Health & Medical

Perverse Economies: Who Is Worth Saving?

Perverse Economies: Who Is Worth Saving? thumbnail

Back when I was a medical student I learned a lesson about who was expendable. I was doing research for the liver transplant team at UCLA, one of the largest organ-transplant centers in the U.S., and one of the surgeons gave me an assignment: can you track how sick the patients are before they come to our operating tables for transplant surgery based on what health insurance policy they have?

He had noticed that the patients insured by one particular HMO (health maintenance organization) were arriving sicker than the others. This was easy enough for him to quantify because we had a patient-status grading system. People who were well enough to be waiting at home for the call that their donated liver had been procured were a stage 1. Those who were hospitalized were a 2. Those who needed critical care were a 3, and the people in the ICU on a ventilator fighting for their lives were the stage 4 liver patients. As a student researcher, I kept a spreadsheet on the patients in several clinical studies we were tracking. All I had to do was enter in their insurance data. The surgeon was convinced that the patients enrolled in that one plan were more likely to receive their liver transplant when they were in a more deteriorated state, like stage 3 or 4. We knew well that patients who were more critically ill when the time came for them to receive their transplant were less likely to survive the operation than the stage 1 and 2 patients. The surgeon thought that if we showed the insurance executives the data, their HMO would incentivize their primary care physicians to refer patients sooner, when they were healthier, and so those patients — their paying customers — would enjoy a higher survival rate and overall better outcomes.

We were naive.

I collected the data, and as far as I know the transplant team shared the results with the HMO’s executives. They asked that the HMO change its protocols to make sure they could refer their patients for liver transplantation sooner than they had been doing.

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Yet, nothing changed. We never published the study. I was told to forget about it. That was when I learned a cruel lesson about the private insurance-based, for-profit, market-driven healthcare system that we continue to operate in the U.S.: It’s cheaper to let people die. It’s more efficient, better for the bottom line. Healthy people pay their premiums, pay into the system. They are a company asset. Sick people drain it. They’re a liability.

If you’re an insurance company or HMO and you refer a patient — again, your paying customer — to receive a liver transplant at an early stage of their sickness, they are more likely to survive their transplant. After that, they are more likely to live, maybe for many years. Over those many years they will require costly immune suppressant medications, and, likely, intermittent hospitalizations for infection or rejections. They are going to cost your corporation hundreds of thousands of dollars, if not millions, in the course of their extended lifetime as a post-transplantation patient. As a survivor. It’s more economically sustainable to refer these customers to the transplant surgeon when they’re later in their illness. That way, more of them die on the operating table and stop costing you money right there. Even if they survive the operation, their life expectancy will be shortened if they get the surgery as a stage 3 or 4 candidate instead of the expensive stage 1 and 2 customers. And if you manage to find a way to not refer them at all for liver transplant surgery, they will die. They will no longer be a liability. They will be off your books.

As we slog through our second year of the COVID-19 pandemic, this cold-blooded lesson keeps coming back to me as I read the news from different countries with their diverse and divergent reactions to the pandemic, many of which seem to reflect politics driven by economic decisions rather than anything resembling a coherent public health strategy meant to keep people alive.

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Now that we are several years in, I’d be interested to see how these different international pandemic responses plot out against economic data in a multi-variate analysis — one that takes a deep dive into public health responses (lockdowns, masking, vaccines) and economic systems (government-run universal healthcare versus private insurance, border controls, recommencing large gatherings). Early in the pandemic, businesses decried lockdowns as likely to cause irreparable economic damage, but financial data in late 2020 into 2021 showed that countries that locked down hard and early (like Taiwan, South Korea, and New Zealand) did better both in terms of public health response — with fewer deaths — and economic rebound, which was faster and stronger than in countries that tried to “get back to normal” sooner than public health experts advised. Fewer sick and dead taxpayers, workers, and consumers may have had something to do with that result. China’s currently unravelling zero-COVID policy has had severe economic repercussions within that country and worldwide; but as a pathologist who knows about the deleterious lingering effects of COVID on the brain and heart, I can’t help but wonder if the Chinese government had been worried about the staffing shortages and supply chain disruptions that had plagued other countries and were looking to preserve the long-term health of their gigantic workforce.

I keep thinking about whether, somewhere, economists are crunching the numbers and calculating the short-term economic impacts of fewer people in the workforce (lower unemployment) and a growing subset of the working population disabled by the irreversible end-organ damage of repeated viral infections. Would the economic impact of so much disability from long COVID — which can affect up to a third of those who get the disease — be worse in places like the U.K., Canada, and New Zealand, which have publicly-funded universal healthcare systems, than in the U.S., where the populace buys into spotty and fickle private health insurance? And if people are so disabled they can’t work, will they become a burden on Medicare and a drain on our Social Security system, which may, in a macabre and unanticipated way, have thus far benefitted from all those early deaths?

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I’m not an economist. But as a healthcare worker, I know what happens when a corporate head office crunches numbers and parses out the enterprise’s assets and liabilities. We living, breathing people are only assets, only useful to them, when we are young, healthy, and paying into the system. Once we are sick or disabled, we are liabilities. Systems designed to maximize profit over preserving life will eliminate the liabilities. Bottom line: They’ll let us die.

Judy Melinek, MD, is an American forensic pathologist and the CEO of PathologyExpert Inc. She is currently working as a contract pathologist in Wellington, New Zealand. She is the co-author with her husband, writer T.J. Mitchell, of the New York Times bestselling memoir Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, and two novels, First Cut and Aftershock, in the Jessie Teska forensic detective series. You can follow her on Twitter (@drjudymelinek) and Facebook/DrJudyMelinekMD.

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