Posted on 02/27/2005 8:40:41 AM PST by traumer
THOUGH Social Security's fiscal direction has taken center stage in Washington of late, Medicare's future financing problems are likely to be much worse. President Bush has asserted that the Medicare Modernization Act, which he signed in 2003, would solve some of those problems - "the logic is irrefutable," he said two months ago. Yet the Congressional Budget Office expects the law to create just $28 billion in savings during the decade after its passage, while its prescription drug benefit will add more than $400 billion in costs.
So, how can Medicare's ballooning costs be contained? One idea is to let people die earlier.
For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent, said Dr. Gail R. Wilensky, a senior fellow at Project HOPE who previously ran Medicare and Medicaid. Thus end-of-life care hasn't contributed unduly of late to Medicare's problems. But that doesn't mean it shouldn't be part of the solution. "If you take the assumption that you want to go where the money is, it's a reasonable place to look," Dr. Wilensky said.
End-of-life care may also be a useful focus because, in some cases, efforts to prolong life may end up only prolonging suffering. In such cases, reducing pain may be a better use of resources than heroic attempts to save lives.
The question becomes, how can you identify end-of-life care, especially the kind that's likely to be of little value? "It's very difficult to predict exactly when a given individual is going to die, in most cases," said David O. Meltzer, an associate professor of medicine at the University of Chicago who also teaches economics. "But there's no question that there are many markers we have of someone who is approaching the end of life."
Even with that knowledge, however, Dr. Meltzer warned against putting the brakes on care just as a patient takes an inexorable turn for the worse. Studies of doctors who intervened at that point to stave off unproductive care have found little success in cutting costs, he said. Instead, he recommended that doctors try to prepare patients and families for less resource-intensive care at the end of life. "There is no question, as a clinician, and as a patient and the family members of patients, there are things you can do to make sure that expenditures with little chance of being helpful won't be undertaken," he said. "You explain to people that the goal of medical care is not always to make people live longer."
Explaining that principle early on could make a difference in the cases that appear to pose the biggest problem: those in which the patient's health changes suddenly and severely. Dr. Wilensky cited recent research showing that these cases incurred high costs with scant medical benefit.
"When someone starts going south, and there was not an expectation that that was going to happen, you probably pull out all the stops," she said.
These choices can actually harm patients, contradicting the purpose of the treatment, said Dr. Arnold S. Relman, a professor emeritus of medicine and social medicine at Harvard and former editor in chief of The New England Journal of Medicine. "Sometimes, you know that death is inevitable over the next few weeks or few months," he said. "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."
Dr. Wilensky said these cases often involved an unusual number of specialists and other doctors visiting the patient, as well as a potentially excessive number of tests. Better coordination of care within hospitals and with other providers could curtail these extra efforts, she said. She also suggested that more use of evidence-based medicine, in which care is guided by documented cases and statistics, could discourage doctors from pursuing treatments with little chance of success.
OMG!
When was I advocating the Final Solution? The government has greatly increased the cost of care, both through regulatory burdens and through the crazy 'malpractice' system. If these obstacles were removed, it would be much cheaper for charitable institutions to provide care, and the problems would be minimized.
I would like to be treated if there is a reasonable chance of recovey. Otherwise, I would prefer to die quickly after a severe stroke like my father, or suddenly during a heart attack like my mother.
A few months ago, a co-worker died of a massive heart attack at his desk. He just quietly slumped forward and that was it. Until, of course, the usual hubbub of emergency workers and police, but by that time he was dead.
Then we take Kozak here, and hocndoc, and a few others I know from this board, and put them in charge of all of it.
Instead, we have now people with a BA in psychology and phD in economics telling us what our healthcare choices are and should be. And insurance clerks with high school degrees.
People can be educated to understand that all the extensive testing and treatments available are options, and make their own choices.
Patients today think that they have to take advantage of every single test and treatment in the world, so we have 85 yo men demanding yearly PSA's. They act as if getting a blood test ordered is the equivalent of catching a good sale.
Personally i think a big help here would be for people to be able to find a family or primary doctor, get to know them and trust them and use them as a major resource in this area ( this will mean some reform of insurance or medicare so that the patients aren't constantly shifted from one doc to another by their insurer).
If I as an ER doc walk into a situation near end of life, its not good. I don't know the patient of the family. I don't know all the history. It is much much much better for someone who knows the patient, and the family and they are comfortable with to be able to decide how to proceed. Then they can go all out, or just ensure comfort and dignity.
"But "First, Do No Harm" isn't operative in a socialist system. When you have a "single payer", the payer is always looking for ways to reduce costs. Rationing is one way; benign neglect of the very ill with an eye toward their more speedy demise is another."
Agreed. Someone from the UK was telling me that this was common practice with the NHS. It made her very distrustful of a system that might decide to give up a family member who still had a chance. It also struck her has basically unfair to triage someone just because they're older.
And there we have it. This kind of article is sometimes called "revelation of the method". Whenever the powers behind a heinous plan think their success is certain, an article like this miraculously appears. It's their way of saying, "This is what we're going to do to you and there's not a d@mn thing you can do about it".
That wager sounds like a sure bet to me.
Actually, I found her to be a delightful child. That puts her a little outside of the American "norm" for children, however, and that's a good thing since we seem to be raising a nation of brats.
And the shots for pneumonia. My mom gets one every two years, I think.
Approximately what percent of ER patients do you think are not worth working on?
"The cost takes a backseat to the powerful, instinctive need to save our children "
The children are needed to produce, to re-produce, to feed and take care of us (and US) !
Interesting observations. Would our government really allow such a thing?
Why not? We don't stop them.
Dr. Kevorkian
Bastard though he be, at least Kevorkian does not subscribe to the painful prolonged Michael R. Schiavo brand of euthanasia.
The answer to contain the costs of medicare now is the prescription drug coverage, stop that part and there wouldn't be a problem.
Stop paying for unnecssary procedures and there wouldn't be a problem.
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