What if They Had Had to Pay?

What if They Had Had to Pay?

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A true story, with changes made to protect privacy.  An 89-year-old man with dementia, a heart condition, and other serious medical conditions fell in his Arizona apartment and broke his hip.  His children, wanting the best possible care, arranged for him to be air-lifted to New York.  There, the orthopaedic surgeon advised them that the chance of their father surviving hip surgery was very low, but he would do as the family wished.  The man’s three children could not agree.  Two would have avoided the surgery, but a third felt very strongly that everything that could be done for the father should be done.  The other siblings, out of guilt and respect for the third, acceded.  The surgery took place, and the father spent three days in the ICU before his heart gave out.

Here’s the terrible and hard-hearted question I pose:  If the costs of this procedure and hospitalization had not been covered by Medicare, would the man’s children have proceeded along the chosen path?  I am guessing not.  I don’t know the total bill incurred, but it was certainly in the range of tens of thousands of dollars.

In the US, we don’t have a good societal process for making these decisions.  In the United Kingdom, though, they do, as reported by Bob Wachter in a recent blog post.  Here are some excerpts:

[D]uring my six months on sabbatical in London, when I asked British physicians or hospital administrators who have spent time in the US about their main impression of our healthcare system, I nearly always heard some version of, “You people don’t know how to say no to anything.”

In the UK, they have built an organization that makes these tough decisions: the National Institute for Health and Clinical Excellence (NICE). I was lucky enough to spend several hours with its leaders last week in the organization’s London headquarters. NICE is awesome, not just for what it does, but for what its existence says about the maturity of the British political system when it comes to healthcare.

I asked Sir Michael [Sir Michael Rawlins, NICE’s founding chairman] what it was about the culture of the British people and the NHS that allowed NICE to function, when America has such problems saying, and accepting, a forthright “no.”

“The man on the street gets it,” he replied. “They know that there is a finite amount of money. And politicians get it as well — they know that someone is going to have to make these tough decisions, and they’d rather it be us than them.”

Imagine that.

Bob concludes:

Decisions over setting limits are invariably wrenching, but our failure to create a transparent way to make these decisions just means that rationing occurs implicitly  and haphazardly.

Ultimately, silly season will end, our society will come to grips with the need to choose, and we will begin looking for a method of making these thorny decisions. When that day comes, it’s nice to know that we have a model to learn from.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

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44 Comments on "What if They Had Had to Pay?"


Guest
Jan 9, 2012

Americans think health care grows on trees…just like money I guess. It’s not hard (as a clinician) to know when to stop, but the majority of families in my experience have no idea of when it’s time to let go of their loved ones.

Guest
Jan 9, 2012

At some point we have to start making decisions based on facts and logic more than just sheer emotion. I applaud you for bringing this up. We are all so worried that other people might find us heartless or even cruel when it comes to decisions that may, at most, extend life for a matter of days. At some point we have to say, “We just can’t justify the expenditure for such a small return”

Guest
Jan 9, 2012

It is very sad any time we come across situations like this. I agree with Lowell in that medical care providers have a very hard job and when it comes to medical care there are very tough choices to make. Great article!

Guest
Nate Ogden
Jan 9, 2012

““The man on the street gets it,” he replied.”

Very ivory tower responce. Why not ask the actual man on the street if he agrees. I personally read a couple hundred articles last year that would disagree. Sounds just like Obama telling us all we need to sacrafice then goes off to his Alice in Wonderland themed party that cost millions.

Those that have been affected by NICE decisions are not quietly and happily accepting it.

Guest
SJ Motew, MD
Jan 9, 2012

The question of payment for ‘the man on the street’ has never had to be asked in this country, nor will it ever likely need to be asked. Even in countries with socialized medicine, there is no need to ask the question, it’s either paid for or not. In this country, no one is denied care if they can get to it.

The real culpable party is the health care providers (ie docs) who fail to take the lead in deciding for our patients what is appropriate or not under terminal or difficult circumstances. We are under no obligation to provide care that unjustly taxes the system. The emphasis in that statement depends on appropriately defining ‘unjust’, a scientific and moral decision based on risks, outcomes and the knowledge that not everyone needs to die with a tube down their throat or an incision on their belly and that resources are critically limited. I think the question to ask the ‘man on the street’ is “Do you want your physician to be honest, guiding and caring when making challenging decisions even if it means a comfortable dignified death?”

Guest
Nate Ogden
Jan 9, 2012

Where are you writing from that no one is denied care if they can get to it?

When a doctor and every standard says further care is pointless how does that prevent the attorney from disagreeing from the pointy end of a multi million dollar lawsuit?

Guest
SJ Motew, MD
Jan 9, 2012

I guess to clarify, if one waits long enough to present with an emergent condition (ie hip fracture) to a federally supported (Medicare/caid) hospital, EMTALA makes it illegal to deny care due to immigration or payer status, hence, everyone can get care (like I noted IF they can get to it).

While nothing prevents a lawsuit from being placed, the requirement for medical tort includes negligence,and/or significant deviation from care standard which then must result in an outcome (harm, disability, emotion P&S etc.) that is other than expected from the disease process. End-of-life care for terminal conditions rarely results in successful malpractice claims if the patient dies.

Guest
Jan 9, 2012

Paul Levy is an earnest advocate of sensible patient care.

However, he misses the solution to the issue of end-of-life hospital care.

Which is this — stop paying hospitals on a fee for service basis, and start paying them with global budgets.

Levy is caught up (understandably given his career) in the classic Medicare and Blue Cross model. The hospital estimates its costs for ICU care and surgery on each patient. This is a mish-mash of overhead recovery, nursing time, amortized construction costs, etc, etc.

The hospital is then paid $20,000 for this patient, and $15,000 for another patient, and so on.

There is another way!

Give the hospital $30 million on January 1st, but pay no claims whatsoever.

Who among us would then know or care whether an 89-year old gets surgery ahead of or behind a 69-year old? Who among us knows or cares how many incidents our local fire department had last year at homes with wood
stoves? It does not matter to us, because we pay the fire department with a global budget and not user fees!

(read the wonderful Canadian Robert Evans for further discussions.)

I know that even with global budgets, there will be occasions when painful decisions must be made about individual patients. A Stage IV cancer patient who needs $500,000 in drugs to stay alive for six months will require some very tough debates.

However, the 89 year old needing hip surgery is not in that category,

Even now, we could have the very old get their surgery at VA hospitals. I have spent a lot of time visiting relatives at the Minneapolis VA hospital, and it has all kinds of empty beds and underused staff. In that case, the 89-year old’s care is already paid for in the VA’s global budget.

The end of life ‘dilemma’ is caused by over-reliance on user fees.

Bob Hertz, The Health Care Crusade

Guest
Janie Williams, RN
Jan 9, 2012

Fanilies will buy snake oil to sustain life. Most patients will not pay for medical care unless they feel rotten.

Senator Grassley knows that LTACs are selling snake oil to families that also lube the cash registers for hospitals such as Levy’s former place.

Guest
sr
Jan 10, 2012

This is exactly why everyone needs an advanced directive. The father should have designated one of his children (or someone else) to make decisions for him – that’s right; one person who is closest to him. I bet it wouldn’t be the one insisting on care. When I suggest this to some people, they balk at designating only one person, thinking it’s better to have it be a “shared burden”. Nothing is further from the truth, as this case shows.

Guest
Bill Riemers
Jan 10, 2012

I really would not want to live in a country were a person’s right to healthcare is measure by the size of his wallet. So a 89 year old from a rich family get a the surgery, while the 89 year old from a poor family does not? Human life should be valued higher than the value of money. That does not mean of course you do everything for everyone. I just means you somehow remove money from the equation when determining what is done with the limited health care facilities and personel available. Those with the likelihood of greater potential benefit from the same resources should receive priority. So if you have the doctors standing around doing nothing, then they should be operating on the 89 year old. However, if you have a 20 year old with equal chance of success, they should treat him/her first.

Sadly, I know my views are opposite of a majority of Americans and even a fairly large minority of Canadians, but that is what I believe.

Guest
Nate Ogden
Jan 10, 2012

You would prefer to tell a rich person who has the money they are not allowed to have the surgery? Sorry sir we know you can afford to pay for your operation but that is unfair so your going to have to die without it so a poorer person doesn’t feel discriminated against.

Oh and poorer people that also needed minor services we can no longer provide those to you becuase the money we would have made off that rich person’s surgery subsidized yoru care, now that we lost that revenue your care will not be provided either.

Good job Bill, you just killed a handful of people but they all died feeling equal.

Guest
Bill Riemers
Jan 10, 2012

That said, I would not really pay much head to UK physicians, since they come from a medical system where people older than 70 are routinely allowed to die from conditions that everywhere else in the world are considered easily treatable with a very high survival rate. Never vacation in the UK if you are over 70. Even if you have money, they have virtually no private doctors or medical facilities to treat you, so if you have a medical emergency you will be allowed to die. My step mother who is a Doctor who has worked in embassies thoughout the world has told me that 100% of the patients transfered to the UK from here care have died. One time she even flew with a baby being transfered back from Indonesia. With in 20 minutes of her landing the UK the managed to F*@# up and kill the baby. While it strictly and antedotal observation, I would say the UK has the worst medical system on the planet.

Guest
Bill Riemers
Jan 10, 2012

@Nate: Clearly you did not read my comment completely through. The 89 year old would receive treatment if there was nobody higher priority left to treat first. So if they are dying it is not because they money, but because someone else needed treatment more. In the current system the 89 year old received treatment, because they could file a medicare claim. Chances are in the same hospital on the same day someone under 65 died because they did not have medical insurance or the cash to pay for it. Is that the system your are advocating for? If so, you are in luck because that is the system you have in the US.

Guest
Jan 10, 2012

I think that the discussion is rushing by me, but just for s—ts and giggles let me go back to my point.

In a system with global budgets the 89 year old and their relatives do not pay anything other than their taxes.

Nor does the 20 year old.

If resources are short, the doctors at the hospital decides who gets surgery first.

My point is not that this produces perfect health care. As noted in the comments about older Britons dying, it absolutely does not produce perfect health care.

But it produces a health system that the nation can afford.

People over 85 have had a good long life. History will think we are a little nuts if we measure our health system by how long people live past 85.

Guest
Barry Carol
Jan 10, 2012

Bob –

What you say sounds sensible enough to me. The problem, though, is that too many people want what they want when they want it either for themselves or their loved ones and they expect someone else to pay for it. They don’t want to hear about limited resources or the need for them to pay more in taxes. This is why I’m glad to hear about recent proposed changes that direct doctors to build the wise stewardship of society’s limited resources into their practice patterns. Sometimes they just need to say that there’s nothing more we can do aside from keep you or your family member comfortable.

With respect to global budgets, I appreciate their conceptual appeal but it’s not so easy to estimate costs a year in advance especially in areas with a growing population. Also, a few very expensive cases can wreak havoc on even the most carefully developed budget. At the very least, every hospital would need to have to have significant financial reserves to carry it through a difficult year. What happens if they burn through their annual budget by November 30th or December 15th? Would patients not get care and employees not get paid until January 1st of the following year? If it were easy to estimate costs well in advance, there would be a lot less resistance to capitation.

Guest
Jan 10, 2012

Bob,

Thanks for your suggestion, but . . . .

I have talked to people in Canada and other countries with nationalized systems and annual budgets, and the same issue arises. Although the details vary, they also cite an sad lack of end-of-life planning within families, and between patients and providers.

In my experience in the US, having seen providers both on global budgets and fee-for-service arrangements, the same issues arise.

Guest
Jan 10, 2012

I appreciate the comments by Barry and Paul. I have run an insurance agency but I certainly have never run a hospital or a clinic, so I may in fact have idealized global budgets.

Barry’s post does lead me to ask the following question:

Other than the use of overpriced drugs, why is any particular patient more expensive than another?

My father was tremendously weak in his last month in the hospital, and needed a lot of nurses— but they were already on the payroll at the VA.

The 89 year old in Paul’s example needed hip surgery, which is labor-intensive — but if the surgeons and assistants are already on the payroll, why would he be an expensive patient?

Where I am going with this is a long-time suspicion I have had that if we controlled the prices of drugs with no substitutes, we could give hospitals a flat per diem and not worry about them running out of money at the end of the year.

Any potential for cost control in Medicare has been sabotaged by having a graded fee schedule that is easy to manipulate. (See George Halvorson’s
1996 book Strong Medicine for some pungent descriptions of upcoding.)

I have wanted to be the analyst to say that the emporer has no clothes in terms of what makes an expensive patient. (once we control drug costs)

I certainly welcome any corrections though because I have no clinical experience.

Guest
steve
Jan 11, 2012

Many physicians are not on the payroll. Medical devices are very expensive. At present, a hospital bills for everything, even if their docs are employed. On a global budget, people then aim to work less for the same amount of money. What we do at my hospital then, is to incentivize docs to do enough cases, but that leads back to the same problem.

Steve