Should insurers cover assisted suicide?

Oregon’s health plan raises ethical concerns

More than a year after the Oregon Health Services Commission voted to include physician-assisted suicide (PAS) as a covered medical service, the debate continues over the ethics of paying to cause a patient’s death when other medical treatments receive no coverage.

The Oregon Health Plan, the state’s Medicaid plan, is unique from other Medicaid programs because it uses a prioritized list of medical diagnoses and treatments as a basis for coverage decisions. Depending on the amount of money the state budgets for the plan, the commission sets a cutoff line at a particular level on the list.

The plan currently has a list of 745 medical services, and the cutoff is at line 574. Lower-priority services, those with a number higher than 574, are not covered.

According to information released by the Salem-based Oregon Deparment of Human Resources in March 1998, assisted suicide ranks 206th on the list, along with palliative care.

"Some curative treatments for cancer are not covered, some hernia operations are not covered, rehabilitation for stroke victims is not covered. They are on the list but are not funded. Under the Oregon Health Plan, there are currently 171 recognized medical services that are not funded, but they will fund physician-assisted suicide?" says Gregory Hamilton, MD, PhD, a Portland psychiatrist and president of the organization Physicians for Compassionate Care, which has opposed the legalization of assisted suicide.

Unfairly influencing the poor?

The public health plan isn’t all that’s worrisome, Hamilton adds. Many private health plans that will pay for assisted suicide also significantly limit payments for hospice care and home health. One plan Hamilton has contacted caps home health payments, for example, at a $1000 maximum, he says. "I don’t think that it is the intent of those involved in making these decisions to herd the poor and disabled into committing suicide, but the result of the funding is that it does herd the poor and disabled into considering suicide as an option."

Despite Hamilton’s and others’ objections, the data gathered on the Oregonians who requested the assisted suicide option in the past year indicate that such concerns are exaggerated, says Ted Falk, JD, PhD, an Oregon health care attorney who has published several articles on coverage issues and PAS.

The Oregon Health Division’s special report Legalized Physician-Assisted Suicide in Oregon — The First Year’s Experience, compared the experience of the 23 patients (15 who died after taking the medications, six who died of their underlying illness, and two who did not take the medication and were alive as of Jan. 1, 1999) with that of a control group who were similar in illnesses, race, sex, rural or urban residence, level of education, and insurance coverage.1

The study’s findings indicate that none of the case patients or control patients "expressed concern to their physicians about the financial impact of their illness." The study authors also found no difference between case and control patients with respect to insurance coverage at the time of death. They concluded that the choice of assisted suicide was not associated with health insurance coverage. "Because end-of-life care is expensive and, in contrast, physician-assisted suicide is cheap, much of the political opposition to physician-assisted suicide arises from the fear that health plans will try to kill off’ their members to lower costs," he says. "I think that is kind of overstating the risks, to the point of almost being fanciful."

In addition to moral objections, health plans would not want to be seen as encouraging their members to choose assisted suicide because it would damage their reputations, Falk says.

In reality, health plan executives don’t consider the ethics of assisted suicide to be an issue they should deal with, he adds. "This is a huge, emotional issue in terms of political agenda, but in terms of health plans, it is a very minor one. In most cases, if the plan offers a prescription drug benefit, the medications used would be covered under that benefit. There would be some question as to whether the plan would even know what the drugs were used for. And, given the modest expenditure of resources required, it is probably not something they screen for."

The main coverage issue to be concerned with, Falk says, is the availability of a mental health screening to the patient considering assisted suicide. "The sponsors of the law, I think, have come to conclude that it was a mistake not to require a mental health evaluation. But many of the professional organizations urge that a mental health evaluation be done in all cases in order to screen out depression."

The Oregon Death with Dignity Act requires that the patient’s primary physician and consulting physician confirm a diagnosis and prognosis. In addition, the law requires screening to determine if the patient is mentally capable of the decision to end his or her life. If either physician believes the patient’s judgment is impaired by depression or another disorder, the patient must be referred for counseling.

There is definitely a question about whether patients would be able to get coverage for mental screening, considering that many health plans have separate requirements for obtaining mental health services. "Many health plans don’t cover mental health exams to determine competency," Falk explains. "They cover mental health diagnoses and treatment."

On the other hand, because the screening typically would require one visit with a mental health professional, it might go "below the radar screen" of what the plan would flag as not meeting mental health guidelines. "A lot of plans don’t apply their more rigorous screenings for mental health services until the member has reached five or more visits. It depends on the specific contractual arrangements of the plan."

Assisted suicide not that expensive

Falk acknowledges that a patient seeking coverage of extensive home health or hospice care would attract significantly more attention from the health plan than a patient choosing assisted suicide. "I think you would have to struggle to use $500 worth of resources in a typical case of physician-assisted suicide. In many cases, you could be talking about one visit to the primary care doctor, a visit to a mental health professional, and a prescription of drugs. That would most likely be below the level that would attract audits."

In contrast, because end-of-life care can be extraordinarily expensive, health plans might place significant requirements in terms of prior authorization for coverage, Falk notes. "Prior authorization is used for medical procedures which are of doubtful efficacy or very expensive, or they tend to be overused, or there is a significant cost difference to be achieved."

Far from being concerned only with cost issues, however, Falk says the law has prompted health plans to begin to take an extended look at end-of-life care so patients are not pushed into an assisted suicide option out of desperation, he says. "It is my perception, but I believe we have seen, for example, that hospice coverage has become more widespread since the passage of this law. And I think that is a logical response."

With assisted suicide now legal in Oregon, there exists a natural cost incentive for health plans to support assisted suicide over other, more expensive "treatment" options, says Nelson Lund, JD, professor of law at George Mason University Law School in Fairfax, VA, and an expert on assisted suicide. Protecting patients from unscrupulous cost shifting is extremely difficult, he says. "It’s very hard to think of a law that could make a distinction between legitimate cost-cutting by an insurance company in long-term care and cancer treatments and an illegitimate cost reduction. Inevitably, you will have these pressures develop."

Insurance companies exert an enormous amount of pressure on health systems as a whole and on individual physicians, he says. "Once strong incentives are created through cost cutting through the managed care system, you naturally are going to get more of the cheaper treatments and less of the expensive treatments. That has to be true; that’s why things are done."

Although protections are written into Oregon law, physicians will face subtle pressures to view patients’ options as more limited than they otherwise may consider them, Lund says. "Even though the law requires a diagnosis of less than six months to live, that is an incentive for the physician to say, This person has only six months to live.’ Once eliminating the patient is considered a form of treatment, the economic incentives are there that I think are unstoppable."

References

1. Chin AE, Hedberg K, Higginson GK, et al. Legalized physician-assisted suicide in Oregon — The first year’s experience. N Engl J Med 1999; 347:577-582.

Additional reading

• Rojas-Burke J. Oregon’s poor slip through safety net of health coverage. The Oregonian, March 29, 1999.

• Rojas-Burke J. Survey gives Oregon Health Plan high marks. The Oregonian, Feb. 3, 1999.

Sources

Ted Falk, 6824 SE 34th Ave., Portland OR 97202. Email: tedfalk@teleport.com.

Gregory Hamilton, MD, Physicians for Compassionate Care, P.O. Box 6042, Portland, OR 97228. Telephone: (503) 533-8154.

Nelson Lund, George Mason University School of Law. Telephone: (703) 993-8045. Email: nlund@gmu.edu.