The Doctor Weighs In

by Margaret Cary, MD, MBA, MPH

Step right up, folks, for the chance to win your life. Oregon will randomly choose 3,000 lucky, low income winners from among the more than 90,000 (out of at least 600,000 uninsured) who applied for available vacancies in the Oregon Health Plan lottery—one in thirty. A decade ago this same plan was considered progressive—a health plan for folks who earned too much to qualify for Medicaid and not enough to afford medical insurance. These lucky winners will be the first since the Oregon Health Plan’s budget was capped in mid-2004. With limited resources for a huge demand, how would you choose? Would you select the 50 year old woman with a rare disease who cannot afford the monthly cost of $500 that would increase her life? Would you choose a 72 year old man who needs a pacemaker? On the same day the Los Angeles Times featured the Oregon lottery, on the other side of the country the New York Times contained an essay, “Many Doctors, Many Tests, No Rhyme or Reason,” by Dr. Sandeep Jauhar. Dr. Jauhar’s book, Intern: a Doctor’s Initiation , was reviewed last Sunday by the Times . He wrote of a cardiologist friend who must do at least ten nuclear stress tests each month just to pay for the overhead for the machine’s various costs. This physician tried to do the right thing when he started practice, but his patients—the worried well—wanted technology. If he did not order the tests, the patient would see the next cardiologist, who would order them, and then be praised for his thoroughness. CT scans for headaches and stress tests for young, healthy people with palpitations. This technology is much more expensive and labor intensive than a blood test to determine whether someone is tired from anemia or from hypothyroidism. These are people trying to survive, by taking a chance on winning the lottery or by making a living by increasing volume. Someone wins. Someone loses. Last week I attended an event, “Our Looming Medical Cost Catastrophe: What’s to Be Done?” I thought I was in the 1990s—the same points and the same arguments. The main difference is the numbers—costs, people, procedures—have increased. Significantly. Déjà vu, anyone?