perspective

Officers of The Center – 2015

field notes Compassionate imagining. I will always remember my first months at The Hastings Center as set against a backdrop of calls for social justice and the protection of vulnerable populations. Following weeks of civil unrest sparked by police brutality in Ferguson, Missouri, the fatal strangulation of Eric Garner, a black man, by a white New York police officer gave rise to “die-ins” across the country. I blogged for Bioethics Forum on the Ebola outbreaks in Guinea, Liberia, and Sierra Leone, with a focus on retrofitting governance systems that ignored a dangerous lack of health infrastructure and created populations vulnerable to public health emergencies. Back home in Virginia, I celebrated with family and friends the legalization of same-sex marriage after the Supreme Court let stand rulings in favor of it in five states. Voices of protest have focused our attention on the injustices faced by populations made vulnerable, particularly people of color, the poor, victims of public health crises, and lesbian, gay, bisexual, transgender, and queer communities. Health is a condition deeply affected by social systems shaped by inequities. As legal scholar Karla Holloway observes in a Virtual Mentor essay, “‘Vulnerable’ patient populations are not an invention of bioethicists in search of a subject”; vulnerabilities are not necessarily “intrinsic,” but are often “decidedly extrinsic,” as a result of conscious and unconscious biases. Institutional, regional, and personal biases burden particular populations with vulnerabilities that make members susceptible to impeded health care access, poor health care quality, and poor health outcomes. Since joining the Center in August 2014, I have worked on projects examining the needs of recognizable, yet heterogeneous, groups—such as LGBTQ patients and undocumented immigrants—who confront institutional prejudices in pursuit of health and particular notions of a good life. Addressing the vulnerabilities of LGBTQ communities, Andrew Solomon writes in the September-October 2014 issue of the Report that we must consider the extent to which gayness is a mutable set of behaviors or an integral identity, and he describes bioethics as “the field in which [the] distinction between gay acts and a gay self may be argued most directly.” As I try to help a beloved and openly gay younger brother navigate the many barriers he faces, the stakes of this debate feel quite high. Solomon points out that it remains to be seen whether science will explain sexual preference and gender identity as either innate or chosen traits, but one thing is clear: law and medicine continue to render gay, lesbian, and bisexual populations more or less vulnerable based on existing presumptions about the nature of sexual preference. It is a contentious affair when one group of people seeks to make a claim for recognition and respect but meets with resistance from others who fail to see them clearly, or even to try. Particularly in the case of LGBTQ rights and health, the most significant defense against intolerance and discrimination in a bioethicist’s arsenal might be the ability to compassionately imagine the struggles of others in a way that affords a real possibility for social transformation. —Chelsea A. Jack Research Assistant

David L. Roscoe

Chair Mildred Z. Solomon

President and Chief Executive Officer Harriet S. Rabb

Secretary

How Much for That Stress Test?

Andrew S. Adelson

Treasurer

BY SUSAN GILBERT

Board of Directors – 2015 Andrew S. Adelson Liza Bailey Daniel Callahan (ex officio) Edgar Cheng The World-Wide Investment Co., Ltd. Rebecca Dresser (ex officio) Washington University School of Law Joseph J. Fins Weill Cornell Medical College Alan R. Fleischman Albert Einstein College of Medicine Willard Gaylin (ex officio) Francis H. Geer St. Philip’s Church in the Highlands Thomas B. Hakes C/S Group Geoffrey R. Hoguet GRH Holdings, LLC Kim Kamdar Domain Associates Patricia Klingenstein Ilene Sackler Lefcourt Sackler Lefcourt Center for Child Development Robert Michels Weill Cornell Medical College Michele Moody-Adams Columbia College Gilbert S. Omenn University of Michigan Michael E. Patterson Richard Payne Duke Divinity School Robert Pearlman (ex officio) National Center for Ethics in Health Care University of Washington VA Puget Sound Health Care System Harriet S. Rabb Rockefeller University Eve Hart Rice David L. Roscoe Michael Roth Wesleyan University Blair L. Sadler Institute for Healthcare Improvement Mildred Z. Solomon (ex officio) Francis H. Trainer, Jr.

W

hat if we could shop for health care the way we Clearhealthcosts.com began collecting data in New York, shop for a car or airline tickets, turning to online San Francisco, Los Angeles, Houston, the Dallas-Fort Worth tools to learn the fair price? Would this kind of area, Austin, and San Antonio, and expansion is in the works. consumerism be good for patients and for health care more Public radio has joined the effort. The Brian Lehrer Show on broadly? We are poised to find some answers to these ques- WNYC in New York teamed up with clearhealthcosts.com tions, since several relatively new resources enable anyone in 2013 to ask women what they or their insurers paid for with an Internet connection to search for prices of specific birth-control pills and mammograms. Nearly four hundred interventions and services and, in some cases, to identify women participated, and WNYC data journalists mapped who offers the best deal. and graphed the results. (While the ACA mandates that Health care prices have long been hidden from patients, screening mammograms are completely covered for women only to be revealed in an “explanation of benefits” or a bill over age forty, diagnostic mammograms often require outafter a service is rendered. While the Affordable Care Act of-pocket payments.) Since last year, clearhealthcosts.com (ACA) has increased the number of has been involved in a similar crowdpeople who are insured, more costs are sourcing initiative in California called n being shifted to patients. Deductibles Price Check, partnering with two puband copayments can run thousands of lic radio stations, KPPC in Los Angeles dollars per person each year, and 52 and KQED in San Francisco. About percent of consumer debt is from medeight hundred people have shared the ical expenses, according to government prices they and their insurers paid for data. So patients have the incentive to mammograms, lower-back MRIs, and n shop around. intrauterine devices. As a former journalist, I have been Health care consumers have other interested to see journalists leading the charge to bring sun- options. Healthcare Blue Book and Fair Health are national shine to health care prices. Doing so is in line with their databases, searchable by ZIP code, of estimated prices of role, stated by the Society of Professional Journalists: to help thousands of health services and procedures based on analypeople “be well informed in order to make decisions regard- ses of health insurance claims. MediBid is an online maring their lives, and their local and national communities.” ketplace similar to Priceline where prospective patients can This is what Jeanne Pinder, a former New York Times re- solicit bids from providers. The catch is that patients must porter, aims to do with clearhealthcosts.com, a website she pay in cash. Why would insured patients want to do that? launched in 2010 with funding from media philanthropies. Because they might pay less out of pocket, when figuring Pinder calls it a “journalism startup.” in deductibles and copayments. Participating providers are With a combination of old-fashioned reporting—a small open to cutting their fees for cash-paying customers (er, pastaff cold-calling health providers—and crowdsourcing, in tients) to avoid the headache of dealing with insurers. And which patients report what they (or their insurance compa- for services not covered by a patient’s insurance, participatnies) were billed, clearhealthcosts.com has built a searchable ing doctors might be willing to make a deal. database of thirty tests, procedures, and treatments and the The growing health care marketplace raises many quesprices charged by specific providers. The data show signifi- tions. Shopping price is one thing, but how can patients cant price variations, as in this sampling of cash prices in assess the quality of the provider? Where does the wheelthe New York area: walk-in clinic visit ($20 to $351), teeth ing and dealing leave vulnerable patients—the less well-off, cleaning ($70 to $350), cardiac stress test ($100 to $2,504), less computer-savvy customers? Surely the Blue Book and lower-back magnetic resonance imaging (MRI) without dye Priceline approaches will cause disruptions in the doctor($400 to $1,200). patient relationship. But now that health care prices have gone public, it’s impossible to ignore them. As impossible, Susan Gilbert is the public affairs and communications manand foolhardy, as ignoring the prices of cars and flights. ager at The Hastings Center. DOI: 10.1002/hast.434

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How much for that stress test?

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