Saturday, November 10, 2012

Taming the beast

Because I’m now on Medicare and have a supplemental insurance plan, my future medical expenses beyond paying premiums will drop to almost zero. This comes with having qualified for Social Security Disability a year ago—a nice perk from Uncle Sam, if you don’t mind having stage IV melanoma to get it. My out-of-pocket medical expenses for 2012 will still exceed $20,000 because of the “Swiss cheese” private plan I had previously, which included a very high deductible and carve-outs for all sorts of services that Medicare will now cover.

Cover, that is, until it doesn’t. As Obamacare is gradually implemented, Medicare premiums will likely rise faster than inflation and certain services will eventually be cut or rationed. I have no argument with that, as current growth in Medicare expenses is totally unsustainable; something has to give. After Social Security and defense, Medicare is the third largest federal program and will cost taxpayers more than $1 billion a day this year.  It’s also the fastest growing entitlement, with spending likely to double over the next decade if nothing is done to slow its growth.

As it stands, the federal government will substantially reduce what it spends to fund Medicare Advantage, which is privately administered insurance that Medicare beneficiaries can buy, if they choose. About 25% of them do. In theory, Advantage plans are supposed to better manage health-care spending than fee-for-service Medicare (in which I’m enrolled), but they actually end up costing 14% more because of waste and overutilization. Obamacare will eliminate this subsidy and peg Advantage payments to quality metrics.

The second cache of money that gets cut from Medicare under Obamacare comes from providers. Hospitals and doctors will see their payments grow more slowly in the future. While benefits to recipients may not change drastically, providers who are paid less may become less inclined to accept Medicare patients, if they can get away with it. A payment advisory board created under Obamacare could cut provider payments even more to keep growth in Medicare spending under a benchmark. This, too, seems reasonable in light of the alternative: profligate spending on healthcare that’s out of proportion to its value.

I acknowledge that as someone in the midst of cancer treatment, this puts me in a paradoxical situation. While expenses for my care have piled up mountainously since August, I won’t be able to place a value on them for many months to come. Should I still be writing trenchant posts on The Ogler two or three years from now, I might decide that the costs of my care were justified. If I’m not, then it will be up to others to decide. Either way, I’m deeply troubled by how much money is being expended to beat back a disease that defies a cure and leaves me living a shadowed life for who knows how long.

I won’t belabor the point, but I believe the whole paradigm for how we treat cancer in this country to be seriously misguided. It’s the cost of cancer care as much as anything that drives the upward spiral in Medicare spending. The whole cancer care edifice is not structured to do what we most need: to determine how to prevent cancer in the first place. Despite decades of promises and a vast sum spent on it, the current model has failed us. Cancer mortality rates remain stubbornly high. We no longer expect to cure cancer and now talk mostly about living longer with the disease.

Why? Why have we settled for a medical system that allows cancer to be recast as a chronic and tolerable disease rather than one we should try to prevent? It’s hard not to be cynical about whose interests are being served here.

The cows are already out of the barn, in my case. I will spend the rest of my life hoping that the cancer that’s run wild in my body can be rounded up. It’s highly unlikely that my final ipi infusion next week will be the last time I’m treated at a cancer center. Once you’re into the belly of this beast, you’re not likely to be belched out. There are fortunes to be made in cancer care and plenty of smart people who know how to get their piece of the action while giving the impression that great strides are being made in finding cures. I’m dubious about that.

To be specific, my insurance will have paid out approximately $197,000 in expenses for the combined ipi and brain radiation treatment that I’m close to finishing. More than half that expense is for ipi alone—not for any of the hands-on care I receive in association with it, but just the drug itself. This is one of the most expensive cancer drugs ever and as I’ve written before, it only helps a small percentage of patients. It’s an outrageous situation.

Until the federal government says “enough” to the indefensible prices set by drug companies for their cancer drugs, and private companies follow suit, the madness will continue. Oncologists and the cancer centers where they practice yield enormous influence in these decisions too, and they need to participate in a solution. Lone bloggers like me don’t have the clout to make a difference. And as angry as I get as a patient, I’m also vulnerable to the blandishments of the cancer care edifice. I, too, want to live; I lack the courage at this point to walk away. I live in the hope that I might be one of the lucky ones who endures temporary unhappiness for more quality time later.

From here on in, American taxpayers will be footing most of my medical expenses, as they do for 48 million others on Medicare. If past is prologue, this won’t be cheap. I suppose I’m fortunate in that restrictions in Medicare services will be phased in over many years--longer than I'm likely to be around. I also have financial resources of my own to draw upon, if needed. That’s good for me, but it doesn’t solve our collective problem: a healthcare system that’s growing uncontrollably and is threatening to kill its host. Spending money to prevent cancer in the first place, rather than developing hyper-expensive therapies that don’t really cure, is a good place to show we’re serious about taming this beast.


Anonymous said...

Hi Peter,

Your own characterization of your work as "trenchant" is tongue-in-cheek immodestly accurate in describing yet another of your editorials, along with "cogent, articulate, balanced and thoughtful," among others. I have half a mind to forward it myself to the Register-Guard, although I won't. Or to the Oregonian. Or the NY Times.

What I would not do, you should consider doing. Your blog deserves, nay, demands, the widest possible audience.


Paul and Karen said...

I second Joe. If you're experiencing brain fog, it hasn't shown up in your writing. You help me understand something about the complex world of insurance and Medicare in bite-sized pieces, and for that I'm appreciative.


Carl Pelz said...

As I read this post, I too felt your case for being in a "brain fog" was severely weakened by such a cogent analysis of our health care system. With all it's complexity and opportunities for indirection, there is a case to be made that we are still in need of insurance reform and health care reform. Sorry that you have to contend with so much along with navigating the murky waters of our health care system.