Selling Physician-Assisted Suicide For Big Savings

Somehow I managed to miss the fuss back in July when the Oregon Health Plan -- the state's medical-coverage plan for low-income residents -- told cancer patient Barbara Wagner that it wouldn't cover the expensive drug Tarceva, but that it would pay for palliative care, including "physician-assisted suicide." (In the glare of subsequent publicity, the state acknowledged its mistake and said it is "working on" clarity and "sensitivity." Wagner ended up getting her lung-cancer drug for free from the manufacturer.)

Enter Richard Fogoros ("DrRich") of the Covert Rationing Blog, who expresses sympathy for the Oregon plan and offers some helpful suggestions as to how insurers might suggest that their members off themselves with greater sensitivity:

It is a fundamental task of health plans to deliver unpleasant news to people whose lives are at stake, and it is normal ?€" even necessary ?€" for those who are charged with this task to grow thick skin. It is perfectly predictable that such thick skin might dull one's ability to discern subtle differences in degree between various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appears to say, is the problem in the case of Ms. Wagner. The solution, consequently, is not a substantive change in any policy, but better public relations....

How Health Plans Should Sell Assisted Suicide
1) Don't be so anxious.
Sure it's easy to get excited about physician-assisted suicide.... Whatever sort of health plan you are running, it's likely that a huge proportion of your spending goes to patients who are in the last year of life. Enticing these end-of-lifers to choose assisted suicide (which you can accomplish in a sufficiently tasteful way for about $100) is such an attractive proposition that it's indeed become very hard to make yourself appear reasonably circumspect about it.... But doing even that much is a mistake....

2) Publicly disown assisted suicide....
What you need to do is pretend that encouraging assisted suicide ?€" even if it's a covered service that patients ought to be made aware of ?€" is the farthest thing from your mind. Instead, you are completely invested in and insistent upon providing full-service end-of-life care, with all the bells and whistles and no holds barred; and ?€" while patients of course have the option to exercise their individual autonomy as they see fit ?€" you take great pride in squeezing every last instant of life out of those elderly, used-up, chronically ill bodies that present themselves in your ICU, no matter what the cost to the patient and family in terms of pain, suffering, humiliation and anguish. It is your mission to stave off death to the bitter end, come what may, and you're proud of it.

3) Have somebody else push it.
In the meantime, clear the path for agencies and interest groups which are dedicated to the end-of-life movement. There are plenty of them out there. Have them do the selling for you....

4) Make the advantages to assisted suicide seem real....
5) Tell patients to consult with their doctors before making this choice....
6) Make physician-assisted suicide legal, but not reimbursable....

I've excerpted quite a bit -- it's a long and cleverly argued post worth reading in its entirety. Just bear in mind that DrRich's overarching point is that the entire healthcare system is rigged to obscure the fact that we really can't "have it all" in healthcare, thus creating a system of "covert rationing" that reins in costs by denying care in subtle and indirect ways. It's a cynical and refreshing take on modern healthcare, although as with any satire, it's sometimes difficult to discern the line between what DrRich actually believes and what he's merely exaggerating for effect.

Also, for what it's worth, the Oregon Health Plan probably did get a bad rap here. For instance, its justification for refusing to cover Tarceva -- that the drug hasn't been shown to improve five-year survival by five percent -- is perfectly reasonable. In general, OHP has long been one of the more forward-thinking and generous state efforts to cover low-income people. Its PR problem has long been that it rations healthcare overtly instead of covertly, which brings to the fore all the uncomfortable issues that most people simply don't want to even hear about, much less confront, in terms of the practical and economic limits to what we our healthcare system can deliver.

Update: DrRich clarifies his satirical intent in an uncharacteristically serious follow-up post that makes a rather thorough -- and convincing -- argument against physician-assisted suicide, especially under a system that practices covert rationing.