Oregon Health Plan Refuses to Cover Cancer Treatments, Pays for Assisted Suicides Instead

Imagine you're in a hospital, diagnosed with lung cancer.  Your doctor informs you that he can prescribe an expensive drug that will slow the growth of your cancer and prolong your life.  You notify your health-care provider about the drug.  Their response?  They won't cover the cost of the drug; they will, however, cover the cost of doctor-assisted suicide if you so choose.

Sounds horrific, doesn't it?  Yet that's exactly what Barbara Wagner of Oregon found out earlier this month.  Her insurance company, the state-run Oregon Health Plan, notified her that they would not cover the expense of Tarceva, the cancer-slowing drug, but that they would cover "palliative care", which includes assisted suicide.  (Doctors in Oregon don't have to worry about being prosecuted a la Jack Kevorkian, as physician-assisted suicide has been legal--and free of court injuctions--since 1997.)

"Treatment of advanced cancer that is meant to prolong life, or change the course of this disease, is not a covered benefit of the Oregon Health Plan," read the letter notifying Ms. Wagner of the health plan's decision.

Understandably, Ms. Wagner did not react well to her health plan's policy.  "To say to someone, we'll pay for you to die, but not pay for you to live, it's cruel.  I get angry.  Who do they think they are?"

Dr. Walter Shaffer, medical director of the state Division of Medical Assistance Programs, which administers the Oregon Health Plan, attempted to defend the health plan's decision.  "We can't cover everything for everyone," he said.  "We try to come up with polices that provide the most good for the most people."  Shaffer then addressed a priority list that had been developed to ration health care.  "There's some desire on the part of the framers of this list to not cover treatments that are futile," he said, "or where the potential benefit to the patient is minimal in relation to the expense of providing the care."

Wesley J. Smith, a prominent conservative bioethicist, says that he was not surprised by the events.  "We have been warning for years that this was a possibility in Oregon.  Medicaid is rationed, meaning that some treatments are not covered.  But assisted suicide is always covered. And now, Barbara Wagner was faced with that very scenario."  In other words, it's not about the health of the patient, it's about the expense to the state.

According to the World Health Organization, palliative care is defined as (italics mine):

"...the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families.

Many aspects of palliative care are also applicable earlier in the course of the illness, in conjunction with anticancer treatment.  Palliative care: Affirms life and regards dying as a normal process; Neither hastens nor postpones death; Provides relief from pain and other distressing symptoms; Integrates the psychological and spiritual aspects of patient care; Offers a support system to help patients live as actively as possible until death;
Offers a support system to help the family cope during the patient's illness and in their own bereavement.
 
Radiotherapy, chemotherapy and surgery have a place in palliative care, provided that the symptomatic benefits of treatment clearly outweigh the disadvantages. Investigative procedures are kept to a minimum."

I checked Oregon Health Plan's Web site and found a document titled "Prioritization of Health Services; A Report to the Governor and the 74th Oregon Legislative Assembly; Oregon Health Services Commission; Office for Oregon Health Policy and Research; Department of Administrative Services; 2007".  On page 48 of this document, in a section titled "Chapter Three:  Clarifications to the Prioritized List of Health Services", I found the following listed under the heading "Comfort Care" (bold, italicized, and underlined text in original document):

DMAP brought to the Commission's attention that patients with terminal diagnoses were not
receiving palliative care types of services when their life expectancy was greater than six
months.  The Commission wished to stress their intent that comfort care should not be denied to patients with terminal diagnoses, regardless of their life expectancy.  The guideline for Line 71, TERMINAL ILLNESS REGARDLESS OF DIAGNOSIS/COMFORT CARE, was altered to read:

Comfort care includes the provision of services or items that gives comfort and/or relieve symptoms to patients with a terminal illness.  There is no intent to limit comfort care services according to the expected length of life (e.g., six months) for the patient with terminal illness. (1)

This category of care does not include services that are diagnostic, curative or focused on active treatment of the primary condition and intended to prolong life or alter disease progression. (1)  Examples of comfort care include:

1) Pain medication and/or pain management devices
2) In-home and day care services and hospice services as defined by
DMAP
3) Medical equipment and supplies (beds, wheelchairs, bedside commodes, etc.)
4) Palliative services for specific symptom relief
5) Physician aid-in-dying under ORS 127.800-127.897 (Oregon Death with
Dignity Act), to include but not be limited to the attending physician
visits, consulting physician confirmation, mental health counseling, and
prescription medications. (2)

(1) The italicized language is being recommended by the Health Outcomes Committee but has yet to be approved by the full Health Services Commission as of the publication of this report.
(2) Services related to physician aid-in-dying are not priced as part of the list and only state funds will be used for their provision.

Fortunately for Barbara Wagner, the Oregon Health Plan did not get the final say in how she was to be treated (and I mean that in both a medical and a personal sense).  A representative from the pharmaceutical company that manufactures the treatment called the cancer patient to say the company would give her the medication for free.  "I am just so thrilled," she said. "I am so relieved and so happy."  As well she should be.

I think somebody needs to sit down with the doctors and administrators at Oregon Health Plan, and with state health officials as well, and have a back-to-basics meeting.  Item One on the list would be the reading and memorization of the Hippocratic Oath, which doctors swear to abide by upon beginning their practice.  Item Two would be a test on the Hippocratic Oath; those who fail should be removed from working in health care of any kind.  Item Three would be a review of the 2007 "Prioritization of Health Services" document and a rewrite of its text to ensure it adheres to the Hippocratic Oath and the WHO's definition of palliative care.  (Note:  Not paying for certain health care services is different from paying for services which are a detriment to the patient's health and well-being, such as physician-assisted suicide.)  Item Four would be to publicly thank the pharmaceutical company that manufactures Tarceva, showing the world that drug companies are not always the money-grubbing villains the government and the media make them out to be.

One can only hope the administrators and doctors of Oregon Health Plan never contract any kind of disease which would require comfort care.  If they do, I'm certain they would do the right thing and select the assisted suicide option with no complaints or struggles.  And if I were a resident of Oregon and covered by the Oregon Health Plan, I'd be right there beside them, forcing them to...I mean, helping them to sign the appropriate papers and holding them down while they struggle...I mean, comforting them as the doctors administered the proper medications to ease their pain forever.