Thursday, September 9, 2010

The cost of dying... and "the path of least resistance"

This just in from Carol Keesecker of VNA Hospice Care:
A segment of CBS’ 60 Minutes, titled “The Cost of Dying: End-of-Life Care,” was shown on August 8. The segment includes interviews and patient visits with Dr. Ira Byock, director of palliative medicine at Dartmouth Hitchcock Medical Center, and a professor at Dartmouth Medical School.

Byock estimates that it costs $10,000 per day for treatment in an intensive care unit. “This is the way so many Americans die,” Byock told interviewer Steve Kroft. “Something like 18 to 20 percent of Americans spend their last days in an ICU,” he said. “And, you know, it’s extremely expensive. It’s uncomfortable. Many times they have to be sedated so that they don’t reflexively pull out a tube, or sometimes their hands are restrained. This is not the way most people would want to spend their last days of life. And yet this has become almost the medical last rites for people as they die.”

Dr. Elliott Fisher, researcher at the Dartmouth Institute for Health Policy, told Kroft that so many people wind up in the hospital because it’s “the path of least resistance.” According to the CBS online story about the segment, “Fisher says it is more efficient for doctors to manage patients who are seriously ill in a hospital situation, and there are other incentives that affect the cost and the care patients receive. Among them: the fact that most doctors get paid based on the number of patients that they see, and most hospitals get paid for the patients they admit.” Fisher estimates that 30% of US hospital stays are unnecessary. It doesn’t stop with the hospital admission, either. Fisher says that patients will likely be seen by more than a dozen specialists who will order many tests, many of them unnecessary. Each of those specialists bills Medicare separately. One 85-year-old woman was given a pap smear, “generally only recommended for much younger women, not an octogenarian who was already dying of liver and heart disease.” Fisher adds, “In medicine we have turned the laws of supply and demand upside down. Supply drives its own demand. If you’re running a hospital, you have to keep that hospital full of paying patients. In order to, you know, to meet your payroll. In order to pay off your bonds.”

David Walker, formerly head of the GAO and now head of the Peter G. Peterson Foundation, advocates reducing government debt. Walker sees a major problem in the fact that most people don’t know what their health care costs, because “85 percent of the health care bills are paid by the government or private insurers, not by patients themselves.” Walker says, “Every other major industrialized nation but the United States has a budget for how much taxpayer funds are allocated to health care, because they’ve all recognized that you could bankrupt your country without it.” When asked by Kroft if that means rationing, he replied, “Listen, we ration now. We just don’t ration rationally. There’s no question that there’s gonna have to be some form of rationing. Let me be clear: Individuals and employers ought to be able to spend as much money as they want to have things done. But when you’re talking about taxpayer resources, there’s a limit as to how much resources we have.”

“If you are wondering whether the health care reform legislation passed in March addressed any of the end-of-life issues raised in our story,” says Kroft as he closes the story, “the short answer is no. The new law is designed to slow the growth of Medicare expenses, and includes a pilot program to reward doctors for the quality of care they provide rather than the quantity. But it also reduces Medicare payments for hospice programs that studies have shown to be very cost efficient.

See (CBS News Website, 8/6)

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