February 27, 2005
Save Medicare a Bundle by Dying Sooner?
Well, sure, at least in theory. At least, that's the topic of an article in today's Business section of The New York Times. The driving force behind the theory is the inexorable rise in the cost of Medicare, as projected by the Congressional Budget Office, which projects that annual Medicare expenditures will more than double over the next ten year and increase from 6+% of total federal outlays to nearly 20%. Health care goods and services in the last year of life account for 28% of the Medicare budget, a share that has held steady for a number of years.
As the article points out, there are a couple of stumbling blocks between where we are now and the eradication of nonbeneficial end-of-life treatment.
First, it is sometimes obvious only in hindsight that these were a patient's last months of life. There are some clinical markers that are helpful in this regard, but a lot of research remains to be done before our prognostic ability gets markedly better.
Second, it is not yet clear that substituting palliative care for more invasive and intensive care will save a lot of money for the program. Hospice care, for example, accounts for a tiny fraction (1.6%) of the Medicare program (and, if my memory serves, is typically provided in the last week or so of life, despite Medicare's six-month hospice benefit). Again, the research to determine how much money, if any, will be saved by a transition to greater hospice use just isn't there.
Third, forgoing high tech interventions when confronted with a life-threatening condition runs contrary to human nature. The best possible care is often equated with the most care obtainable at any price. Unfortunately, this stance ignores the human cost of such decision making in terms of increased suffering. The article quotes Arnold Relman: "Sometimes, you know that death is inevitable over the next few weeks or few months. And then there are some doctors, and some families, who just don't want to confront that, and feel that they want to and should invest everything possible - the maximum amount of resources - in fighting the inevitable. That often results in prolonging the pain and discomfort of dying."
If there is an answer to any of this, it seems to turn on the availability of better research that translates into evidence-based medicine. Without it, the culture shift that is needed before there will be progress on this issue just won't happen. [tm]
February 27, 2005 | Permalink