John La Puma, M.D.
MANAGED CARE August 1997. ©1997 Stezzi Communications

John La Puma, M.D.

The Supreme Court decided last month that laws in New York and Washington states outlawing suicide were valid: Physician-assisted suicide is not a constitutional right.

The fact that so many patients — almost two-thirds in most polls — consistently seem to want a suicide option is an opportunity for managed care to take the high road.

Not that it can afford to take any other. As Ben Mattlin of Los Angeles asked in a letter to the New York Times just before the Supreme Court's June 26 decision: "Why are we rushing to legalize assisted suicide before making every effort to get those of us living on the fringes to feel valued, or at least comfortable? I fear it is because, in this era of managed care, assisted suicide is cheaper."

Like Dennis Rodman, managed care has an image problem, at minimum. Even if physician-assisted suicide were both legally permissible and morally defensible as public policy, it would be the wrong thing for managed care. Why? No one would believe that managed care organizations really wanted to do the right thing. Everyone would think they wanted to do what would not cost much, and what will help them compete in the market.

Unlike Dennis Rodman, managed care cares deeply about how much it gets paid. It is not in the game for love. And that's the problem.

Managed care must have a stronger sense of public mission than merely "the cheapest available option." It must strive to be the Gap, the Microsoft, the Neiman-Marcus of health care systems, not the Dollar Store. Its service must be first-rate, and its concern about costs must be invisible behind its love of quality.

Facing patients' fears

Managed care must explicitly address the fears of patients who request physician-assisted suicide. Fear of suffocation. Fear of pain. Fear of suffering. Fear of being a burden.

Nearly every physician has heard a patient say. "Doc, can't you just give me something to, you know, take care of this if I have to?"

The ethical answer depends on whether you are a doctor to this patient.

Suicide can be moral, but not medical. Rarely, there may be good, sound philosophical reasons why life is no longer worth living. These reasons can only be reliably invoked by a patient with full decision-making capacity. Profoundly disturbing studies in Australia and the Netherlands, however, indicate that some patients' families and physicians are good — too good — at creating these reasons when the patients themselves do not.

But the personal moral act of assisting in a patient's suicide should not be dressed up in physicians' clothing and called "medical." What medical justification could there be to kill a patient? It would be a pretense to say that overprescribing narcotics or injecting potassium chloride or other such gruesome acts are "treatments." What is their indication? Contraindication? Adverse effects?

Can anyone, especially experienced physicians, say that certain people are high enough on a miserableness scale that it is "rational" and "appropriate" to help them die? How far away from those clinical determinations is "medically necessary"? How can we compare these "worthy" patients with those whose illness is less advanced but whose spiritual sense of suffering is greater, or who have fewer family members to express their wishes?

The whole physician-assisted suicide business reeks. It is the wrong business for managed care, already suspect for judgments about ethics and necessity.

Better options

Surprising and comforting patients in need would be a better approach.

Attention to patient and family psychological, social and spiritual needs might be offered by a special quality-of-life team. Nonmedical needs are as important as medical ones, and they exist even for those dying patients who do not wish to refuse all life-sustaining measures. These patients, too, must be given the choice, comfort and dignity that ought to characterize care near the end of life.

If monitoring the quality of life at the end of life were part of the Health Plan Employer Data and Information Set measurements, along with mammography, vaccination and pneumovax rates, then perhaps the demand for physician-assisted suicide would lessen.

If coding and registering "do not resuscitate" orders were routine and centralized, then emergency treatment and unwanted transfer to emergency departments from home and long-term care facilities might be prevented. More than half of the states now authorize nonhospital "do not resuscitate" forms, but none authorize physician-assisted suicide.

These innovative approaches and others must be tested, evaluated, and — if patients find them helpful — implemented. As Christine Cassel, M.D., and Bruce Vladeck, Ph.D., wrote earlier this year in praise of a new diagnosis code for palliative care:

"It is never too late to provide greater comfort, especially since we have extraordinary pharmacologic and other tools with which to do so. Nothing is more gratifying than being able to relieve pain and suffering. Such gratification ought to be taught and modeled as one of the supreme satisfactions and rewards of the healing professions."

Because of managed care's potential for population-based health, it can instill confidence and alleviate fear with more than one patient at a time.

An array of options exists for managed care organizations, including:

  1. physician, physician assistant and nurse practitioner training in supportive care methods, skills and techniques;
  2. better physician knowledge about pain control;
  3. personal, focused advance care planning, with or without recorded advance directives (which are often uninterpretable and seldom discussed with physician and proxy);
  4. expanded use of hospice care, and an expanded definition and scope of hospice itself, and
  5. better communication about patients' fears of being a burden, of suffocating, of having pain, of suffering.

These goals may be hard for managed care to publicize or to feature on national billboards. But they are benefits that get back to people — and their families and co-workers. Achieving these goals will help employers retain enrollees, for the long term, especially in Medicare managed care. People remember who treated them well when Aunt Mary died.

And these changes can be embraced without the need for physician-assisted suicide.

John La Puma, M.D., practices internal medicine at Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based speaker and educator. With David Schiedermayer, he is co-author of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics (McGraw-Hill, New York, 1996).

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.