MEDICAL MIRACLES CAN CARRY HIGH PRICE

Can society afford the price of a miracle?

For Cape Girardeau resident Mike Carlton, the answer is simple. Suffering from multiple myeloma, a deadly form of cancer, Carlton wants a bone marrow transplant at all costs.

St. Louis University Medical Center has agreed to proceed with the treatment with the understanding that Carlton's insurance company, Blue Cross and Blue Shield of Missouri, either agrees to pay for it or Carlton will file a lawsuit seeking a court order requiring the insurer to pay.

Carlton is scheduled to enter the hospital today.

Blue Cross has so far refused to pay for the transplant, contending it's experimental treatment.

As of Monday evening, last-minute negotiations with Blue Cross had not resolved the matter.

Health insurers and medical ethicists say there's a real question if Americans, as a society, can or should continue to pay for costly and often risky experimental medical treatment in an effort to save lives.

Doctors and other medical professionals acknowledge something must be done to bring health care costs under control.

Health insurers, medical ethicists and doctors alike concede the issue is a troublesome one, and one with no easy answers.

"Everybody is for health care cost containment until it comes to their family," said Dr. Randall Treadwell, medical director for Blue Cross and Blue Shield of Missouri.

He said he believes some national standards are needed regarding treatment of various diseases. Such standards, he said, might help hold down costs.

Treadwell said the health care system needs fixing. "The costs are getting unaffordable even for working people," he said.

But he cautioned against a government-run health care system that would end up lowering the quality of care, putting people on long waiting lists for all sorts of treatment.

A leading authority on bone marrow transplants, Dr. Gary Spitzer of St. Louis University Medical Center, says some health care insurers will cover transplants for certain diseases while others won't.

"It's absolute chaos," he said. "We need some greater consistency in the insurance industry, and I think we probably need less carriers. There is no way we can go on with different guidelines for different carriers."

"We have reached a disastrous impasse in making therapy better," he said.

He maintained there are too many inefficiencies in both the medical and insurance systems. "People must demand a different health care system and a different insurance system," said Spitzer.

"It has to come down to some coordinated medical reimbursement system here, where potential, new, novel medical therapies would be supported," he suggested.

"What is extraordinary yesterday is very ordinary today," said the Rev. Raymond Otto, director of pastoral care at Southeast Missouri Hospital in Cape Girardeau.

"There is a lot in the ethical field being written about rationing of health care. But how to go about that is a problem," he said.

Rationing, he said, is being done now in many cases on the basis of ability to pay. "I think we do ration health care in a sense because we make it difficult for many of the poor and others to really get full care in our society."

New federal legislation, said Otto, requires all hospitals to notify patients that they have the right to fill out an advanced directive or living will to stipulate what medical measures they wish to be taken in the event they are no longer able to make health care decisions for themselves.

Otto said in terms of technology, modern medicine is amazing. "We give people a new lease on life all the time."

Gary Johnson, regional manager for Blue Cross in Cape Girardeau, equated the cost of extraordinary, often risky medical treatment with "the price of a miracle."

The issue, he said, is how to pay for it.

State Rep. Mary Kasten, R-Cape Girardeau, who is married to a surgeon, said the health care issue is complex. "We have created a medical technology that we can't afford and morality issues we can't resolve," she said.

Kasten said she doesn't believe state legislation is the answer. "We are not to the point of legislating these kinds of issues," she said.

But others predict there will be increasing efforts to regulate health care treatment and control costs.

Hamner Hill, chairperson of the philosophy and religion department at Southeast Missouri State University, teaches medical ethics. He cited an Oregon plan as an example of efforts to ration health care.

Hill said Oregon came up with a plan on allocating the state's Medicaid dollars, but the federal government rejected the idea earlier this year.

Said Hill: Oregon "tried to figure out what was the wisest use to make of the health care dollar. There are some particular treatments that are fairly risky and have little chance of success, and are very expensive.

"That (plan) meant certain people would not get liver transplants or bone marrow transplants," said Hill. Instead, for example, more money could have been spent on prenatal care for poor women, he explained.

Today, economics ration health care. "You can't pay, you don't get it," he said.

Hill said 37 million Americans don't qualify for Medicare and Medicaid assistance but can't afford health insurance. "These are the people who get left out in the cold."

Americans, he said, are "schizophrenic." They say citizens should have access to the best health care, but they don't want to pay higher taxes to provide that care to everybody.

"I doubt that society is willing to pay the price to give everybody the best health care that we could," said Hill.

"Half the money you spend on health care in your lifetime is spent on your last six months of life," he said. "The last couple of months of life are frequently spent, if not in intensive care, an acute care facility. You would be amazed how much you can spend in a hospital in a week."

Dr. Melvin Kasten of Cape Girardeau said, "Twenty-five percent of the Medicare dollar is spent in the last week of life and 10 percent in the last day.

"We are doing all these things to keep people alive," he said. "Maybe we should let them die peacefully," said Kasten, an active member of the American Medical Association.

Hill said voters in California will decide in November on a ballot measure that would legalize physician-assisted suicide for patients with terminal illnesses who have six months or less to live.

Kasten said rationing of health care in one form or another is increasingly being talked about. "Do we take care of everybody and go broke or do we care for just some of the people?"

Kasten and others in the medical field contend that government regulations are partly to blame for rising health care costs.

"I personally feel that Medicare and Medicaid have been the ruination of the medical system," he said.

Hill said the health care problem can't be blamed on any one factor.

"I don't think you can find a single evildoer. I think that there is more than enough blame to go around," he said.

The Rev. Kevin O'Rourke, director of the Center for Health Care Ethics at St. Louis University, believes part of the problem is society's unwillingness to face death.

"No one is going to live forever and we have a hard time accepting that fact.

"Economic limits are hitting us right square in the face, and still we are trying to abstract or ignore the fact that death is part of life and death should be factored in in planning for communal health care," he said.

O'Rourke said the whole health care system is in a state of confusion.

"There is no health system in the United States, and the for-profit motivation of many segments of the health care providers makes it impossible to control costs," he maintained.

"Many people don't receive adequate health care because they lack insurance," said O'Rourke. Health care costs, he said, increase by about 12 percent annually. "Most of that increase in prices comes from pharmaceuticals and health care supplies and insurance."

From 1982 through 1991, increases in drug prices were three times that of the nation's general inflation rate, a U.S. Senate committee report says.

Drug companies explain the prices are driven up by the cost of research needed to develop the pharmaceuticals. The Pharmaceutical Manufacturers Association says the average research cost to develop a single drug is $231 million.

John Fidler, president of St. Francis Medical Center in Cape Girardeau, said hospitals and doctors in many cases provide health care where there is no hope of payment. "We don't deny anyone needed clinical service," he said of St. Francis Medical Center.

But he acknowledged that medical care is rationed to the extent that some people cannot afford to regularly visit a doctor. "There are people whose only access to health care is through the emergency room," said Fidler.

In many ways, the thought of rationing health care goes against the principal goals of doctors and hospitals.

"Physicians are there to save lives," he said.

"Our ethics tell us that we are here as an extension of God to care for others and that to the extent we have resources available, we should provide those to people based on their need," said Fidler. "That is a good theory, but many of the services increasingly are not covered by third-party payment," he said.

"In many ways to the extent they (insurance companies) can serve as a gatekeeper and even in rationing service, that is seen as a cost-saving mechanism on their part."

Fidler said there is a real argument to be made that those who engage in detrimental health practices, such as smoking, should have to pay more for health care.

Some insurance companies are refusing to insure smokers or are charging them higher rates, he said.

Fidler said the threat of malpractice lawsuits has forced doctors and hospitals to practice defensive medicine, such as giving patients a battery of medical tests.

And ever-improving medical technology is also costly.

Blue Cross' Johnson probably summed it up best. "Technology is always going to outpace our ability to pay for it," he said, "but we have to keep taking a look at the new technology and making those tough decisions."