[ Pobierz całość w formacie PDF ]
.But only the physicianon the ground can make the determination as to whether less serious condi-tions of these sorts will grow worse.Yes, this will be a judgment call.Theprocess will be subject to moral hazard, which is the tendency for medicalproviders to supply more health care than necessary, simply because it is notthey nor the patient but the insurer who will have to pay for it.A doctormight claim that a patient s athlete s foot will develop into something worse,even when this is unlikely, simply to obtain coverage for that patient.Yet as it is, the risk of moral hazard is ever present.Right now, physiciansassociated with health maintenance organizations face an incentive to claimthat a patient s condition continues to remain serious when it has in factimproved, so that insurance will continue paying for treatment.To curb thiskind of abuse, nearly every state has established external appeals committees(discussed in chapter 8) composed of independent physicians.These commit-tees could expand their purview to embrace public health insurance and toconsider disagreements over whether a patient s current condition is likely tobecome more serious.In any event, the private market criterion for covering less serious conditions the principle that such conditions should be covered 0333-4-07 ch07:Layout 1 10/29/09 3:34 PM Page 111THIN THE SOUP OR SHORTEN THE LINE? 111only when they will grow more serious and hence more costly should notextend benefits as far as would the public sphere criterion, which can be usedto argue that any and all conditions deserve equal recognition and coverage.The basic structure of the debate over expansion or contraction of publichealth insurance, and its consequences for the extent to which families shouldhave to rely on their own private resources to meet their health care needs,replays itself in every state.It will emerge, too, in any federal-level debate overa national public insurance program.That basic debate pits those who wish tosee public health insurance cover the sickest, even if not the poorest, againstthose who would like to see insurance cover the poorest, even in circumstanceswhere they are not the sickest.And each side draws equally albeit in inverseways on public sphere values of civic validation, and private market valuesof a fair return for effort and expenditure, to make its case.A defensible consensus between these two sides can be reached, though, byappealing to only one of those two commonly held sets of values the privatemarket values and combining each side s interpretation of them.So whetherlegislators are expanding or contracting the public health insurance system,they should set eligibility levels to furnish working individuals with an appro-priate return for their efforts, not to buy their civic support.And they shouldcover less serious conditions to provide the public health insurance systemwith an appropriate return for its outlays, not to extend civic validation topoor individuals suffering from those conditions.These private market crite-ria will, in the foreseeable future, be demanding enough for strained publicbudgets.When faced with a difficult choice of shortening the line or thinningthe soup, we should at least choose for the right reasons. 0333-4-08 ch08:Layout 1 10/29/09 3:37 PM Page 1128TOURING THE BOUNDARYOF MEDICAL NECESSITYDeborah Fuller was proud of her long, brown ringlets when she wasa child.But as an adult she suffers from alopecia areata, an ailment that causessubstantial, often total, hair loss from the scalp.Testifying before a state legisla-tive committee in New Hampshire in 1992, Fuller asked whether she mightremove her wig: If it would not upset anyone, she said, I would like todemonstrate what it looks like to have alopecia. The committee was consid-ering whether the state should mandate require private health insurers topay for wigs for such patients.The question in New Hampshire and otherstates has been: Are wigs in such cases a medical necessity ?Yes, they are, Fuller argued. There are people who consider suicide becauseof [alopecia].I didn t because I am a strong person, but I will tell you that this, and she pointed to her wig, replaces a shrink in a minute. 1 The problem isthat a proper wig can cost up to $3,000, and many patients cannot afford onewithout help from their insurance companies.Yet it could cost as much as $6billion to provide wigs for the estimated two million to three million womenin the United States who suffer from the disease.No one, including spokespersons for the insurance industry, would denythat cancer care or hip replacements are medical necessities and warrant insur-ance coverage unlike, say, a visit to a spa to relieve stress.But between thepoles of the clearly necessary and the plainly not, the terrain grows ever morecontested, with patients arguing for medical necessity where insurers see none.112 0333-4-08 ch08:Layout 1 10/29/09 3:37 PM Page 113TOURING THE BOUNDARY OF MEDICAL NECESSITY 113Indeed, what used to be a cold war has recently turned hot.During the pastcouple of decades, legislatures in every state have considered bills that wouldmandate private insurers to cover everything from wigs for alopecia patientsto Viagra to abortion.The amounts of money involved can be substantial.Viagra, which came on the market in 1998, now racks up over $1.6 billion insales annually.Infertility afflicts around 6 million American women and theirpartners; the cost of treatment ranges anywhere between $10,000 and $40,000,depending on the number of rounds needed.And in addition to legislativehearings, forty states in the past few years have established external appealspanels: rosters of independent physicians who arbitrate disputes betweenpatients and their health insurers, including health maintenance organiza-tions, making decisions thousands of them annually about what ismedically necessary in particularly hard cases.Insurers sometimes claim to be agnostic about the medical necessity of thecontested procedures.Their real concern, they say, is that each new coveredservice drives up the price of insurance.But if cost were the only issue, theywould be covering contraceptives, which they don t, but not cancer care, whichthey do.In fact, insurers employ an arsenal of arguments in their struggle withpatients in order to draw the boundary of medical necessity to exclude orinclude various conditions.One of their weapons of choice is analogy: insur-ers will liken a proposed procedure to one that anyone would concede liesbeyond the realm of medical necessity.If insurers were required to cover wigsfor alopecia sufferers, what would be next? Would they have to cover wigs formale pattern baldness? Or long-sleeved shirts for eczema sufferers? Patientscounter with analogies of their own: because insurers cover ointments foralopecia, they have in effect acknowledged that alopecia unlike male patternbaldness is a real medical condition.And because insurers cover wigs forchemotherapy patients, they have acknowledged that wigs unlike long-sleeved shirts are a genuine medical treatment
[ Pobierz całość w formacie PDF ]
Tematy
IndexMark A. Noll, Luke E. Harlow Religion and American Politics, From the Colonial Period to the Present (2007)
Jesse Fox Mayshark Post pop cinema; The search for meaning in new America (2007)(1)
William Inboden Religion and American Foreign Policy, 1945 1960, The Soul of Containment (2008)
R. Murray Thomas Manitou and God, North American Indian Religions and Christian Culture (2007
Philip Gordon, Jeremy Shapiro Allies At War, America, Europe and the Crisis Over Iraq (2004)
Jane Elliott Popular Feminist Fiction as American Allegory, Representing National Time (2008)
Cathy J. Cohen Democracy Remixed, Black Youth and the Future of American Politics (2010)
Kate Roman Lionheart
WhiteFeather Sher Egzotyczny ptak 10
Lama Zopa Rinpoche Teachings from the Mani Retreat