Agraphia Medical Tragicomedy

28Oct/10Off

A Modest Proposal

This is a guest post I wrote for The Brio Reporter - I'm the healthcare correspondant. See my previous post for them here.

The system is broken.

We've heard it over and over again, shouted from pundits, over radio and TV, inked across the blogosphere. "Where," we cry, "do all the healthcare dollars go?"

I can tell you, because I've spent them. Millions and millions. The most expensive piece of equipment in all of medicine, as they say, is the doctor's pen.

There's a particular problem with American health care, which is that the cost of everything is removed from the equation. I'm taking care of an 80 year-old, morbidly obese woman in the ICU in multi-organ failure right now. Her hospital bill so far? Upwards of $400,000. Match her against a group of similarly-ill people and her expected mortality is 95%. It's an underestimate.

We keep tacking on more and more therapies since nothing makes her better. There are 10 or so consulting physicians on board, all who believe her survival to be impossible.  Yet, the husband wants us to "do everything". I told him a month ago we were fighting a losing battle. He didn't want to hear it. Instead I've spent almost a half-million dollars with futile therapies, buffering my risk against a lawsuit by acquiescing to the family's demands. Will she die? Absolutely. Has the money we've spent been a waste? Absolutely.

It's easy to take the bird's-eye view and place blame. "Why on earth," you scoff, "would you even consider spending $400,000 on an obese 80-year-old who has a 95% expected mortality?" It's an excellent question, and the answer is mired in medicolegal quagmire.

It's a problem deep rooted in the American psyche. We don't want to be told that anything is impossible. As such, we look for a solution to every problem, without recognizing that some problems cannot be fixed. There is an adage: "just because you can doesn't mean you should." This has been forgotten in modern medicine.

With our ever aging, ever fattening, ever sickening population we need to take a big step back from the precipice. Parents cannot afford antibiotics for their children, diabetics cannot afford their blood sugar medicines, and yet our ICUs are overpopulated with critically ill patients with no chance of survival. Oncologists are prescribing rounds and rounds of expensive chemotherapy for terminally ill cancer patients with 5% expected 5 year lifespans. Nephrologists are dialyzing people with failed kidneys who are not transplant candidates.

Why? Because no doctor ever says "I'm sorry, that treatment is too expensive, and the money could be better used elsewhere." Nor would patients want them to. And so my belief is that the decision needs to be taken away from doctors and patients; we physicians have proven that we cannot police ourselves.

It all boils down to one fundamental truth:  the money we spend on futile care is gone forever.  The amount of money in the system is finite, and this becomes more apparent every day.

Here is my modest proposal.

1) Establish a set of "covered" illnesses. Diabetics should get their blood sugar medications for free. Why? Because they should never have to choose between a rent check and insulin. This directly increases the number of hospitalizations for diabetic complications, and increases the total cost to the system.

2) Establish an algorithm for "non-covered" illnesses. Take insurance out of the equation. My 80-year-old, morbidly obese patient with multisystem organ failure?  Every single physician who saw her believed her case to be futile. Just because she has insurance doesn't mean we should be wasting $400,000. That money could be better spent - no, must be better spent. There are children dying.

3) Generate a firm "no" for certain treatments. Pancreatic cancer is a devastating and incurable illness; survival is typically 3-6 months with a 5-year survival of 5%. Why spend hundreds of thousands of dollars on a treatment we know won't work when that money is needed elsewhere? That said, favor the young. Premature babies cost a lot but also have the highest potential benefit.

4) Adopt a 3-strikes-you're-out policy. Cocaine users who present to the Emergency Department for chest pain should not have those visits comped by the public. Same goes for the alcoholic brought in for withdrawal symptoms, the hypertensive who doesn't take his meds, and the drug seeker looking for a narcotics fix.

5) Fund the system by taxes on high-risk behaviors. Any food containing HFCS, all tobacco products, and all alcohol should contribute a direct proportion of their earnings to the healthcare system they are overburdening.  I support your right to eat at McDonalds every day.  I also support my right to not be affected by your decision.

The system is broken.  Without any oversight we have created a massively expensive healthcare monster that prioritizes all the wrong things.  If we have any hope of providing the best care for everyone - without bankrupting our country - we need to make some very tough decisions.

The debate is not how to fix it, but when.  All of our lives hang in the balance.

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  1. I am glad to practice in Australia where ICU physicians can and do say no after long discussions with the family. Further, they often won’t accept them into the unit to start with, which saves the question of ongoing treatment once in the ICU. The septic 50yo post-bone marrow transplant patient- sure they’ll give it a go, but the patient you described – no way in hell.

  2. Your idea reeks of commo-socialism-nazism from a mile away. I like it.

    Jokes aside, there is plenty of evidence everywhere that a free market system does not work for health care. We do need the government to impose rules like the ones you advocate.

  3. Zac,

    If your father was one of the unfortunate with pancreatic cancer, would you believe he was in the 95% where treatment is futile or hope and pray for the 5% cure? I agree that something has to be done, but it is easy to play the percentage game when you are not affected.

    Just a thought,

    -A

  4. A –

    It’s a difficult answer. From a strictly medical sense I would argue for a brief course of chemo, and if no response, palliative care. Partly this is because I know how unbelievably devastating pancreatic cancer really is.

    Unfortunately when every doctor’s default is “do everything”, “everything” gets done for only a very few patients. We need to be proactive about what sorts of treatments we as a society believe to be worthwhile, not reactive.

    Your argument, of course, is why nothing will ever actually get done about this problem. People will cry foul about “death panels”, as has already been done, and the proponents of rationing care will slink back to their holes.

    It’s unfortunate, because it is a problem that cannot be ignored. As we continue to get sicker and sicker I fear greatly for our country.

  5. There’s a difference between “doing nothing” (what you suggest), and pursuing a reasonable course of therapy, and switching for palliation when things take a turn for the bleak. We (doctors) suck at that too.

  6. In the interest of hyperbole, the article was written as you see it :) I can’t agree with you more, though… reason is the name of the game here.

  7. You hit it right on the ball! There is as much abuse in the world of health ins. as there is in car ins. I’m self-employed with no health care due to plan costs. I’m also an asthmatic who knows how it feels to panic w/o an inhaler and not being able to afford an extra $300.00 a month for Advair because there is no generic alternative. I’ve worked in health care my entire adult life and it’s sad to see the amount of money wasted in all the wrong areas. It’s hard to put a price on life but there has to be a better way to run our health care system in the States. My parents were world travelers and my mom learned while in Ireland if you are past a certain age limit, say 80 – the government will not pay for certain types of health problems – say open heart surgery, etc. You have to let nature take its course at a certain point of your life. In the States we tryin vain to fight nature and keep people alive with zero quality of life while millions who could have one with a little medical help are ignored. Such irony!~

  8. Having worked in the healthcare field for over 30 years, I cannot agree with you more. We need to be more realistic in this country, but like you said, Americans want everything…It is amazing to me that we profess to be a good Christian country, yet we are so afraid of death. If heaven is so wonderful, why won’t we even conceive of letting Grandma go there? There are fates much worse than death found in ICU’s all over this country.

  9. I like 1, 2, and 5. I would add asthma to #1.

    3 and 4 the way you describe them are problematic for me.

    People do survive pancreatic cancer. It should never be a blanket, denial of care by simple diagnosis. People do survive, people are more than their diagnosis. I don’t think it’s ethical to deny them a fair chance.

    And I hate this mentality that old people need to just die so prevalent in medicine, it is so disrespectful. People without hope of recovery should be allowed to go in peace period, there is no need to discuss this in conjunction with age as it then smacks of ageism.

    Denying care to drug addicts and alcoholics or making care self pay is just impractical. They won’t have the money to pay so any legislation is meaningless. Telling them no won’t stop them from coming in.

    What will happen is the problem will be transferred to the police who will be called to haul these people away from the ER and it would tax the legal system–you haven’t eliminated the burden, just transferred it, which might be better for the medical field but it isn’t actually helping society at all nor eliminating costs.

    M

  10. Ok. So I have a problem with: 4) Adopt a 3-strikes-you’re-out policy.

    A HUGE problem since it is VERY alarming. Some people need to be told more than once. How would you police it?

    It seems that this policy, like the very short-visioned 3-strikes-you’re-out policy for certain crimes in some states is VERY ambiguous, and will probably make a situation worse. In many states, you get busted for very minor possession 2x, then instead of getting busted for a break-and-enter, perps go down shooting wildly at everyone, and everything, often maiming and killing bystanders, police, and usually themselves (since going to prison the 3rd time means life imprisonment, which really is NOT reasonable).

    So with your policy, where and when does it end? And by ‘end’ i mean… what is the criteria? If I miss dialysis 3 times and end up in severe septic shock, I’m not allowed to go to ICU?

    I agree that there are huge problems. There are really easy solutions (medicare for all to compete with evil insurance companies+increasing medicare reimbursements+decreasing student debt+tort reform+getting rid of insurance company abuses=pretty close to harmony if you ask me…. but i guess it’s not complicated enough for some). Usually once you institute a sort of social contract (access for everyone, tort reform for MDs, reasonable reimbursement, patient protection), things do get better. Just saying.

    But maybe i’m too idealistic of a med student.

  11. 3 strikes and your out?

    Well then I was dead 5 years ago.

    But I am not. I got my life back together, and am *more* than exceeding in my life.

    I am worth way more than 3 strikes. And so are many people who are just like me.

    A little less utilitarianism perhaps?

  12. hi… very nice blog… i do love to read posts… very interesting…

    year 1 dental student :-)

  13. zac, great post. i have had many of these same thoughts but when it comes to #3 i always return to this- if you stop treating certain diseases will you lose financial (or other) motivations for research? ie- if there is no treatment for pancreatic cancer will drug companies (and other researchers) put in any effort to find a cure? it’s such a tough issue.

  14. I really like your idea of rule #5- taxing high risk behaviors. That could be a great way to increase the cost of foods with chemicals like hydrogenated oils (which have tons of health risks) and encourage people to eat them less, as well as fund the system.

  15. None of this will ever happen. Why? America is ruled by Lawyers, heck our president and vice president are trial lawyers. You suggestions are reasonable and could save the health care system, but due to malpractice none of them are feasible. If Joe public is unhappy with the care provided or lack their of they will and do sue.

    The solution to the US health care crisis is simple, but will never happen, not even after it has gone bankrupt, crashes and burns. All we would have to do is base our malpractice law on any other country in the world besides the US. However, our constitution spells out our current legal system and guarantees our right to sue, so just hope you are healthy when the hole US health care system collapses like a house of cards.

  16. Lol I wonder if anyone understood the satirical reference? To the satire entitled “A Modest Proposal”? Not to be taken literal but rather to provoke thought…

  17. I think there is a point worth making that you don’t touch on in your post. As doctors, we are taught to respect patient choice when deciding on treatments, a fact that your posts touch on often and an appropriate approach in my opinion. And the patient or patient’s family obviously has very limited information about both the medical situation and the costs/benefits of treatment, i.e. the expensive and futile treatments and consultants that you reference above. So it is easy to point the finger in that direction. However, we as doctors are compensated for our services, as is the hospital. If the patient’s family chose something expensive and non-reimbursable as their treatment, we would probably not give it to them. We would then point our fingers at Medicare or their health insurance company. But we’d still be right where we are now, standing in the middle of the expensive mess and pointing our fingers at other people.

    (I’m an ED doc, too, by the way, but I very much include us in all that I said above – and am not trying to call out specialists or consultants specifically any more than I am family doctors. This is a problem for all of us.)


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