I apologize for the length of this article but the subject matter doesn't lend itself to brevity.

There has been a lot of back and forth about 'death panels' in the course of the healthcare reform debate and those who've raised concerns about the likelihood of faceless government bureaucrats making individual patient care decisions have been dismissed as right-wing kooks, haters, uncaring, venal, mean, etc.  (Many of you will recognize the foregoing as a classic Obama rhetorical tic, but if it's good enough for him, it's good enough for me.)  The phrase originally applied to an 'independent' agency that would be tasked to decide what sorts of treatment regimens would be allowed under UHC and who would be eligible for them, but has come to represent the broader issue of bureaucratic intervention in all manner of individual healthcare decisions not necessarily so closely related to 'life & death.'  Again we've been told that any worries about such matters are nothing more than the fevered imagination of right-wing nutjobs.

Well, the mechanisms for such bureaucratic behavior are already in place and already being used by third-party 'benefits managers' to do exactly that - make insufficienctly informed decisions about whether or not to pay for certain treatments for specific individuals.  These currently are being used only for decisions on prescription medications and certain diagnostic imaging studies but will simply be scaled up for micromanagement of all sorts of clinical decisions.  I encountered a perfect real-world example of how this works, and will work, just this morning.  I suspect most of you have not run into this sort of issue personally or if you have you may not be acquainted with the 'back story,' so I thought I'd share this with you.  So you know what's going on.  Bad as what I describe below may be, don't blame the insurance companies alone for our current situation - they are only following the rules and incentives laid down by our federal and state governments, which have unwisely interfered in and perverted (in my opinion) the natural relationship between insureds and insurance companies.

I have a patient, a gentleman in his early 70's who has moderate renal insufficiency (kidney failure), a history of coronary artery disease and severe recurring gout, an exquisitely painful condition, in part related to elevated serum uric acid levels.  Despite excellent control of his serum uric acid level he has been experiencing frequent recurrences of acute gouty arthritis.  Acute episodes are best treated with short courses of potent anti-inflammatory medications but their use in the presence of chronic renal insufficiency is risky and often worsens kidney function, infrequently drastically and permanently.  This was the case with my patient when recently treated with traditional inexpensive anti-inflammatory (NSAID) medications.  Fortunately, his kidney function recovered to baseline once the NSAIDs were stopped, but he's continued to have recurring episodes of gout & each exposure to NSAIDs increases the risk of further, potentially permanent, kidney damage.  He also has gastroesophageal reflux disease (GERD), a condition which can be exacerbated by NSAIDs, especially with long-term treatment.

There is another class of anti-inflammatory medicines called COX-2 inhibitors which are effective for gout and other types of arthritis.  Although they, too, have the potential to affect renal function, adversely affect GERD and increase cardiovascular risk, the risk is somewhat lower, provided that a patient is closely monitored.  After a short trial of the only COX-2 drug currently available was well-tolerated, without adverse acute effects on his kidney function and very effective for one of his acute attacks, and after we thoroughly discussed the various long-term options and risks of each, as well as the risk of doing nothing (continuing acute attacks of gout) we elected to start long-term treatment with the drug to reduce the likelihood of recurrent acute attacks, the other options having been tried and failed or having greater associated relative risks.  Understand, now, that there is no alternative 'risk-free' option - we either do nothing or something, both of which entail risk.  The point of the discussion so far is not to invite a debate about what the optimal treatment might be, but to give you a feel for where we were and how we got there.

Well, you'd think that after such careful consideration including trials and observation of alternatives, there would be no problem obtaining coverage for the COX-2 medication from his insurance carrier, which, as it happens, required prior authorization (review) before the drug would be paid for (subject to the usual co-payment, of course).  And, you'd be wrong.

A week or so after providing all the required relevant clinical information to an anonymous individual answering an 800 number, as per their prescribed procedure, we received a faxed Notice of Denial of Medicare Prescription Drug Coverage including the following language:

We denied this request because:  The patient is at high risk (e.g., >10% 10 year CV event risk by history or cardiac workup) for cardiovascular disease or has pre-existing cardiovascular disease.  CKS RPH...

OK.  CKS is a registered pharmacist, sitting at a computer somewhere, who has never met my patient and knows nothing about him other than the answers to a list of questions asked by the anonymous individual answering the 800 number.  In other words, a faceless bureaucrat.  And he's decided to overrule the considered judgement of a practicing internist with more than thirty years of experience, one who is fully cognizant of the patients entire health history and the relative risks and benefits of the medication in question, and who has made a decision in concert with this patient to pursue this course of treatment with full knowledge of those risks and potential benefits.

Of course, citizens of the US currently have certain 'rights,' among them the right to appeal this faceless pharmacist's decision.  That right was explained in the Notice of Denial as follows:

What If I Don't Agree With This Decision?

You have the right to appeal.  If you want to appeal, you must request your appeal within 60 calendar days after the date of this notice.  We can give you more time if you have a good reason for missing the deadline.  Your have the right to ask us for an exception if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower cost-sharing amount.  You can also ask for an exception to utilization management tools, such as a dose restriction or step therapy requirement.  Your physician must provide a statement to support your exceptions request.

Who May Request an Appeal?

You or someone you name to act for you (your appointed representative) may request an appeal.  You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you.  Others may already be authorized under State law to act for you.

You can call us at: 1-866-XXX-XXXX to learn how to name your appointed representative.  If you have a hearing or speech impairment, please call us at TTY: 1-866-XXX-XXXX.

You can argue, if you wish, that the faceless pharmacist did not really 'deny' anything, he just refused to pay for it.  That is technically true... for now.  But you can rest assured that won't be the case in the future planned for us by UHC proponents.  If they can force us to pay for insurance and deny us the option to purchase any healthcare outside the confines of the 'system,' such denials will be de facto (and arbitrary) rationing.

Imagine for a moment a 'system' where every such healthcare transaction is subject to this kind of bureaucratic micromanagement and to such appeal requirements (assuming any appeals will be allowed once UHC is adopted).  How could anything requiring clinical judgement outside the confines of generic one-size-fits-all algorithms get done in anything resembling an efficient and timely manner?  The answer should be self-evident.  This will be how it's done and you will have no choice in the matter.  The loss of choice may not be immediate, in the sense that you will have appeal rights (such as they are) for awhile, but as the 'system' matures and becomes more highly granular in its proscriptions and control, as more and more data is in the hands of distant bureaucrats thanks to mandatory electronic health records, choice (not to mention privacy) will become an inevitable casualty of cost-control.  While initially affecting relatively small things like this prescription, that loss of choice will be inexorably extended to more and more substantial and complex decisions, up to and including whether to let you live or let you die.  It is simply inevitable.

I planned to say here that I probably won't be around long enough to see that last bit come to pass, but on reflection I'm not so sure that is the case.  In fact, if UHC as currently proposed is enacted this year or next, I expect it will directly impact me and that my life (or death) will be subject to the decrees of such faceless bureaucrats.  Struggling with any serious illness is difficult enough in its own right, and doing so within the current insurance-based system has its frustrations and inequities (the causes of which are open to debate), but UHC proponents are asking us to double down on the flawed system we have and make it even worse, by making it even bigger, more densely bureaucratic, and distancing decisions even further from the exam room or bedside, rather than trying to fix its flaws and return choice and power to the individual.  I can't imagine anything worse than being robbed of the freedom of choice when faced with life- and health-related decisions, decisions that should be the purview of a sovereign individual and the advisors he chooses to involve in those decisions.  Or anything more illiberal.  Or more unprogressive.

I hope I am proven wrong.