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    Applying the 'cataract test' to skyrocketing health-care costs

    A personal take on why health-care costs are rising so quickly, by a man who decided to live with one bad eye.

    A magnified view of cataract in a human eye.

    A magnified view of cataract in a human eye. Dr. Rakesh Ahuja/Wikimedia Commons

    The health-care debate has focused on why medical costs, decade after decade, have increased far faster than other goods and services, as if the laws of inflation don't apply to medical services. Various explanations have been advanced, but three circumstances, and their synergy, have largely escaped attention. The first of these is our society's propensity to pay for things without regard to utility. This is illustrated by what might be called the cataract test.

    In the early '90s, while living in Europe, I developed a rare eye disease that among other things led to a cataract in the affected eye. Fortunately the disease had bypassed the other eye. Still, it chastened me to learn that the public health system would not approve a cataract operation in the sick eye: a person with one healthy, cataract-free eye could live more or less normally, and therefore had no entitlement, I was told, to a procedure underwritten by the public sector. The socialized healthcare system covered only the minimum needed for utilitarian purposes.

    Years later, once the disease had rendered the affected eye useless in any event, I came to agree with the logic. Being half-blind hasn't diminished my access to a driver's license, for example, in any of the several states I've lived in since returning from Europe.

    Be that as it may, the health insurers I interviewed recently all stated that their policies would have covered the surgery — “lens, prosthetic (intraocular) with cataract extraction, one-stage, with second eye healthy,” to use the official terminology. They also stated that they would pay for such exotica as frequent urination and chronic fatigue syndrome, or “yuppie flu” (conditions I myself have “suffered” from, but whose classification as diseases leaves me bemused), assuming “medical necessity” — a very malleable criterion in a society where someone is trying to profit from virtually every facet of medical care.

    It is hard to resist the conclusion that health insurance is trending toward covering more and more conditions and procedures, at more and more expense. Those diagnoses and procedures are catalogued in an arcane, periodically revised set of codes known as the international classification of diseases, or ICD. The latest revision of this lengthy roster will make it much longer still, going from 17,500 to 140,000 codes. But Rhonda Buchholtz of the AAPC, medical coding's professional association, says that the new ICD will add only specificity, not new diseases and therapies; the one code for an ankle sprain will become 72, for example.

    The revision could perhaps best be described not as an expansion, but as a translation into a more detailed language. More to the point, however, the ICD cannot include procedures that do not yet exist; nor can it anticipate what conditions future medical researchers might “discover” to be pathological. MRIs didn't have codes before their development 40 years ago. (They now have nine.) The ICD's 1965 version made no mention of chronic fatigue syndrome. Medicine is an expanding universe, forever entering new realms. 

    President Obama's health-care reform act remains an uncertain factor in these developments, but it is difficult to argue that it will shrink the scope of recognized, insurable care. As Marianne Udow-Phillips of the Center for Healthcare Research & Transformation has pointed out, no one can say whether fertility services and eating disorders, to cite two rubrics, will acquire the status of “essential benefits,” as defined by the reform statute, and therefore become legally required elements of health insurance.

    We can assume that lobbyists are lining up to tip the decision-making process toward the ailments and procedures they (so to speak) champion. Whether the ultimate decision-maker, the U.S. secretary of health and human services, “will be able to be conservative is a real question,” Udow-Phillips opines. “Politically, it is easier to be more comprehensive when it comes to benefits than to limit the scope of coverage.”

    The steep curve of medical inflation thus appears to involve more than the habit of buying. The second factor — this proliferation of innovative procedures and capabilities, and of new diagnoses — is peculiar to only certain sectors, the medical industry among them.

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    Posted Thu, Jun 9, 10:38 a.m. Inappropriate

    Great article. We've lost sight of the purpose of insurance. We don't purchase car insurance and expect it to pay for oil changes, brakes or other "regular" maintenance. We don't buy home owners insurance and expect it to cover the cost of a leaky faucet or faulty light switch. Can you imagine how expensive car or home owners insurance would be if we expected it to cover maintenance. But, we expect health insurance to cover the cost of going to the doctor for every little ache, pain and runny nose. Because medical providers of every kind are paid on the basis of numbers of patients seen, tests performed, procedures, etc., it is to their advantage to promote the "need" for easy access to unnecessary "care".


    Posted Thu, Jun 9, 1:05 p.m. Inappropriate

    I am continually hounded to get "screened" for various things, and when I ask health professionals why I should submit to these procedures, they cannot give straight answers. Never mind that I have no family history of any of these dread diseases. Also, I am now being told my blood pressure is "high" even though it hasn't changed one iota from the high end of normal where it's been my entire life. SteveC is right, it's all about the money.


    Posted Thu, Jun 9, 1:28 p.m. Inappropriate

    C.B. Hall's "cataract test" is a criteria that no responsible physician or health policy expert in the U.S. -- conservative, liberal, or in-between --would support. I'll have to check on whether the Canadian, British, German, French, or Swedish health care systems would deny coverage for treatment of a cataract in one eye, but I seriously doubt it. Neither would any responsible expert support non-treatment of disease in one kidney even though people can survive on the other kidney. That is not the accepted international standard for determining what medical services should be covered by public or private health insurance. The general standard is whether a service has reasonable evidence of medical effectiveness, and whether it's as effective or more effective than alternative services. Britain and other countries also consider whether the service is cost-effective, while in the U.S. public and private payers shy away from explicitly using cost criteria (though they do consider such criteria quietly). There's no question there is lots of inappropriate, wasteful, and harmful medical care in the U.S. system and leading medical organizations, with new help from last year's health reform law, are working on weeding out that wasteful care. But Hall disserves this debate, and the worthwhile information in the rest of his article, by offering up this bogus "cataract test." See my 2009 article on how Washington state is doing this coverage determination work in a responsible way.

    Posted Thu, Jun 9, 4:54 p.m. Inappropriate

    Very good article. Conservatives (me, for example) would ask whether or not you would pay for the cataract surgery with your own money, the market standard for balancing utility and cost. You do not specify whether that was an option in the case of your eye.

    Harris Meyer, is there an "..accepted international standard.. etc."? if so, who wrote it? Mr. Hall writes a narrative that awakes the reader to a real set of values. He does his readers a fine service.


    Posted Thu, Jun 9, 5:18 p.m. Inappropriate

    Kieth, there are professional organizations in all the advanced countries that do this work of evaluating the effectiveness, safety, and cost-effectiveness of medical interventions (including government agencies such as the National Institute for Health and Clinical Effectiveness in Britain), and there is international consensus on the criteria (though as I said, cost-effectiveness remains a politically delicate issue in the U.S.). Try arguing in the political arena in the U.S. or any other advanced country that people should lose the use of an eye to save on health care costs. That's not going to fly with Tea Partiers or liberals or anyone else -- and it shouldn't. Some might call that a form of death panels (sight panels?).
    Besides my article, here are some links if you want to learn more about comparative effectiveness research and how it's used to make health insurance coverage decisions.

    Posted Thu, Jun 9, 10:03 p.m. Inappropriate

    Mr. C.B. Hall should have paid for his cataract surgery out-of-pocket as his story reveals the evils of government involvement into the health insurance world. Single payer should mean that the individual pays; ie: no 3rd party involvement. Employer paid for insurance (especially taxpayer payed for insurance where the taxpayer himself may not have insurance) distorts the system and gives non-taxable compensation to the chosen few. Health insurance should be de-coupled from employment and purchased the same way as all other types of insurance.


    Posted Thu, Jun 9, 10:19 p.m. Inappropriate

    I may be missing something, but I thought that what C.B. Hall was saying was that the cataract was secondary to a disease that would take the eye in time (and did) and that this fact weighed in the denial and possibly in his decision not to pursue having it done on his own.


    Posted Fri, Jun 10, 12:26 a.m. Inappropriate

    OK, C.B. Hall, I'm calling you on this one. In what country did your purportedly happen? Let's check on what that country's health coverage policy is now (and then as well). I will be shocked if any advanced European country currently has a policy that its national health insurance system won't pay for a cataract operation to save someone's eye. This discussion has gotten surreal. I sure am glad that none of these commenters are in charge of the U.S. health care system or any other health care system and thus are not in a position to deny someone an operation to stop a totally preventable loss of sight from occurring. Let's hear what country it was and we can all check. And commenters should contact their Tea Party representative and ask them if they would be willing to sponsor legislation to prohibit Medicare, Medicaid, the VA, Tricare, the Federal Employees Health Benefit Program, any public employee health insurance program, or private health insurers from covering cataract operations to save one eye when the person has a perfectly good second eye to see with. Please report back on what your representative says.

    Posted Fri, Jun 10, 10:07 a.m. Inappropriate

    Harris Meyer, assuming Mr.Hall is relatively young and normally healthy, not covered by Medicare or Medicaid, he would have the choice of either foregoing the treatment or paying for it himself in this country, the USA. It's obvious that Mr. Hall would have chosen the former and, from what he writes, would not have regretted the decision. Are you saying he should not have that stark choice? that such choices are not consistent with a decent society? if so, I think you are wrong. By that reasoning we would be obliged to live much more restrained lives than most of us do; no drinking, no smoking, lots of broccoli. How we treat our bodies is our own choice. It's part of life.


    Posted Fri, Jun 10, 11:06 a.m. Inappropriate

    Everyone has the choice in the U.S. to decline even treatment that could be life-saving. That is very different from having public or private health insurers refuse to pay for a medically effective treatment to save someone's eyesight, kidney, or to address any other condition. It's the latter type of sight panel-rationing that C.B. Hall offered as his model or litmus test for controlling costs.

    Posted Sat, Jun 11, 12:37 a.m. Inappropriate

    Still waiting, C.B. Hall, come on, man, tell us what country so we can check your story.

    Posted Sat, Jun 11, 10:55 a.m. Inappropriate

    HM, he said "Europe", he didn't say "Western Europe".


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