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February 27, 2005

The NYT's Solution To Saving Medicare: A Highly Personal Reflection

Today's New York Times includes an article with the rather provocative title "How to Save Medicare: Die Sooner."   Flippancy of the headline aside, the article has a serious point.

...how can Medicare's ballooning costs be contained? One idea is to let people die earlier.

For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent, said Dr. Gail R. Wilensky, a senior fellow at Project HOPE who previously ran Medicare and Medicaid. Thus end-of-life care hasn't contributed unduly of late to Medicare's problems. But that doesn't mean it shouldn't be part of the solution. "If you take the assumption that you want to go where the money is, it's a reasonable place to look," Dr. Wilensky said.

End-of-life care may also be a useful focus because, in some cases, efforts to prolong life may end up only prolonging suffering. In such cases, reducing pain may be a better use of resources than heroic attempts to save lives.

This probably seems reasonable to all of us but, as the article notes, it is often easier said than done.

The question becomes, how can you identify end-of-life care, especially the kind that's likely to be of little value? "It's very difficult to predict exactly when a given individual is going to die, in most cases," said David O. Meltzer, an associate professor of medicine at the University of Chicago who also teaches economics...

... he recommended that doctors try to prepare patients and families for less resource-intensive care at the end of life. "There is no question, as a clinician, and as a patient and the family members of patients, there are things you can do to make sure that expenditures with little chance of being helpful won't be undertaken," he said. "You explain to people that the goal of medical care is not always to make people live longer."

... he recommended that doctors try to prepare patients and families for less resource-intensive care at the end of life. "There is no question, as a clinician, and as a patient and the family members of patients, there are things you can do to make sure that expenditures with little chance of being helpful won't be undertaken," he said. "You explain to people that the goal of medical care is not always to make people live longer."

I'm going to beg your indulgence, and take the highly unusual step (for this blog) of stepping out of my role of economist for a moment.  Two days after this past Thanksgiving , and less than a month after his 68th birthday, my father lost his battle with lung cancer.  Although his struggle was relatively brief in the larger scheme of things -- he had been diagnosed in the fall of 2003 with advanced-stage disease -- he followed the all-too-typical pattern of the many, many others similarly afflicted: Hopeful optimism as the first round of chemotherapy provided a brief respite, concern as the cancer came raging back, weariness as the much rougher second round of treatment took its toll, and despair as it became clear that the miracle we had all hoped for would not materialize. 

To an objective observer, it was obvious that the end was very near on Thanksgiving eve.  But despite the fact we had watched him virtually disintegrate in front of our eyes, the idea of my father's death was somehow still very abstract.  When you are living one day at a time, making it to the next sunrise becomes an obsession.

The cancer did not wait for us to come to grips with our emotions, and the moment came to make the terrible choice.  Seek (against my father's wishes) the extraordinary measure of medical care that might grant us one more desperate day -- or week? or month? or more? you never know, right? -- or resign ourselves to the dying of the light that had always, always burned so brightly in our lives.

We chose the latter.  A call was made to our local hospice organization.  On Thanksgiving morning we received the first of many visits from the remarkable human beings who would would help us usher my dad through his final days on earth.  He died -- I can think of it no other way -- as I hope I do.  In his own bed, in the home he loved, surrounded by children and grandchildren, in the arms of the woman that had shared his life's journey from childhood.   

The Times article ends with this observation.

AN alternative to saying no would be to encourage severely ill patients to choose hospice care, where the emphasis in treatment shifts from cure to quality of life. Patients are made to feel as comfortable as possible, and reducing pain takes precedence over radical procedures. At present, only about 1.6 percent of Medicare benefits pay for hospice care.

Despite the less-intensive brand of treatment, hospice care may not be cheaper than hospital care. "The assessment of hospice has not indicated that it's a clear money-saver," Dr. Wilensky said. "It can be, but we don't have very good examples."

Maybe so.  Compared to the alternative, I don't really know the ultimate price of the care my dad received in taking those last steps home.  But I do know its value.

You can find information about hospice care here.

February 27, 2005 in Health Care | Permalink

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From the New York Times "Economic View" column by Daniel Altman: [H]ow can Medicare's ballooning costs be contained? One idea is to let people die earlier. For the last few decades, the share of Medicare costs incurred by patients in their ... [Read More]

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Comments

Sorry to hear of your family's loss. Having been through it myself, I was totally unprepared.

Financially speaking, I think there are other areas in which savings are easier to come by. Prevention (both public health measures and preventive care by organized medicine) is often an excellent investment financially in addition to the obvious health benefits. In addition, the overuse phenomenon is really quite large and easier to identify in advance then is the end-of-life situation which is often known only in retrospect. Car wrecks, heart attacks etc are often sudden and fatal, andthe costs of their care are labelled end-of-life but nobody would seriously suggest less agressive treatment in most of these instances.

Posted by: quietstorm | February 27, 2005 at 02:50 PM

Sorry about your Dad. It has been years since my Dad died of lung cancer. He too died at home, never spending a day in the hospital. My best friends dad was diagnosed with cancer about the same time. His family opted for agressive care. He lived about six months longe than my Dad, had multiple rounds of chemo, and died in the hospital with a pain drip going. He may have lived longer, but the quality of his life was awful. (Not to mention what was spent.)

I believe there is a considerable amount of money to be saved in end of life care. Having worked in a hospital for years, I saw many patients come in for extraordinary care, even with a diagnosis of terminal cancer. Many died in the hospitl or the skilled unit.

A difficult issue to deal with.

Posted by: JWC | February 27, 2005 at 06:15 PM

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