The high cost of dying in America
I often hear people voice the opinion that the real problem in our health care system is that we spend too much money to save the lives of elderly people whose time has come.
Based on the fact that end of life care is the largest percentage of Medicare expenditures, it has to be said that these people have a point.
Indeed, earlier this year, Dartmouth University published a study that revealed significant variations in the high cost of treating patients during the last two years of their lives. The study focused on the top five U.S. teaching hospitals (as ranked by U.S. News & World Report) during the years 2001-2005.
According to the investigation, the average cost of treatment for those who ended up dying within two years of presenting with critical illness ran about $67,000 per beneficiary. However, at the University of California-Los Angeles (UCLA), the numbers were considerably higher at $93,842 per beneficiary while the renowned Mayo Clinic in Minnesota experienced considerably lower costs of $53,500 per patient who died.
The numbers come into even starker focus when we compare what Medicare is paying these institutions for care during the last six months of life. At UCLA it runs $50,000 per patient versus Mayo’s costs of $25,000.
Considering that many believe getting these costs down could save Medicare hundreds of billions per year, this disparity has not escaped the attention of the Obama Administration, particularly Budget Director Peter Orszag, who commented,
One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical. We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.
Via The New York Times
While Orszag’s statement would appear to be difficult to argue, it turns out that this whole thing is not quite so clear cut as it may at first seem.
The Mayo Clinic is undoubtedly one of the finest medical institutions in the world. Not only do they offer extraordinary physicians combined with state of the art medical research, Mayo has found a way to do all this at a lower price tag than other medical centers in their ‘league’. Their secret to keeping costs down has been to pay all physicians a salary, therefore removing any incentive to conduct tests and prolong treatment as a means of earning more money. Mayo has also established a collaborate system of medical practice where all physicians involved with a patient work together to make the decisions involved in the patient’s care.
UCLA is also a very highly respected medical center, lauded for both its medical treatment and research – but at a much higher cost.
If both are so good, why is UCLA twice as expensive when it comes to end of life?
It begins with a certain institutional mindset. UCLA prides itself on being a hospital where the physicians will go to any length and expense to save a patient’s life. As Dr. David T. Feinberg, the hospital system’s chief executive, puts it –
If you come into this hospital, we’re not going to let you die.
Via New York Times
Admirable – but expensive. And precisely the attitude that has led people like Orszag to criticize their practices.
At UCLA, patients with critical illnesses are often seen by dozens of different specialists, subjected to a large number of tests and given high-tech treatments in the hope of saving a life. All of this results in longer hospital stays and a significantly larger bill for Medicare. But, if you are interested in surviving, it doesn’t hurt that UCLA doesn’t view any particular period as being the ‘end of life’ until they have done everything they can think off to try and prolong that life.
The Mayo approach involves being slow to bring in specialists where the front line physicians do not believe it will produce a meaningful result, just as Mayo works to avoid extensive treatments that offer little or no benefit to the patient. Bear in mind that these front line doctors are among the best in the world so this is not a matter of Mayo caring less than UCLA. It is simply a different take on what should or should not be done when the effort to save a life destroys the opportunity for a peaceful end of life.
The problem is that while the Dartmouth Study takes into consideration the costs of those who ended up dying, the study never considers nor quantifies these costs in view of the patients who survive thanks to the intensive-and expensive-intervention.
In response to the Dartmouth findings, UCLA joined with four other medical centers in the University of California system, and Cedars Sinai Medical Center, to find out if anyone was actually getting any benefit from spending more money in the effort to save lives. For their study, they focused on elderly people experiencing heart failure as this is a leading cause of elderly death. While the study was designed to count the dead, as did the Dartmouth study, this effort would also count those who lived.
Guess what they discovered?
The hospital that spent the most had 33 1/3% fewer deaths after six months of an initial hospital stay.
Even Dartmouth took notice of the results. Dr. Elliott S. Fisher, one of the lead investigators at the Dartmouth study, acknowledged that the California researchers’ analysis might have done a better job than Dartmouth had expected in identifying cases in which more intensive care might prove beneficial. Fisher had this to say-
Sometimes more medical care is better, but the question is when.
Via The New York Times
Dr. Fisher has asked the central question in this entire debate.
Since we rarely know when the clock has begun ticking on the last six months or a year, it becomes impossible to know how something will turn out. Thus, physicians understandably feel an obligation to do anything to fulfill their responsibility of prolonging our lives.
In many ways, this becomes a uniquely American question. The interest of the one has always been given the highest possible status in our system, even to the disadvantage of the many. So , while the Mayo Clinic approach is clearly what is best for the survival of the Medicare trust fund and, therefore, good for our elderly as a class, it may not always be what is best for the individual.
I cannot help but wonder if Peter Orszag would see things quite the same way should it be someone in his own family. Would he be willing to accept a decision to allow someone to die peacefully based on the odds being weighted against that person’s survival or would he be more inclined to want everything and anything to be done to save the life of a loved one? Should the UCLA findings suggesting that one out of three stand to survive when more money is spent holds true for other illnesses beyond heart failure, I’m guessing Orszag might not be so quick to throw in the towel.
I know that I wouldn’t.
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You are absolutely right, the question is when should the spending happen and when shouldn’t it? But differences in philosophy such as those you illustrate here make it hard to create process and medicare needs process. Moreover, you are talking about two great institutions, and not the thousands of lesser institutions where such a process would actually play out.
True, this will play out at the lesser institutions – but the people who check into these lesser institutions should have the same opportunities to survive. Is one possible answer for Medicare to gather the data on all hospitals whom are in their system, see who is getting survival results for their expenditures (rather than the approach of the Dartmouth survey which looked at how many deaths they were getting for their money)and pay accordingly? Would this incentivize secondary and tertiary hospital systems to keep up on the latest techniques in areas where lives can be saved along with a return to a decent quality of life?
In response to another comment. See in context »Well Rick, it was the government which forced our seniors into Medicare, the government set up the Medicare system, made the rules, forced medicare withholding upon america’s wage earners……and now it is the government’s responsibility to live up to its promises….
See how the health bill was debate, drunk senator baucus on the sENate floor:
http://www.youtube.com/watch?v=M5Y9X5ggxzA
Sorry to climb back on this soapbox. But WE CANNOT LIVE FOREVER. WE DIE, THAT’S WHAT HUMANS DO. Until we in this country confront that reality, start looking at life’s quality and our own mortality, and start talking about end-of-life options we would choose for ourselves, the immoral weighting of resources and expenses in the last few weeks & months of life will continue to make a wreck of our health care system. I am 77. When I met with my new oncologist last year the first thing I did was bring her into the understanding my family and I have about interventions should my cancer recur. Excepting a VERY small, insignificant and easily treatable issue I choose palliative care only. This is NOT heroic, it is simply sensible — life is good, I don’t like pain, and don’t want this good life to be capped off with months or years of suffering & debility. I am fine with anyone else toughing it out, spending everything they have, hanging on for their own reasons. But the truth is most of us, I believe, would skip the heroic, aggressively treated, horribly expensive indignities that are part and parcel of life’s end for uncounted thousands. THIS IS WHAT WE HAVE GOT TO TALK ABOUT: OUR OWN MORTALITY, OUR OWN CHOICES. Forgive me. I’ll get back down off the soapbox now.
PS, Rick, I can’t help reflecting that I read this same NYTimes article & some of the Dartmouth study info, and did a small post a few days ago…. but mine was titled “The Cost of Trying to Live Forever.” As in “in this hospital we won’t let you die,” some days it does seem that’s what we think we can do.
I certainly see your point of view, Fran. And with respect to money spent once we know a situation cannot improve or when a person, like yourself, has reached their conclusion about how they want something to go in lieu of the pain and struggle that comes with trying to reach another result, I couldn’t agree more.
But, as you correctly point out, not everyone views it the same way. And those people also have to be considered. What I liked about the UCLA experiment was that they chose heart failure. Heart failure is right up there in the cause of death category. And here we find out that by spending some more money, 1/3 of these people not only survived but return to a fairly normal existence. That’s persuasive, no?
In response to another comment. See in context »Rick, “The interest of the one has always been given the highest possible status in our system, even to the disadvantage of the many” was a line that jumped out at me. The idea that we can throw any cost out the window to treat every patient is why we are in the mess we are in today. The study may be on to something or it may be a statistical play based on screening patients. I really have a hard time believing LA could provide that much better analysis and treatment than Mayo. Also, if the patient is alive but not having a quality life who is to say they would pay for this end of life rescue effort if it did not buy them a few more years of quality living? Just keeping me alive an extra 6 months, without the ability to enjoy it, has no appeal for me personally.
Fleet- obviously, I”m not in a position to defend or attack the UCLA study. However, it is fair to note that the researcher from Dartmouth appeared to accept the findings. With respect to quality of life, I agree with you – but I think, in the example of the UCLA study, someone who is improved in a condition involving heart failure likely will experience a descent quality of life following improvement. Of course, I’m sure there are examples where this might not be the case, as pointed out by Fran in her comments. At the end of the day, the individual should get to make the call and we should respect it.
Now, as to your reaction to the needs of the one being more important than the many (star trekian, eh?) let me ask you a question.
Enormous sums of money are spent holding trials, providing counsel, paying judges and prosecutors, etc. because we entitle criminal defendants to extraordinary protections so that their individual rights are protected to the maximum. Should we reduce the costs here too? If we change the jury test from a unanimous vote of people who agree the defendant is guilty “beyond a reasonable doubt” to the lesser standard used for civil trials “a preponderance of evidence” and a majority vote of the jury — we would, no doubt, save billions of taxpayer dollars. Should we change this too?
In response to another comment. See in context »I don’t see the connection. I was getting at the point where a patient, even with an advance directive, is sometimes at the mercy of the system when they enter a hospital. The decisions are made for them without benefit of a cost/benefit analysis because the treating physicians and the hospital administration are not going to leave anything undone that could be seen as opening the door for a lawsuit if they miss something or have a bad outcome. We need a peer review board, similar to the German system, where medical decisions based on medical standards of practice protect the hospital and physicians from malpractice claims where nothing was done wrong, but you still have a bad outcome. We can never control costs until this is addressed.
In response to another comment. See in context »“The interest of the one has always been given the highest possible status in our system, even to the disadvantage of the many” was a line that jumped out at me. The idea that we can throw any cost out the window to treat every patient is why we are in the mess we are in today”
Yea, that jumped out at me too but not for the same reason. First of all we are not in the mess we are in today because we have spent too much money to save lives. Second of all we are not in a mess.
However I would like to know how it has been determined that others suffer if we spend too much to save the life of another? I’m wondering how saving one is a disadvantage to many? In what way? Actually, millions have been spent in clinical trials with the goal to save a few people with rare diseases. An example of one such disease is melanoma. It used to be an incredibly rare disease. Now it isn’t. The millions spent on a few have resulted in the saving of many lives. Leukemia is another.
What kind of culture do we want? Do we want a culture that dispenses death? Is that sick? I think so.
It would be more detrimental to our culture not to do everything we can to save a person’s life,if they want to be saved.
Generally,70 year olds want to live to 80 and 80 year olds want to live to 90. I have seen numerous 90+ year olds living meaningful active lives.
.
It disturbs me that I see this issue addressed so frequently. What kind of mean country have we become?
I can tell you one thing. There will never be any test or treatment (if they need it) denied to anyone I know. The doctor or institution won’t have the final word on it either. I will or the indiv. who is sick will.
Life and death decisions should be left to the indiv.and his family. It is not the business of anyone else and if someone else. It’s a matter of a person’s dignity.
In response to another comment. See in context »As I recall, I don’t get to agree with you all that often. So, I’m happy to say, agreed!
In response to another comment. See in context »During my nursing career working in a step-down unit from CICU, there were so many times where my elderly patients just wanted to be “let go.” They had many chronic illnesses – heart, diabetic, lupus,..
When a procedure needed a consent form signed, they would refuse (knowing that they would die). When family members found out about it, the patient reluctantly signed the consent form.
Other times, family members weren’t ready to let go of their loved one, even when a patient had had several heart attacks, strokes, and/ or in advanced stage of cancer. (I had to give CPR to a 90 yr with bone cancer, cracking ribs while doing so…and he survived and went back to the ICU.)
I think that every one who wants health insurance, should have to sign an advance directive, which you could change when you want. Then NO ONE can override it. Just make sure you don’t get admitted to a Catholic hospital:
“Advocates for choice in end-of-life care are worried that Catholic hospitals, nursing homes and other health care facilities may refuse to honor patients’ wishes that they not be kept alive by artificial means. …”
http://www.sundaypaper.com/More/Archives/tabid/98/articleType/ArticleView/articleId/4844/Do-no-harm.aspx
WIth you all the way on this, peg1. Actually, I’ve always suggested that people sign an advance directive (also capable of amendment) when they first sign up for Medicare. That seems like a completely reasonable approach to our seniors, who are the most likely to face end of life questions, to express their own wishes and desires.
In response to another comment. See in context »EVERYONE dies of heart failure, right?
Yes, but some sooner and some later. If they can be saved along with an acceptable quality of life, why shouldn’t they be? Wouldn’t you want this?
In response to another comment. See in context »i was being snarky — the heart fails no matter what health problem you have. sorry for my “snarkitude.”
i recently found your blog. glad i did!!
In response to another comment. See in context »thanks. happy to have you.
In response to another comment. See in context »Just so we are clear, my post is in no way advocating that physicians must save people who don’t want to be saved. this is an individual choice and one that needs to be respected. This is why it was a good idea to have the provision in the health care legislation that permitted new Medicare beneficiaries to meet with a doctor to discuss end of life care issues at no cost. This is, of course, what Betsy McCaughey and Sarah Palin told us was the creation of the death panels. Families also need to be involved in this. As you say, elderly are often swayed to do what their families want rather than what they want for themselves, which, while understandable, is unfortunate.
In response to another comment. See in context »The point here is to do what we can to meet the interests of what an individual wants rather than make decisions for them based on the costs.
I’m also with peg1. And re your “what the individual wants,” I get right back up on the soapbox about trying to get individuals to think about these issues, and talk about them to family and friends. I serve on a board (compassionandchoicesnca.org, check it out, please; or compassionandchoices.org), the national group) with a fine, highly respected physician who heads several ethics committees. He will confirm that 90% or more of the cases that come to ethics groups are because someone is dying, and the issues have to do with unsaid words and unfulfilled actions (or unresolved family issues having nothing to do with the dying person.) If we would ALL, young and old alike, quit acting as if life could go on forever and instead talk about quality and meaning of life, a lot of the cost problems would be solved. Those who do not choose heroic aggressive interventions would leave plenty of funding for those who do. Where reasonable quality of life could be restored, it also could be funded.
In response to another comment. See in context »I wonder how many extra months of life we would get if these patients had preventative medical coverage when they were younger, preferably with the same amount of enthusiasm.
No doubt quite a few more which is only one of the reasons by preventative medicine and taking care of one’s self is a good idea. But, it is not really the issue I am addressing here.
In response to another comment. See in context »Rick,
A study can never adequately explain the individual circumstances of each of these patients. Were those 33% who survived the wealthiest people who had supportive families and lifelong preventative care? Were they left as zombies in an eternal ICU? If the money that saved those people had been spent on prevention instead, might we have saved more lives?
I’m with Fran Johns, I’d rather get the most out of the time I have than get the most time.
misterb
In response to another comment. See in context »To answer some of your questions-
1. The study was based on people who were out of the hospital and healthy six months later, so, no, they were not left as zombies in an eternal ICU.
2. Let’s, for the sake of argument, assume that the 33% who survived are the wealthiest people who had supportive families and lifelong preventative care. I don’t see your point. The fact is they would have died without the money being spent to save them so, whatever the reason they are alive because the effort was made to continue their lives.
3. I don’t disagree with you or Fran as to getting the most out of time rather than the most time. However, that is not the issue here. Individuals should be allowed to determine what they want for their life in this regard. If they are told that they can be saved but will be a zombie in an eternal ICU, pretty good chance they would make the same choice as you. However, if you are suffering from cancer and the doctor tells you that there is a 50-50 chance you can be cured and returned to a reasonably normal life, wouldn’t you take the doctor up on the opportunity? Should society tell you that you shouldn’t have this option?
At the heart of fascism is a society that places accounting considerations above human life and human concerns. This is the immoral, “banker-centric”, failing of our time which is reflected in our willingness to commit trillions of dollars to Wall St. fraud (derivatives, credit default swaps, etc.) while millions go without medical care and now jobs.
To illustrate this idea, instead of using the term “money” when discussing medical treatment need to save human life (near its end or otherwise), use the term “fairy dust”. E.g. “We would love to save Grandma’s life; we have the medicines and technology, if only we had more fairy dust!!”
As long as we allow monetary and financial policy/thinking to be defined by the usury-centric ideology of Wall St., this discussion will not stop here. You will soon be making decisions on who gets medical treatment based on their perceived value/contribution and abilities. Soon, we will all claim to be watchmakers.
Best regards,
Mathew