Rationing Care Is the Wrong Way to Cut Oregon’s Medicaid Costs

The authors contend that people on Medicaid could be harmed by treating patients with a particular illness the same way, which will occur with the rules adopted by the Health Evidence Review Commission.
The Lund Report

OPINION – June 26, 2013 – Imagine walking into your doctor’s office and seeing someone else standing there, telling you they get to make the final decision about your healthcare. Instead of doctors and patients making important health decisions, they make the final call.

 For those in Oregon’s social safety net, that day is coming. The Health Evidence Review Commission, or HERC, is designed specifically to cut healthcare costs by overriding decisions made by doctors and their patients.

 Such restrictions are frustrating enough for those with private insurance. Those on Medicaid, however, have few, if any, alternatives. They cannot switch insurance plans and they have no way to afford the medicines or treatments their doctor has chosen for them. They are locked into a system where chronic illness, pain and other ailments fester and grow worse.

 The goal is one we can support – cutting healthcare costs – in the same way everyone can support removing a tumor. The question is, do we use a scalpel or a chainsaw?

 Here are how HERC’s rules work.  The Oregon Health Authority says the HERC will examine treatments with “Marginal Benefit and High Cost.” If HERC decides, on average, a treatment does not provide enough benefit to patients, the state will refuse to pay for it, requiring patients to use other medicines. This creates many problems.

First, it runs counter to the direction of scientific innovation in healthcare. Oregon’s thriving bioscience innovation sector focuses on creating personalized medicines, working with an individual’s specific DNA and illness to offer effective treatment.

The HERC rules, however, head in the opposite direction, treating all patients with a particular illness the same way. Even if a medicine is only effective in 20 percent of people, it makes no sense to refuse to cover a treatment for them because a medicine does nothing for the other 80 percent.

Second, as the Health Authority admits, it has no definition of “marginal benefit” or “high cost.”

Supporters of HERC’s restrictions argue it is a science-based process. This is not accurate. Ultimately, the decisions about what treatments the state covers depend on subjective decisions about the definition of those terms. What may be “marginal” to one person may seem essential to another.

Additionally, the very purpose of the HERC rules is to cut costs. Given a choice between providing care and cutting costs, the bias is to restrict access to care.

As long as decisions are based on such flimsy and debatable definitions, any claim that decisions are based in science, not politics, is not accurate, especially in an environment where the goal is to cut costs by overriding the decisions of physicians.

Finally, while science only draws conclusions about what is known, HERC’s rules encourage the consideration of what isn’t known. In its explanation of application of the rules, the Oregon Health Authority provides an example of a medicine that helps those with Multiple Sclerosis walk. Their example says “It is not known whether a small increase in walking speed can help improve the ability to carry out daily activities or if can help those who already are wheelchair bound.” Knowing this information is critical to making an accurate decision about the value of that treatment. How can the state make a decision when it does not know this information? It can’t.

 On the other hand, the patient’s physician will see, first-hand, if the treatment helps. Ultimately, those who admit they do not have evidence about the treatment’s benefits for the patient will override the decision of the doctor, who has actual evidence.

 Supporters will claim that physicians can ask for exemptions for their patients when necessary. That process, however, is difficult and discourages such exemptions. This is a strategy used by some private health insurance companies and is often a mere fig leaf where the reality does not match the promise.

As non-profit organizations, we certainly understand the need to contain costs.

 Withholding care, however, should be the last option, not the default. If we truly care about providing health care to those who need it, the state must get rid of these flawed and callous HERC rules.    

Image for this story by Adrian Clark (CC BY-ND 2.0) via Flickr.                                                      

Debbie McCabe is with Molly’s Fund Fighting Lupus and Lorren Sandt is with Caring Ambassadors.

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Just recently, Oregon Patients Rights Association (OPRA) in Douglas County started to take a look at HERC and the prioritized list of health services. This came about after we agreed to assist a Medicaid recipient with a denial of pain medication by our local Coordinated Care Organization (CCO) and the Oregon Department of Medical Assistance Programs (DMAP). What we discovered in researching the case is that HERC not only creates the prioritized list of health services for those on the Oregon Health Plan, they create guidelines for certain conditions in order to further reduce what is covered. The glaring exclusions we found have to do with the treatment of chronic pain. It seems that although a condition may be above the line and covered, the guideline excludes coverage if the only symptom is pain---no matter how severe. Given what we have discovered so far, it seems that HERC has overstepped its bounds and is denying poor people (because you have to be poor to be on the Oregon Health Plan) pain management. This is in spite of the fact that Oregon has an intractable pain law that guarantees every citizen the right to have their pain managed. OPRA agrees with the authors, people need to start taking a look at HERC and what they have been doing. The CCO model that is governed by HERC’s list may soon be the managed care organization for others, not just Medicaid patients, in our state. If the governor and others have their way, HERC will soon decide the covered health care services for those on Medicare as well as public employees.