End-of-Life Choice, Palliative Care and Counseling

Reducing costs does not mean reducing good careby Sonja

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In an attempt to rhetorically beat down efforts at health care reform, the Weekly Standard’s Bill Kristol makes the same “rationing” argument we’ve heard time and again:

But the most important implication of the Kennedy-Shrum claim–“Most of these readmissions are unnecessary, but we don’t reward hospitals and doctors for preventing them. By changing that, we’ll save billions of dollars.”–is this: The government is going to decide–ahead of time, obviously, since deciding after the fact wouldn’t save any money; and based on certain general criteria, since the government isn’t going to review each individual case–what kinds of hospital readmissions for the elderly are “unnecessary” and what kinds aren’t. And it’s going to set up a system “to reward hospitals and doctors for preventing” the unnecessary ones. That is, the government will reward hospitals and doctors for denying care they now provide, care the government will now deem “unnecessary.”

Indeed, this understates the case. For in reality the government isn’t going simply to reward “good” and penalize “bad” admissions. It’s going to prevent insurance companies from paying for “unnecessary” admissions and procedures, if those companies want to participate in the government system. In other words, government bureaucrats are going to deem entire categories of treatment inefficient for all or certain categories of patients, and put those treatments out of bounds for doctors and hospitals.

Kristol seems to suggest that if health care reform reduces medical costs at the end of life, this must be at the expense of good care and necessary treatment. Recent research confirms what we’ve learned from decades of experience improving care and expanding end-of-life choices: More treatments do not mean better care. Futile and painful end-of-life procedures often yield nothing but needless suffering, even as they add great expense. Real reform requires shifting from profit-centered to patient-centered care.

We cannot reform our healthcare system without addressing the fact that it is driven by profits. We must adjust the system when the drive for profit works against excellence. Medicare, as a public system, is the only source of comprehensive data on expenditures. Approximately 5% of Medicare beneficiaries die each year. In 2006, 30% of Medicare expenses were for their end-of-life care. 10% of all Medicare costs occur in the final 30 days of life. Most of the money in those last 30 days pays for intensive care and invasive, unwanted treatments intended to extend life, like feeding tubes and mechanical ventilators.

Ironically, these exorbitantly expensive procedures do not even serve their goal. A large, authoritative study appearing this March concluded:

Analysis demonstrated that higher medical costs in the final week of life were associated with more physical distress in the last week of life and with worse overall quality of death as reported by the caregiver. There was no survival difference associated with higher health care expenditures at the end of life.Few patients get the chance to discuss end-of-life preferences with their doctors. Patients who do have these conversations are much more likely to reject futile, painful procedures and select hospice care. But fee-for-service payment systems – both Medicare and private insurance plans – encourage health care professionals to do as many things to people near death as is medically possible.

Our healthcare system should be driven by what patients need, not what profit demands, a system that pays doctors to talk with patients about peaceful endings when death is imminent and pays for hospice care in the home as readily as it pays for intensive care in the hospital.

True reform will remake this profit-centered industry into a patient-centered one that delivers the comfort care and supportive services people truly want and need at the end of life.