decision, in a case known as Pegram versus Herdrich, said explicitly that HMOs ration care, they offer doctors incentives to ration care, that that is legal, that the Congress of the United States approved of this when it enacted the HMO Act back in the early 1970s and that there ought be no liability for it, at least under federal law.

But other courts, state courts, in hearing cases when insurance companies have refused to cover care, have oftentimes insisted on the provision of all potentially beneficial care. And to a large extent, the courts defer to doctors to set standards of care.

DAVIES: Well, you've told us how doctors are often withholding care in some cases, rationing it; sometimes consciously, sometimes unconsciously. But you also believe that, in a way, this is inevitable, right?

BLOCHE: Yes. Yeah, absolutely.


BLOCHE: Well, first of all, we're going to have to find some way to set limits. We cannot afford anything like what we're spending on health care today, and we're certainly not going to be able to afford what we're projected to spend in the future.

We spend almost a fifth of our national income today on medical care. And within 25 years, unless we change dramatically, we're going to be spending about a third of our national income on medical care. And we're doing that by borrowing from our kids.

This is a huge part of why we're running a one-and-a-half-trillion-dollar federal budget deficit and why those deficits are projected to continue at nightmarish levels.

The debates in Congress today over discretionary spending - chump change compared to what we're spending on the Medicare program and the Medicaid program. So we have to find some ways to set limits.

DAVIES: Our guest is Gregg Bloche. He is an attorney, health policy analyst and a psychiatrist. His new book is "The Hippocratic Myth." We'll talk more after a short break. This is FRESH AIR.


DAVIES: If you're just joining us, our guest is Gregg Bloche. He is a physician, a psychiatrist, an attorney and health policy analyst. He's written a new book called "The Hippocratic Myth: Why Doctors Are Under Pressure to Ration Care, Practice Politics, and Compromise their Promise to Heal."

Now, you've written that a lot of people say that 30 percent of health spending is wasted on care that is not effective. If we know that a lot of the tests and treatments that we're providing don't really help, how do we get a handle on that? I mean, can you wean out those which aren't effective and thereby reduce costs?

BLOCHE: To some extent yes, but that's not going to be the whole of the solution to our problem of health care costs.

There's two things going on here. Number one, we're just not putting the resources in to doing research on which treatments do and don't work that we ought to be putting in.

Now, the health reform law takes a big step forward with a - an unprecedented committed to what's called - what we policy wonks call comparative effectiveness research. And that's just a fancy way of referring to research that tries to figure out which of the treatments we use now actually work.

What's amazing is that probably only about 10 to 20 percent of the treatments that doctors use today have been tested based on the so-called gold standard of clinical science, the randomized clinical trial.

And then even when a treatment tests in, a treatment is shown to work really well for the sample that's studied in the clinical trial, in the real world patients are all different. And so we're never going to be able to have solid science that can tell us in advance, for sure, whether the treatment is going to work or not.

So let's do the research, but let's be realistic. Let's pragmatic about the limits of that research.

DAVIES: Now, one of the things you write in the book is that when high-tech, very expensive treatments and tests are developed, they tend to get employed, and patients billed for them, whether we really know whether they work or not. Can you give us an example of that?

BLOCHE: Exactly, exactly. Well, one recent example, really a nice piece by the health journalist Julie Applebee, sets this example out.

Back in 2007, a so-called 64-slice CT scanner came into use, really high- resolution. Cardiologists loved it. They started buying it for their offices, and...

DAVIES: What does that mean, 64-slice?

BLOCHE: It means 64 different levels of images very close together. A CT scanner works by taking a cross section of the part of the body that it's scanning.

DAVIES: So you get a three-dimensional picture, in other words, right?

BLOCHE: Exactly. It's a three-dimensional picture that's made up from a whole bunch of slices. Imagine looking at cross sections, at multiple levels of something. You can do a cross section of the brain at multiple levels. And the closer the cross sections are to each other, the finer the resolution on the CT scan.

So 64-slice is just a fancy way of saying a really high-resolution CT scanner, so high-end resolution that you could put people in it and look at their hearts and figure out how much coronary artery blockage they had without putting a catheter inside their arteries to pump dye into their arteries, which was a rather scary way of assessing levels of coronary artery blockage.

So the cardiologists loved this. They could buy this machine and charge a huge amount for it and show beautiful pictures, stunning pictures, colorful pictures, of people's coronary arteries and the degree of blockage.

Only thing is that this test, it turn out, only turned useful for a very small number of patients who had serious coronary vascular disease. Medicare agreed to pay for it only for this small number of patients.

But the cardiologists exercised their right to petition their government. They lobbied Congress. Seventy-nine congressman from both parties wrote a letter to the agency that runs Medicare, saying: Cover this thing. Medicare soon rescinded its limiting rule and agreed to cover the test much more broadly.

So politics plays a big role in the movement of expensive technologies that yield only tiny benefits right into the marketplace. And then the developers of these technologies know that. And so they keep spending. The investment bankers know it. The venture capitalists know it.

And so the money train of investment keeps pouring resources into the development of technologies that are at once astonishingly, dazzlingly impressive in engineering terms and in computer software terms and really crude in terms of the human biology that they rely upon.

DAVIES: So it seems that we have two things working at cross purposes here. We have this expensive stuff being developed that may be marginally effective but which then gets used a lot because powerful interests promote them.

T: Not so fast. We think we can give you Tylenol and send you home.

BLOCHE: Exactly, exactly. And the two sides represent the two sides of us. The special interests who are able to get their technologies onto the market despite lack of proof that they work rely upon use loving the technologies, having hope in the technologies and believing that those technologies will save grandma.

That's why they were able to get 79 congressmen, in the case of the 64-slice CT scanner, to write in because those congressmen know that it's really easy to portray government as stinting on grandma's care.

DAVIES: And doctors - I mean, one of the examples that you point to is doctors - how often should they order MRIs for women looking for breast cancer, right?

BLOCHE: Right.

DAVIES: And there's a truly legitimate question there about how often those should be ordered, and they're expensive, right?

BLOCHE: That's right, that's right.

DAVIES: So is that one of those cases where you think in the real world, in a rational world, doctors are going to have to make some tough decisions and use that less frequently than you would if you wanted to be completely thorough and catch every single case? How do we make that calculation?

BLOCHE: Yeah. There's a tiny, tiny advantage that you can gain in lots of cases by doing an MRI to assess the risk of breast cancer, compared to doing a mammogram. And yet doing an MRI can cost upwards of $1,000. A mammogram is, of course, much cheaper. And so there's a balance to be struck there.

We need to talk openly about that balance. Right now, the practice rules that tell doctors when they should and shouldn't order MRIs to screen for breast cancer say nothing explicitly about the role of cost. We need to have an open conversation about how to count costs, about how to count costs not just when we're talking about MRIs to rule out breast cancer but in a bunch of other situations involving both diagnostic screening tests and actual treatment.

If we have an open discussion of cost, if we have rules about much cost will count in health plan contracts so that people can make choices in advance, then, you know what, we will have a sense of tragedy. We will have a sense of possibilities foreclosed by the realities of our budgets. But we will not have the kind of outrage that emerges when we think our doctors are doing all, and in fact they've covertly counted costs.

DAVIES: You say in discussing what we need to do, that we need to empower doctors to say no to care that's technologically possible and may prolong life, that you have to empower doctors to do so even when the consequences seem tragic and develop rules that will, at times, result in heartrending outcomes.

And it strikes me that this involves really hundreds of decisions about different kinds of tests and treatments. You decide what's a reasonable, rationable set of recommendations, and then you expect doctors to tell their patients: We as a society have decided we can't afford to give you this test for this condition.

BLOCHE: What the doctor can then do is to say to her or his patient: That's not something that I'm allowed to do, that's not something that the rules permit me to do, just like a lawyer is not allowed to present false information to a tribunal, even though it's a lawyer's obligation to stand by his or her client. The key here is that society ought to be making these rules.

We make these rules in other parts of our public and private lives. The federal government values life for the purpose of making decisions about airline safety, making decisions about occupational safety. The Environmental Protection Agency acts based on values of life. And the Office of Management and Budget within the White House tries to make sure that regulations are consistent in different agencies in how they value life.

In fact, there's people who research this, and the general consensus is that we value life, for purposes of public policy, roughly between $5 and $10 million per life saved.

Now, this all sounds pretty brutal. It certainly is a way in which economics earns its moniker, the dismal science. But the reality is if we go above that, if we, say, spend $50 million to save a life in health care, as opposed to $5 to $10 million, then that $50 million we don't have to save a bunch of other lives, and that's $50 million that leads to the sacrifice of other people's lives.

And so those decisions need to be made as visibly, as publicly in health care as they are in other areas of our public affairs.

DAVIES: Well, Gregg Bloche, it's been interesting. Thanks so much.

BLOCHE: Thank you very much, Dave, for having me.

DAVIES: Gregg Bloche is a health policy analyst and law professor at Georgetown University. His new book is called "The Hippocratic Myth."

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