Correspondence

. . . And How the Decisions Are Made

N Engl J Med 1994; 331:331-332August 4, 1994

Article

To the Editor:

We have some pretty tough days too, for in addition to the clinical, academic, and administrative functions that are part of our careers, we now have to spend many hours persuading health insurance companies that we are not trying to manipulate them into paying more money than Medicare does for kidney transplants, as Dr. Boren insinuates (Feb. 17 issue)1. He is making his work unnecessarily difficult by equating understandably difficult decisions about whether to approve autologous bone marrow transplantation for patients with metastatic breast cancer with decisions about approval of predialysis transplantation for patients with end-stage kidney disease. So-called preemptive transplantation for a patient with chronic renal failure whose condition is deteriorating inexorably averts the morbidity of the early months of dialysis and the necessity for potentially mutilating and often repeated surgery to provide access for dialysis2.

It seems inappropriate to us that a single person should be the arbiter of such difficult decisions. It is our hope that in the future decisions about access to care will be made collectively and applied in an evenhanded fashion so that apparent or actual rationing of care will be more palatable to patients in need.

Gabriel M. Danovitch, M.D.
Alan Wilkinson, M.D.
J. Thomas Rosenthal, M.D.
UCLA School of Medicine, Los Angeles, CA 90024

2 References

1
Boren SD. I had a tough day today, Hillary. N Engl J Med 1994;330:500-502
Full Text | Web of Science | Medline

2
Katz SM, Kerman RH, Golden D, et al. Preemptive transplantation -- an analysis of benefits and hazards in 85 cases. Transplantation 1991;51:351-355
Web of Science | Medline

To the Editor:

Dr. Boren maintains that it would add $28.5 billion to the nation's health care bill if all 190,000 women who will be given a diagnosis of breast cancer this year were to receive high-dose chemotherapy combined with autologous bone marrow transplantation. But no one is proposing that all women with breast cancer should receive this treatment, and it is rhetorical excess to suggest otherwise. High-dose chemotherapy with autologous bone marrow transplantation is a treatment of last resort for women with refractory breast cancer. Hillner et al. estimated that about 25,000 women per year would qualify for the treatment 1 -- at an approximate cost to the nation of $3.5 billion. Even if all 46,000 women who will die of breast cancer this year were to receive the treatment, the cost would still be less than one fourth of Dr. Boren's figure.

Michael W. Zimecki, J.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15213

1 References

1
Hillner BE, Smith TJ, Desch CE. Efficacy and cost-effectiveness of autologous bone marrow transplantation in metastatic breast cancer: estimates using decision analysis while awaiting clinical trial results. JAMA 1992;267:2055-2061
CrossRef | Web of Science | Medline

To the Editor:

I was greatly saddened by Dr. Boren's account of a day in the life of a medical director for a large insurance company. A reasonable conclusion from reading his article is that our health care system is morally bankrupt and the problem stems in large part from the lack of integrity among physicians. Dr. Boren describes how some physicians lie for financial or professional gain; lack the courage to inform patients when death has become inevitable, and meaningful palliation impossible; and cynically manipulate third-party payers and the emotions of both patients and other physicians.

Charles Levenback, M.D.
Anderson Cancer Center, Houston, TX 77030

To the Editor:

After almost 40 years of clinical practice, often arguing with medical insurers and infuriated by some of their decisions, I am now in the opposite position, reviewing medical claims under my company's group-benefit policy. Since we are entirely self-insured, the issue of a profit motive does not enter into any of my decisions, as it might with an insurance company. On the other hand, for my company to remain competitive, expand, increase wages, and provide other employee benefits, our health care costs, currently increasing by 14 percent per year, must be contained. Although we have no hesitation about providing funds for very expensive but necessary procedures, such as interferon for hairy-cell leukemia or chronic hepatitis B, or interleukin for renal carcinoma, each costing thousands of dollars per patient per year, we deny claims for procedures that do not meet our clear criteria for cost effectiveness and medical necessity. . . .

In his editorial (Feb. 17 issue),1 Dr. Light correctly states that physicians who review claims often make complex medical judgments without having seen the patients involved. I can only assure him that Dr. Boren, most other claims reviewers, and I are fully aware of this profound responsibility and do not make decisions without a careful prior review of all the clinical data in each case. Regrettably, until physicians, the predominant prescribers of treatments and procedures, become more knowledgeable and more concerned about what these things cost and what is medically appropriate, some type of claims review or gatekeeping will be needed to contain health care costs.

Elmer Pader, M.D.
A.P.A. Transport Corp., North Bergen, NJ 07047

1 References

1
Light DW. Life, death, and the insurance companies. N Engl J Med 1994;330:498-500
Full Text | Web of Science | Medline

To the Editor:

In deciding whose medical expenses should be paid by the insurance company for which he works, Dr. Boren does not pretend to follow objective criteria. His decisions are based, at least in part, on what he thinks of the patients' behavior (whether they drink or smoke), the degree to which they evoke his sympathy, and whether he thinks they are worthy of medical intervention. (If a woman has terminated a pregnancy -- out of wedlock, at that -- she does not deserve help to improve her chances of conceiving later.)

If nothing else has convinced the Clintons of the error of their ways in building insurance companies into their health care plan, Dr. Boren's article should.

Ruth Hubbard, Ph.D.
Harvard University, Cambridge, MA 02138

Author/Editor Response

Dr. Boren replies:

To the Editor: Zimecki believes that only 25,000 women per year would be treated for breast cancer with high-dose chemotherapy and autologous bone marrow transplantation. Unfortunately, despite his belief and Hillner et al.'s analysis,1 many patients are receiving this treatment, as well as tandem transplants, for earlier stages of the disease. Thus, Zimecki's calculations do not appear to be complete.

Danovitch et al. complain that they spend too many hours dealing with insurance companies and that a single person should not be the final arbiter of such difficult decisions. I also practice and teach medicine in inner-city teaching hospitals. I too dislike contacting health maintenance organizations. Until a better mechanism is available, however, the present approach, physician to physician, is the most reasonable.

Hubbard complains that I do not use objective criteria. She failed to read my article carefully. I approved or disapproved treatments solely on medical grounds and contract language, not on the basis of my personal beliefs. Most of the patients received the requested treatments. All the women who requested infertility treatment received it, since it was covered contractually.

Levenback is concerned that our system is morally bankrupt and that many physicians lack integrity. My position gives me a distorted view, since I usually deal with problematic situations. I believe, however, that most physicians are concerned about their patients. I work with many caring physicians. Unfortunately, many physicians and families are not willing to accept the death of a patient after all reasonable therapy has failed.

Pader's points are similar to my own. Most American companies want to help their workers but cannot afford to remain competitive and still pay escalating medical claims2,3. Patients and physicians want limitless treatments, yet as a society we are surprised that medical costs increase. It is irrelevant that medical directors do not see any of the patients about whom they make clinical judgments. Medicolegal cases rest on the opinions of expert witnesses who have not examined the patients involved. The Journal's “Case Records of the Massachusetts General Hospital” features physicians who analyze cases with fantastic accuracy, without having seen the patients. Obviously, it would be impossible for a company physician to examine every patient about whose treatment an opinion must be rendered.

In my view, the questions and comments in Light's editorial illustrate the greatest problem with changes in health care. Too many experts on reform fail to understand either the insurance field or the clinical practice of medicine.

Stephen D. Boren, M.D.
CNA Insurance Companies, Chicago, IL 60685

3 References

1
Hillner BE, Smith TJ, Desch CE. Efficacy and cost-effectiveness of autologous bone marrow transplantation in metastatic breast cancer: estimates using decision analysis while awaiting clinical trial results. JAMA 1992;267:2055-2061
CrossRef | Web of Science | Medline