Critical Care Medicine - List
http://www.pitt.edu/~crippen/

Resource utilization by manipulative intent: the visa as an unlimited medical access charge card.

David Crippen, MD, FCCM
Department of Critical Care
St. Francis Medical Center
Pittsburgh, Pa

AND

Marjorie Lazoff MD
Assistant Professor and Attending Physician
Temple University Hospital/Emergency Dept
Philadelphia, Pa

Should Mt. Sinai have treated this patient gratis as a humanitarian gesture?

David Crippen, MD

I think this was was a calculated move to abuse our resources and I am not sure we should have to buy into it because of a tug on the heartstrings. If this was a humanitarian gesture, then I must ask after our priorities. If we are into humanitarian gestures, should we not begin at home? What do we owe foreign nationals deposited on our doorstep in relation to what we owe our own needy citizens? Who should make these decisions? That an entertainment celebrity like Marlo Thomas would identify this child as a high priority for deviating from the usual resource allocation scheme we use in the USA does not necessarily change things. I have no doubt that St. Judes Hospital does admirable deeds, but they, and other facilities like them, cannot be counted on for other than politically desirable patients, or to take advantage of positive publicity. High profile charitable institutions like St. June Hospital are funded differently that Sinai and are more resistant to financial shell shock because of their endowments.

The affluent tend to mobilize large amounts of money to save the lives of emotionally identifiable individuals with the benefit of wide media coverage. Witness the distribution of photographs of sad appearing children with appeals for funds or organs for transplant. Those who would "give" in such a manner like an identifiable form and substance which they may proudly point to and say "I gave of my resources to help this particular needy person". In this way they gain some immediate ego gratification and also, in some way feel that they have directed the utilization of their gifts. Those with less identifiable disorders, or those merging more with the great unwashed are ignored. Does this mean that this child was in any more need than the great unwashed who suffer daily?

Marjorie Lazoff, MD

Although I don't deny their present financial hell, I think Mt Sinai should have first cared for the child with cancer and then presented the (real) bill to the American public, saying, "our hearts won't let us withheld treatment, but our present endowments and insurance and government reimbursement don't allow us the resources to absorb the costs for her care ourselves. And if we can't afford her care today, and the cuts still keep on coming, how are we going to afford to care for others who can't afford to pay tomorrow -- like those who live across the street from our great hospital?" It strikes me that to hold a little girl with cancer medical hostage until her parents, or the US government, or someone, comes up with a quarter million -- or promises not to cut back on Medicaid reimbursements -- is cruelly melodramatic. To most of us, a seven year old of any nationality with a treatable cancer is a medical emergency, in the ethical if not the medical sense of the word emergency.

America isn't obligated to care for the world, but in humane celebration of our relative good fortune we ought to fully support those international organizations that do, and squeeze every cent from our own medical banks to benefit others when we can. Maybe it's that St. Jude's has taken this opportunity to both 'do the right thing' and project a favorable image of themselves doing the right thing. I think it's also appropriate for a hospital to help arrange for such care in the patient's country or to seek out international organizations -- regardless of the ability of the hospital or this nation to pay. What I do not think is appropriate is outright refusing emergency care, unless such care is clearly futile (which I'm assuming in this case it was not).

David Crippen, MD

Of course there is a place in the world for selfless altruism and unfettered devotion to those less fortunate. But such services still have to be administered somehow in order to get them to needy individuals. So, how would you administer altruism? First come, first served? Tearjerker quotient? Age, IQ, sex, physical characteristics? Jack Bailey used an Applaus-o-meter to select "Queen for a day" in the fifties. Should we install interactive push-buttons on the sofas of each viewer of their 11 o'clock news? If you believe this argument to be fatuous, how then would you administrate scarce resources meant for the community surrounding each hospital? Difficult decisions must be made. Some potential consumers must be cut out in order to maximize benefit for the many. I suggest that conservation of resources begins at home. For the hospital to get involved in international medical politics is unrealistic. The point of this patient's presence at Mt. Sinai is to mobilize an emotionally compelling argument to circumvent the rational American resource allocation system. There is nothing the hospital can do to put them back on a track already found wanting.

Marjorie Lazoff, MD I resist looking at this solely from the standpoint of economics; that kind of simplicity risks distortion because it ignores the political, emotional, live-threatening, and financial complexity of this situation. This family didn't come looking to invest a quarter million in T-bills; they came to save the life of their child because there was perceived to be no other way. None of us know the financial capacity of the family. We assume they came here planning to pay 'nothing' yet that might not be the case at all. Perhaps they sold their last goat to get the airplane tickets. Perhaps they are middle class in Bolivia and came checkbook in hand, willing to pay tens of thousands of dollars in care -- but they simply don't have anywhere near the $250,000 Mt Sinai requested. It may never have occurred to them the bill would be so overwhelming. They may have done their own medline researches and spoke with professionals and saw that Mt Sinai in NYC has wonderful pediatric cancer facilities. Unable to secure a medical contact through their own physician, they came in desperation to Mt Sinai themselves. Without a clinic appointment or admitting physician, they were directed to the emergency department so their sick child could be assessed immediately.

Or lets say they're streetwise and here to play the press and obtain care they knew on the plane they couldn't otherwise afford. They already knew without $250,000 in hand a direct referral might refuse them even before they left the country -- and then where would their daughter be? Maybe they did further research and discovered there are ways to 'milk' the American public to cover their child's medical bill, but they'd have to play up the "desperation angle": go straight from the plane to the ED, look forlorn and confused into the camera with tears in their silently pleading eyes, etc... Can any of us blame parents for doing all they can -- including humiliating themselves on TV, finagling in a foreign country, begging, and even stealing -- for someone to save a life of a loved one they themselves cannot afford to save?

And why are we so cynical towards those millionaires helping another out in front of the cameras? Let Marlo Thomas feel good about what she and St. Jude's are doing, let her bask in the public's glow of her humanitarian act -- it's legions more than any of us are doing. In her mind it may be 'free' publicity for her hospital or an act in her father's memory. And even if it is for her -- must everyone be a 100% saint lest they be fatally criticized for whatever good they do? It may not be fair that she responds to publicity and not the great American unwashed, but that's not her fault any more than it's the Bolivian family's fault -- it's our fault, for making this media circus the only practical way philanthropists and the needy can meet. (Here's a real cynical thought: we do it this way deliberately, because it entertains us to watch people in pain while those Real Americans (just like us, if we millions too!) come to the rescue...)

David Crippen, MD

Your argument continues to rely on an applaus-o-meter score higher than the next potential Queen for a Day in the lineup. Unfortunately, there are realities that transcend a tug on the heartstrings. Hospitals in this country are in extremely precarious financial shape. Some estimations are that 20% will go belly up in the next ten years. In addition, we face the reality of cuts in reimbursement for patients "on the public dole". Hospitals like Mt. Sinai are facing staggering operating deficits. They cannot continue a policy of practical altruism with the hope that the money will "come from somewhere". Current cost shifting strategy is targeted for extinction in the future. A policy in which hospitals render care with no consideration of the tax base that supports it means layoffs of American labor forces as well as declining resources to treat the community constituents.

Marjorie Lazoff, MD

I'm not convinced we Americans understand the difference between a true 'limited medical resources' crisis (aka Bangladesh) and the compromises being forced upon us by the greed of self-interest groups as they try to insure the medical feeding trough continues to financially support many businesses comfortably -- aka pharmaceuticals, insurance, managed care and hospital administrators, organized medicine (AMA et al) and individual physicians, and medical supply companies. I didn't support Clinton's health plan because it seemed to me little more than a way to appease these groups while holding down health care costs, rather than deal with the deeper financial issues: the inefficiencies that make for clumsy paperwork, maldistribution of health care facilities and personnel, inconsistent medical care, and unrealistic government reimbursements.

Moreover, there will always be people who will dump their problems on others rather than take control of their lives. As we know, sometimes they do so out of laziness, sometimes they do so out of depression, sometimes they do so because they can't think of another alternative or don't know what else to do. It seems to me our goal as physicians should be to help design a medical system that doesn't ENCOURAGE abuse. But whether such a system is in place or not, I don't think we should ever waste time ferreting out and destroying ONE BY ONE those who dump their cancers at our medical shingles.

Final comments, David Crippen, MD

This case sets a frightening precedent for the future. We have the potential to see a mass of ill patients from foreign countries arrive for medical care since this girl was successful in obtaining treatment? In some states, the precedent has long since been established. Current estimates suggest 3,000 illegals per night coming across the southern California border. Included in this 3,000 is a substantial number of gravid females desiring to produce US citizens in US hospitals on the public dole. The general public decries the attitude of Californians regarding the illegal alien problem, but it must be remembered that the majority of those criticizing Californians have no such problem in their home State.

It is very frustrating not to be in a position to heal all the ills of the world population. I do not believe that Mt. Sinai desired to be portrayed in the media as a mountain of meanness. The sad reality is that we have a choice here. We can fritter out resources by an aplaus-o-meter.....the saddest tale generating the most applause, or we can make difficult decisions about how to allocate our resources...decisions that must necessarily be nationalistic.

Final comments, Marjorie Lazoff, MD

I have an opinion as a private citizen what we ought to do with little Bolivian girls with cancer, as I have an opinion on what we should do with widgets if I were in charge of their distribution. But to me such opinions are completely and necessarily distinct from my physician persona and so have no place in this particular argument. I think that a physician -- in contrast to an administrator or politician or general citizen -- ought not to judge the appropriateness of rationing or providing care for a patient, but only provide such care on demand.

Two fictitious people come into the ED, both with gun shot wounds. The quick and dirty story is that one was robbing a store and in the process shot the storekeeper, then was wounded himself seconds later by the same storekeeper defending his turf. Both need immediate medical attention, but there is only one OR ready to go -- both will get care, hopefully neither will die, but which will get PRIORITY care? Would you agree that the appropriate course of action is to do what's done at present throughout the country: to triage both patients based SOLELY on their medical needs, use the available OR on the patient most salvageable/least able to physiologically tolerate waiting for the second room to be ready, and allow the police and judicial system to sort out the legal issues later? Let the Law and Order regulars take their full TV hour to figure out that the drawing of guns was in response not to a robbery but to the shopkeeper alleged molestation of the other's child.

My point is that society should specifically discourage physicians getting involved in deciding who is deserving of care. We should treat whoever is before us, however they got there, and our role is to make it as easy as possible for all who desire care to be seen. I think our physician role is not to assist in determining rationing based on financial realities but to inform the country what our health care needs are and the expected medical ramifications of proposed rationing scenarios -- none of which are good news. I continue to see the role of rationer as antithesis to those concerns, since they involve medical management with other than the patient's best interest at heart. In so doing, I am not turfing the physician's responsibility of rationing so much as redirecting efforts away from what is (not just unpalatable but) a wholly unsatisfactory answer to limiting health care resources: denying lifesaving care to anyone, lest of all 7 year olds.