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.”
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.