HealthLawProf Blog

Editor: Katharine Van Tassel
Case Western Reserve University School of Law

Sunday, November 6, 2011

Guest Blogger Kathy Cerminara - Relative Value of Health Care Options at the End of Life: The Elephant in the Room

Kathy CermineraThank you to Katharine Van Tassel and the other editors of the Health Law Profs blog for the opportunity to share my thoughts with all of you. I look forward to your comments throughout the month.

Exactly a month ago, the IOM released its much-anticipated report, Essential Health Benefits: Balancing Coverage and Cost, recommending that HHS consider, among  other matters, the relative value of health care options when defining the essential benefits package that health insurance exchanges and individual and small-group health insurance policies must offer beginning in 2014.

Brushing aside temporarily the difficulties presented by determining what care is “medically necessary,” it is well-nigh impossible to dispute the IOM’s starting point of relative value as encompassing both cost-effectiveness and medical necessity.  As Ezekiel Emanuel recently pointed out, and as health policy scholars have long argued, the United States’ health care system delivers a little for a lot.  Rather than providing cost-effective, medically necessary care to the majority of patients, the United States spends a great deal on relatively few people and relatively nothing on millions of uninsured persons – relatively nothing, that is, until emergences land those uninsured persons in facilities with complex conditions that could have been headed off with basic preventive care.

Near the end of life, the relative value of medical care is especially out of whack; according to the Dartmouth Atlas, “[p]atients with chronic illness in their last two years of life account for about 32% of total Medicare spending, much of it going toward physician and hospital fees associated with repeated hospitalizations.”  HHS should encourage discussion of that fact when crafting its essential health benefits package proposal.  Relative value in end-of-life care merits frank discussion between patient and physicians, among physicians, between patients and their families, and in all spheres of policymaking.

 Rather than calling for consideration of those purely imaginary death panels, this suggestion marries the realities of health care economics with good, patient-centered, medical ethics. As Mary Ann Baily argues here , it is ethically necessary to consider costs near the end of life. Greer Donley and Marion Danis argue here  that patients deserve to consider costs with relation to many choices near the end of life, so that they may consider which treatment plan options might be most compatible with their values and life goals.  Certainly, Zhang et al. have demonstrated that patients who discuss with their physicians end-of-life options ranging from highly intensive care to foregoing of treatment often choose less-intensive (and thus less costly) paths through their final days.  For many of those patients, the real motivation in taking the least costly path is obtaining relief from highly technical, impersonal, sterile treatments and instead peacefully spending time with their families and friends in their last days.  The reduction of costs is a happy by-product of increased patient empowerment and peace at the end of life.

The danger HHS faces in addressing the issue of relative value in end-of-life care is clear from the “death panels” furor.  Yet the reality is that lower-cost interventions constitute better care for many dying patients.  Ignoring the issues posed by medical costs near the end of life, as a polite guest might ignore the presence of an elephant in her host’s drawing room, only leads to stilted, less-than-honest conversation.  The process of crafting the essential health benefits package should include discussions about the elephant.

- Kathy Cerminara

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