Thursday, August 27, 2009

Allocating Medical Care

Brant S. Mittler: Oregon ‘allocates’ medical care

01:00 AM EDT on Thursday, August 27, 2009


WHILE NO ONE wants to pull the plug on Grandma, there are a lot of well-educated folks around the country looking for ways to use “scientific evidence” to do just that. One such place is Oregon, where the state’s Medicaid program has featured a Prioritized List of diagnoses and treatments for the past 20 years. “Prioritized List” is another way to say rationing. So is “allocation of scarce medical resources.”

You may have seen the headlines last summer, when Barbara Wagner, a 64-year-old Oregon great-grandmother with advanced lung cancer, got an unsigned letter saying that the Oregon Health Plan (OHP) would not pay for a $4,000-a-month chemotherapy drug, but would pay the $50 cost of physician-assisted suicide.

That’s because in 1989 Oregon decided to make a comprehensive list of all treatments and diagnoses and rank them by importance to society in preventing disease and doing the most good.

Oregon appoints a panel of 11 experts, called the Health Services Commission, “to rank medical services from most to least important to the low-income population.” Five commissioners must be licensed physicians. Other members include a public-health nurse, a social worker and four medical consumers to construct the Prioritized List.

They use evidence from specialty groups and scientific clinical trials — the kind the Obama administration and Congress want to use — to rank these diseases and treatments from 1 to 679. Then the legislature decides how much care poor people get by drawing a line every two years — lately between treatments 502 (cysts of the vaginal area ) and 503 (a skin condition called lichen planus) based on how much money they have to spend. Everything above the line is covered; everything below the line is not paid for.

In case you’re wondering, the American Academy of Dermatology says, “There is no known cure for Lichen Planus but treatment is often effective in relieving itching and in improving the appearance of the rash until it goes away.” That treatment often requires prescription-strength steroids.

For its 2010-2011 budget, Oregon ranks Pregnancy/Maternity Care at No. 1; Abuse or Dependence of psychoactive substance is No. 5; Type I Diabetes is No. 10; Type II Diabetes is No. 33; and acute heart attack ranks No. 75; Heart Failure is No. 108, only slightly behind Undescended Testicle No. 103.

There are other rules. For example, they don’t pay to treat cancer patients who only have a 5-percent or less chance of living for five years. That’s why Mrs. Wagner didn’t get the chemotherapy — until the drug company that made it sent it to her for free. But she died five months later — as the evidence predicted. But 53-year-old Randy Stroup, of Dexter, Ore., a grandfather of five, managed to live over a year after the OHP denied him chemotherapy for advanced prostate cancer.

Oregon’s treatment of Wagner squares with another approach to rationing advocated by White House medical adviser Dr. Ezekiel Emanuel, a cancer specialist and medical ethicist. Emanuel and co-authors wrote in the Jan. 31 issue of the Lancet that the rationing of scarce medical resources would best use a “completed lives” system that favored those resources — such as hard-to-get donated kidneys and hearts — for those who had the most life to live. That means the very young and the very old are at the end of the line.

How successful has Oregon been with its allocation scheme? Has it been able to care for more poor people than other states? Has it been able to free itself of budget worries?

The answers are mixed. When it first took effect in 1994, Oregon had about 18 percent uninsured. That number dropped to 10 percent but then climbed back up to 17 percent as budget woes in 2004 caused the Oregon legislature to cut back on services and close new enrollment. The latest cuts are in vision care and dental care.

University of North Carolina health-policy Prof. Jonathan Oberlander described the “unraveling” of the OHP over time, brought on by high unemployment and taxpayers’ refusal to fund the program adequately. The Priority List and the managed-care plans that have administered it have been no cure for increasing numbers of uninsured and medical inflation. Oberlander concluded that “rationing is no substitute for revenues, and without that financial commitment, large-scale public insurance expansions cannot succeed, in Oregon or elsewhere.”

Oregon’s OHP is but one of the many state experiments in health reform – along with Massachusetts and Maine — that offer some insight into what’s in store with national health reform. Rationing for the poor may become rationing for everyone if the OHP’s model is adopted nationally.

Brant S Mittler, M.D., is a cardiologist and a lawyer with an interest in health-care reform. He may be reached by e-mail at

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