Friday, October 3, 2014

Living, dying, and doctors

Forbes has an interesting article about the health care implications of end-of-life care and how you may be affected.  Obamacare's so-called 'death panels' are, of course, a reality, no matter what name you use for them, just as similar decisions will be made on your behalf by any socialized medicine scheme.  The article offers useful perspectives.  Here's an excerpt.

Any government-funded health care system must necessarily set limits on medical spending. No government can issue a blank check for unlimited medical care for everyone. The only issue is where and how it draws that line.

This is an inherent part of any socialized medical system, such as in Canada or the UK. Put simply, if you expect “somebody else” to pay for your health care, then “somebody else” will ultimately decide what care you may (or may not) receive.

. . .

... the US debate over end-of-life decision making has been reignited by a 500-page report from the Institute of Medicine (IOM) urging drastic overhauls in the end-of-life care system in the US as well as by a recent proposal by the American Medical Association for the government to start paying physicians for end-of-life consultations with Medicare patients. (Currently, doctors can’t bill Medicare for this service, so many must do so on their own time, putting even more pressure on their already overloaded schedules.)

. . .

However, commentators ... warn of a potential dark side to government-funded end-of-life counseling — namely that it might be a vehicle for future covert rationing of medical services.

End-of-life counseling per se is not synonymous with “death panels.” However, this can become a problem if doctors are also under hidden incentives to limit care in the name of “cost effectiveness.” Doctors are increasingly being rewarded (or punished) for their adherence to “appropriate care” guidelines — with “appropriate” defined by government entities. (For example, in my own field of radiology, reimbursement from Medicare will be linked to adhering to “appropriateness criteria” starting in 2017.)

When a doctor advises a patient (and their family) against further care, are they giving their best unbiased advice? Or are they being inappropriately swayed by incentives to save money? As of 2011, 28% of Medicare’s $550 billion budget was spent on the last 6 months of patients’ lives. Hence, this is literally a $170 billion dollar question.

There's more at the link.

The real kicker is going to come in the form of decisions as to which lives are "worth saving".  I'm sure you're going to find this utilitarian justification creeping into end-of-life decisions.  If a limited amount of medical resources are available, should they be spent on someone who's nearing the end of their natural lifespan, or on someone who still has many productive years ahead of them?  Who's more important to society - a plumber who fixes things, or an author who writes things?  (And what if it's the doctor's favorite plumber?  Or his wife's favorite author?)

I'm afraid we're going to see a lot more of this sort of dilemma as we increasingly lean on Big Brother to pay for our medical care.  I think the only way out of it is to revert to a user-pays system . . . and even there, medical insurers are going to want input into such decisions so that their economic interests are taken into account.

(I note that other countries are reacting differently to the same problem.  Switzerland, for example, has just rejected socialized medicine, opting in a referendum to retain a private-insurance system.)



Anonymous said...

Yes to the above. I know of an individual who has a heart murmur and was advised that replacing the heart valve would likely occur before the individual was too old. Younger person - quicker recovery. But the conventional wisdom was to wait until the valve was judged as too far gone before that occurred. It seems that these valve replacements have a limited life and will need future replacements too. Surgery too early - more future surgeries.

Sounds like a 'death panel' decision to me, kinda sorta.

I'm also pretty sure that insurance companies will begin to hold back paying out on individuals who choose life styles that are more likely to cause long term effects. Heavy drinking, large amounts of food - maybe even unsafe sporting activities.

I can partially see the logic in that - you were the cause of it. There has to be a line drawn where that occurs - who determines that ?

Brad said...

I'm Swiss, and that's not quite true. We rejected a single-payer system, but the current system (put into place about 15 years ago) is the next best thing. While you can pick your insurance company, the government dictates the price they charge and the coverage they offer. Your only flexibility lies in the extra options you can purchase: private hospital room instead of general ward, dental coverage, that sort of thing.

Some government regulation is appropriate, otherwise no insurer would accept anyone over the age of 50. However, one must leave some room for the free market to do its job, otherwise there is no incentive for cost control. Switzerland, unfortunately, is not an example of how to do this...

Old NFO said...

Good post, thanks and worth the time to dig into the backstory.

Aesop said...

Ponder the logical implications of the statement:
"Effective immediately, there will be no medical funding for the last six months of your life."

It's not like people come stamped with a freshness date on their hindquarters that anyone can know, so Monday-morning quarterbacking of "end-of-life care" by the .Gov is malarkey.

The odds are, if you hadn't needed care, your life wouldn't have ended, now would it? In my limited experience, the number of people who die from nothing in particular is pretty limited at around 0% of cases.

But to do other than carp about that tautology, they'd have to pre-select the universal termination date of all future services, beyond which you would be cast adrift, just like Eskimo elders on ice floes once were.

And the surest voting bloc is old people, so nobody wants to getting all logically consistent when it will cost them elections.

Whereas the obvious Soylent Green implications of death panels trouble the government's minions not a whit.

Hence that's exactly what we get.

Mike_C said...

The link in the Forbes article to another article called How Doctors Die is worth reading. As a profession and a society we seem to have lost track of the difference between "can" and "should." I have some terrible memories of flogging patients in the ICU to no purpose. But one example: when the neuroradiologist tells you that there is "massive loss of grey-white matter differentation" on the brain scan after a massive stroke that patient is done for because the brain is now mush. Add the renal and liver failure and the congestive heart failure and the probability for any recovery is zero. Yet we dialyzed and transfused and intubated and ventilated for over a week because a few family members wanted "everything done." That they responded to any attempt at discussion about prognosis with "You want to kill him because you're all racist!" (this to a team of Chinese, Indian and Jewish doctors, yet) didn't help, but that was just the icing. That said, the worst part was having to see the rest of the family, who simply wanted Grandpa to not suffer any longer, suffer themselves as they watched what was happening to him. (There was also a morbidly funny incident: a grandchild hung her toy stuffed blue monkey - which had a scary grimace on its face - from the suspension-panel ceiling so that it spun lazily in the air about 6 inches above Grandpa's face, "So it will cheer him up if he wakes up." I recall thinking that I'd probably crap myself if I woke from a coma to see a grimacing blue monkey inches from my face.) In any event, Grandpa did not wake up and died during a code a few days later.

Lest anyone think my position is "for thee, but not for me and mine," my 87-year old mother died last year after a seemingly minor stroke. Turned out the very localized stroke took out her ability to swallow. She began running high fevers, despite big-gun antibiotics, from aspiration pneumonias. She did not want a feeding tube, as her quality of life had been poor for several years due to Parkinsonian symptoms and mild-moderate dementia. A very intelligent woman who basically fended for herself since age 10, the cognitive deficits, of which she was very aware, were extremely troubling to her, as she hated being dependent on others for her care.

After talking things over, she elected hospice and we stopped all but comfort medications. She died three days later. I was at the bedside for nearly the entire time, and intermittently read aloud to her from a book of Buddhist parables, which she had loved, and old children's stories. (We got through the Wind in the Willows just fine, but The Velveteen Rabbit broke me and I began crying. I had thought she was in a coma by this point, but she opened an eye and asked "Why are you crying? I'm okay," and closed her eyes again. That was the last thing she said to me.) Around 10 AM the next morning the nurse (all the hospice nurses were excellent) and I could see the end was near. Three hours later she was gone.

The above notwithstanding, I've also sent an a man in his late 80's for aortic (heart) valve replacement surgery, among similar things. It all depends on the particular patient. There is no one-size fits all rule that can apply universally.

Anonymous said...

service in a nursing home in alaska taught me to treasure quality of life. a living will eases the family decisions. the health care system suffers from much the same problems the education system does. too much regulation and not enough freedom carries too much bureaucracy over priced and restricted by cya protocols. don't get caught in the fallacy of thinking insurance reform is care reform. obamacare is properly the health insurance company profitability preservation act.

Anonymous said...

Mike C, I read that HOW DOCTORS DIE link and think that is probably the most reasonable course of actions. Prolonging the inevitable to gain every precious second of life (and suffering every minute of it) only hurts your family and your dignity.

The old Eskimo tradition of wandering out to the ice - ancient wisdom. Falling asleep and not waking sounds like a good way to go to me. At least compared to being surrounded by machines with tubes stuck in every orifice, machines beeping away 24/7, having blood drawn every couple of hours - bah!

The Raving Prophet said...

This is happening now.

My wife is a pharmacist. She sees what various insurance companies including the Medicare part D plans are doing.

Starting a few months ago, if a person was handed over to hospice care or otherwise had a terminal condition, a great number of medications suddenly began requiring prior authorization. That is, the moment you were classified as on the way out a good chunk of your drugs are effectively cut off.

Evyl Robot Michael said...

At the risk of sounding overly snarky, it's almost cute how you keep using, "I'm afraid" and "I think."

Mad Jack said...

Good post and well worth reading, especially the article about how doctors die.

We, all of us, are going to die. What I want is some choice about treatment during my end of life.

Quentin said...

What you're all missing is that - at least here in the U.K. - you can have private health insurance on top of the state healthcare system.

Y. said...

..wait.. Private insurers do not have death panels and are willing to shell out unlimited funds, even for treatments that are efectively pointless?

Interesting article about the doctors. The one I know best said to me that if she ever falls unconscious past the age of 75, we're not supposed to resuscitate.