`Less care, not more’

A unanimous Supreme Court ruling Monday does more to explain the frustration Americans have with the current state of health-care coverage than any dozen patient surveys. The ruling should be of interest to Congress, which helped create the frustration and the lack of care that causes it.

The case involved an Illinois woman, Cynthia Herdrich, who, in 1991, developed severe abdominal cramps that suggested appendicitis. Instead of an appendectomy, however, her health maintenance organization, Carle Care, wanted her to take an additional test, an ultrasound examination. The wait for such a test was eight days. Her appendix burst during the wait and she developed peritonitis. The Ms. Herdrich sued for malpractice and was awarded $35,000, but then sought further compensation through Employee Retirement Income Security Act, which governs employer-sponsored health plans.

In rejecting this claim, Justice David Souter pointed out that, In an HMO system, a physician’s financial interest lies in providing less care, not more. Later on, he wrote that an inducement to ration care goes to the very point of any HMO scheme, and rationing necessarily raises some risks while reducing others (ruptured appendixes are more likely, unnecessary appendectomies are less so…). That is, denying Ms. Herdrich emergency treatment in favor of less expensive tests is not only acceptable medical practice, it is part of the financial logic of an HMO.

This shouldn’t be shocking, given the decade of debate over paying for health care. Yet it is. Americans may have grown accustomed to rationing care through access (or the lack of it) to insurance, but the assumption remains that if you can afford coverage you are entitled to receive the best care in the world. The Herdrich ruling suggests otherwise. It says that, within reason, care might be meted out according to the condition of an HMO’s financial report for the last quarter.

There’s nothing wrong with the court’s interpretation in this. As Congress congratulated itself for killing major health-care reform in 1994, it encouraged the creation of HMOs as a way to hold down costs. At the time, there was a lot of talk about holding down costs by cutting administrative expenses, emphasizing preventative care and sharing information to find the most efficient ways to practice medicine. It turns out, however, that the best way to hold down costs is to deny or delay medical services.

It’s too late this session – or, more to the point, this campaign season – to do much about a health-care system that thrives when it fails to provide services. But Congress should re-examine its role in this failure, or explain to the many Ms. Herdrichs in the country why the pain they are experiencing is perfectly normal, just a side effect of a system failing its patients.