Health Care Reform — a l’Americaine

As I begin my first blog, it seems appropriate to talk about one of the most pressing issues in American society — health care reform and how it’s being defined in our society and by the new Administration.  Don’t get me wrong.  I’m all for letting the new president go at it.  But how is the problem being defined?  What’s being discussed?  What’s being left out? Like the kind of national tax supported health care system every other developed country has — except our’s.  But more on that in another blog.  What I want to talk about now are some of the hidden cost escalators in the system and why they are rarely included in the discussion about generating the kinds of cost-savings that would allow us all the get the kind of high quality care we need.

What’s rarely put on the table is the scandalous over-use of health care resources in futile care that simply drives people into the ground.  Here’s an example.  She’s a 91 year old woman had a triple A — an abdominal aortic aneuryism.  She’s operated on — of course — recovers slightly and then begins to decline.  One thing after another happens — falls, infections, paralysis that no one can figure out.  Things go from bad to worse to worst.  There is no significant involvement of a primary care provider.  No one in the family is willing to discuss DNR (Do Not Resussitate) not to mention Do Not Hospitalize.  No one is reading the excellent Handbook for Mortals by Joanne Lynn and Joan Harrold.  (Instead of getting an offer for AARP membership when you’re in your fifties, we should all receive a free copy of this book, courteous of a government that really wants to save money).  The woman goes from hospital to home, from home to nursing home, from nursing home to hospital.  Etc.  Finally, a few weeks before she dies, physicians find what might be (might being the operative word here) a tumor on her spine.  So it’s into the OR for her.  Guess what? No tumor.  She does, however, end up on the ICU, develops pneumonia.  She’s transferred yet again to a different hospital where the brilliant new ( the family has by this time lost count on how many doctors have been “in charge”) physician takes over and discontinues the anti-biotic and her infection really takes off.  Finally, by the last day of her life, more heroic measures are proposed and finally — finally after months — the family is ready to get the message that someone with some time and empathy could have conveyed months earlier — the 91 woman is going to die.  They actually  beg for mercy and she dies that same day.  Hearing the story I was reminded of poor George Washington’s horrendous last days when physicians bled him almost to death and he just begged STOP!!! THE TORTURE!!! and died.

Only more than 200 years later the torture is a lot worse and a whole lot more expensive.  I can’t imagine what the cost of this exercise in futility came to.  $500,000?  A  little more?  A little less?  This family suffered needlessly because no one had the time or expertise to have a serious talk about the facts of life — one of which is that none of us make it out of here alive.  More to the point — and this is the horrible thing — the system and all its players benefit from this drawn out kind of death.  Every time the doctor visited, there was a charge.  Every time she was put on a IV drip, someone benefited.  All those anti-biotics sold, all those dollars gained by some institution or other.  

How many people — young and old —  go through that experience every single day because doctors aren’t trained (and I use that word advisedly) to deal with death.  Because we don’t have enough primary care providers and at least some of them (like the one who was supposed to take care of this woman) are missing in action.  Because nurses aren’t empowered to say, “stop the action.”  There are so many cases like this.  The New York Times did an incredible front page story on the unnecessary and exorbitantly expensive ($100 million a year) use of cardiac CT scans — scans that actually deliver more than 200 worth of X-Rays at one time — usually for no clinical benefit.  Yet Medicare — after announcing it would not pay for the scans — copped to pressure from cardiologists and said, okay, you can do them in spite of the fact that there is no evidence of benefit and only evidence of harm.  So now we, the taxpayers, are  giving cardiologists  federal money so, like the leaders of the nation’s collapsing banks,  they can use it for the equivalent of hefty bonuses.  Does this make sense?  When are we going to stop using our now very scarce resources like this and start a national conversation about using them more wisely.  If discussions about health care reform don’t include topics like this then we will never be able “afford” the care we really need.