Part I

Luigi Mangione perpetrated a horrific crime in murdering an insurance company executive in a premeditated brutal manner. But Elizabeth Warren, the senator from Massachusetts, stated it was “… a visceral response from people across this country who feel cheated, ripped off, and threatened by the vile practices of their insurance companies…” Also, there has been widespread sympathy for Mangione. Undoubtedly, Warren would have agreed with Vladimir Lenin: “How can you make a revolution without executions?” One can only speculate how Warren would have justified the assassination of Trump during the campaign had it been successful.

Interestingly, there is no record of any negative interaction between Mangione and a medical insurance company, so one wonders what provoked him. More importantly, I think it important to consider what exactly are the perceived problems with insurance companies, what they stem from, and who or what are the true villains. So I plan a series of eight articles to address these topics as I envision them (I suspect not everyone will share my views) and the interactions among patients, providers, drug companies and insurance companies.

I would invite readers to email me their thoughts on the issues raised in these articles as they appear in the Link and, depending on the response, I will put together one or two articles with readers’ comments after my eight articles appear.

This week I received from the dentist a detailed plan for dental work for the next six months to fix my teeth. (Yes, I should have flossed.) The estimated cost made Elie and me gape. I mention this because dental insurance is a contrast to medical insurance—it does not come close to providing the same degree of coverage. I reviewed my options—going forward forgoing steak and eating farina and chocolate pudding; eliminating various items on the list; negotiating the price; schlepping to Staten Island to our nephew who would probably give a better price. This is the consequence when price and cost matter to the consumer, i.e., the patient.

You might think that those in the European Union or Canada, for example, where there is universal health coverage, are in a similar situation as the insured in the U.S. There are some similarities, but there are also some major differences as best I can appreciate them, both positive and negative.

1. Insurance has, for most purposes and considerations, freed the main players in the healthcare process—patients, physicians, drug companies, hospitals—from giving any serious consideration in their decision-making to cost.
2. I cannot recall the last time a patient or family member asked me how much a treatment or procedure would cost. And why should they? When effective and reasonable interventions are being offered and utilized, even at extreme cost, that is precisely the blessing that insurance has provided. But perhaps if cost were an issue, if the consumer had an iron in the fire, prices would be reduced and circumstances improved for all.
3. A recent study in the Journal of Clinical Oncology reported that about 35% of patients receive chemotherapy within 30 days of death. What was noteworthy was that a high percentage of this chemotherapy consisted of the newer, more expensive immunotherapeutic and biologic agents. Many factors go into this phenomenon, but undoubtedly when patients or caregivers are offered this option at late stages, the “Why not?” sentiment that the absence of financial considerations provides plays a significant role. To be precise, we are talking about very costly treatments that have, under the circumstances, almost no chance of providing any benefit. The same considerations apply in DNR decisions—there is no consequence to the family in maintaining a hopelessly terminal patient, so their care may drag on pointlessly for days as insurance bears the cost.
4. The healthcare system is a fee-for-service one for the most part. It would be naïve to think that this does not affect decision-making by healthcare providers. On the whole, one would assume that decisions that offer a billable choice versus a wait-and-see choice are going to generally be tilted towards the former. This is true not just in oncology but for joint replacements, stents, and otherwise. Studies indicate that something like one-third of surgeries are unnecessary.
5. Drug costs in the U.S. also reflect the fact that insurance pays for it. No other country pays what we pay here.
6. The nationalized healthcare systems are much better at regulating the costs and prices of items and limiting the more outrageous items. But the limitations in those systems also lead to profound delays in access to services—long waits for diagnostic scans or appointments with specialists or elective surgeries. I am certainly not an advocate of the nationalized plans for the U.S. The deficiencies in those systems have led to the creation of parallel private pay-for-service clinics, which highlight the major flaws in the nationalized systems.

Unfortunately, I believe the problems stem from a lack of involvement or concern of the consumers in the process and a natural bias on the part of healthcare providers to increase billings. The insurance company is caught in the interplay between these two groups with the role of acting as the interlocutor. Obviously, this will make it unpopular with both groups even if its activities are necessary. By no means do I think that insurance companies have no flaws or make no errors, but they do provide a necessary major role in the healthcare system, which I believe needs to be appreciated. We will explore these interactions in more detail in the coming articles.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: ain1@columbia.edu.

 This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.