In a guest column for the Joplin Globe (1/30/2011) Anson Burlingame discusses the financial ramifications of the end-of-life issue as it bears on MediCare and taxpayers. In my opinion he does a good job in summing up the problem but as you will read here, I respectfully disagree with his solution. First, I will offer this summary of his column, but in my own words:
- The costs of medical care with its modern technologies have outstripped our capacity to afford them.
- A disproportionate part of these burgeoning costs come near end-of-life (EOL) as that often entails such things as ICU care and extensive testing such as CAT and MRI imaging.
- Typically, many of the expensive EOL efforts have little success and often even prolong suffering by both patient and family.
- Viable solutions to the cost problem appear to be missing from either the medical establishment or politicians.
- The political right (GOP) has formally rejected the Obama administration’s attempt at dealing with health care (ACA), including any notion of funding EOL counseling by government, but has thus far not specifically revealed how they plan to deal with the cost issue. However, the GOP has in the past favored measures intended to increase competition in the health-care insurance industries to deal with the problem.
Anson asks, “Why would or should any responsible physician charge anyone for end-of-life counseling?” and concludes that, “Doctors and patients alone should make
that decision. And no one should pay for that discussion or charge for it. Period.”
I have problems with his solution. One is that doctors, and hospitals too for that matter, may have conflicts of interest and also may not be emotionally or professionally motivated to deliver EOL counseling well. Medicine in America is big business, and it has become increasingly specialized. Our own family physician recently told me that he will no longer visit his patients while they are in the hospital. That function is now performed by physician-specialists called “hospitalists”. Why? He said that it was a matter of time efficiency.
My great-great-grandfather was the self-taught country doctor of Berryville, Arkansas in the mid-nineteenth century. He made house calls and sometimes forgave payment. By all accounts he was much-loved and honored in his community. That’s all gone today of course. Doctors now sometimes band together in their specialty businesses, one local example being “Orthopaedic Specialists of the Four States, LLC”. This group has recently constructed a new facility just across the Kansas state line from Joplin in Galena, a tiny town. I assume there is a financial advantage to the location and I also assume they have invested in their own imaging and testing equipment.
What evidence is there that profit is a lively topic of interest to doctors? Here is one LINK to that effect.
Now, I would not criticize doctors for wanting to maximize their earnings if the system involved fair capitalist competition, but in many cases it does not. Once in the system, patients have few options and no incentive to question costs. They in fact are dealing with the system as we have it, a system that in my opinion is deeply flawed because by its very nature it enables conflicts of interest and lacks competition. Here is a LINK which details an instance where a doctor referred his patient to a lab for a CT scan without revealing that he had a personal interest in the lab. Was this legal? Apparently. Was it ethical? Not in my opinion, nor in the writer’s.
Another serious flaw in the current system is that new doctors typically graduate with a mountain of college and medical-school debt and are no-doubt very anxious to pay it off. That, in my opinion, is not an appropriate motivation with which to begin a career in helping humanity.
Here is an example of medical conflict of interest in a case investigated by the Wall Street Journal. In certain spinal-fusion operations in Louisville, Kentucky, journalists discovered “strong ties between the surgeons and medical-device manufacturers. The REPORT mentioned that, “. . . in the first three quarters of 2010, the WSJ reports that each of five spinal surgeons at Norton hospital in Louisville Kentucky received more than $1.3 million from Medtronic – the leading manufacturer of spinal fusion devices.”
The same report later said this. “According to the WSJ’s analysis of Medicare claims, spinal fusion went from costing Medicare $343 million in 1997 to $2.24 billion in 2008. And as the Journal points out, the screws used in spinal fusion implants can cost between $1,000 to $2,000 apiece for reimbursement but actually turn out to cost less than $100 to make.”
Given such situations, is it then unfair of me to wonder if such financial aspects of medical care could account for why the medical community is not more forthcoming with cost-solutions? And would it be unfair of me to question the contributions of the medical community and the medical insurance industry to politicians? And is it fair to ask whether the Citizens United decision of the Supreme Court facilitates larger contributions to politicians who voted to repeal the entire ACA?
I consider the term, “medical community” to include medical insurance companies and their affiliates, one of which is a company named “Ceridian“. Ceridian’s mission is to administer COBRA accounts for medical insurance companies. COBRA, in turn, is an acronym for a government program which mandates that insurance be continued for people who, for whatever reason, leave an employer who negotiated health insurance for them and provided a part of the premium. Users of COBRA are required to pick up the employer’s portion themselves, but its main advantage is continued coverage of pre-existing conditions at the previously-negotiated rates.
Therefore, if you believe the right’s opinion that the cost problem can be solved through private insurance, then consider this example of one COBRA patient with cancer, one Ronald Flanagan. He was scheduled to receive a stem cell transplant surgery that he hoped would save his life when he got notice from Ceridian that his insurance had been cancelled. Why? Because his wife had made an innocent error and under-paid one month’s bill by two cents. Yes, that’s right, 2 pennies. While Ceridian eventually crumpled under pressure of publicity, even then they refused to apologize! The message could not have been more clear: business is business. A more complete version of the story is HERE.
Anson says we should expect our doctor to give us EOL counseling at ZERO additional charge, so I pose this question? Which of these options is most likely to result in the best EOL counseling? (And by “best”, I mean best for the family and the patient.) A family physician (the lowest-paid kind of doctor) who makes $83 per hour, depending on how fast he can process patients and who will make ZERO for the counseling, or a trained counselor who makes $20 per hour and whose sole job is to patiently lay out all the options and ramifications? I contend it is the latter.
Now some might say, and Sarah Palin would be first in line, that independent counselors might also be incentivized by the government to minimize costs by recommending hospice over expensive efforts to briefly prolong life. But I say that transparency of process could overcome this, whereas the issue of conflict-of-interest concerning doctors is nowhere near resolution. Any attempts to control that are likely to be contested with utmost vigor by the AMA and similar groups and PAC’s.
Here’s my bottom line to all this. Healthcare is an industry in which the costs (and profits) have year after year after year grown faster than GDP, and in which there is NO incentive for the insured customer (the patient) to shop for lower costs. What is happening is unsustainable. For the approximately 40 million uninsured, mainly the young and the poor, there is every incentive to ignore proactive (preventative) healthcare
until a crisis develops, at which time they may seek aid in the nation’s ER’s where the law mandates treatment regardless of ability to pay. That is the system we have now and the only law ever passed to deal with the problem has just been resoundingly rejected by the GOP, who vow now to gut it financially in the House.
The GOP says they are going to deal with the cost issue. If they say it’s going to be through making health insurance more available across state lines, are you going to be convinced? I’m not.
Here’s what I recommend:
- Politicians, MAN UP, and come up with a system that incentivizes the patient to shop around for non-emergency health care with cost in mind.
- The government should subsidize medical education for the most talented applicants so they don’t graduate with massive debt, and should demand a term of service in appropriate areas and set salaries in return for same, just as the service academies do.
- And, I say that Sarah Palin’s scare tactic about “death panels” is pure demagoguery that damages America. It’s bogus. Reinstate MediCare payment for counseling at end of life.
And if you expect the health insurance companies to have any compassion for you, go read Ronald Flanigan’s story again.