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QUALITY/POLICY: Gerald Ford–the poster child for what’s wrong with health care

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Gerald Ford died last night aged 93. By any standards he had a great life. He was a moderate Republican in the House for many years, and then a stop-gap President after Nixon, famous mostly for pardoning Nixon who hadn’t yet been charged with a crime. And then lived on for nearly another 30 years. The American dream of the College jock becoming President and achieving great wealth and happiness—and people liked him!

But it’s the manner of his death that I think is very important. Just two months ago in a “discussion” I had with David Gratzer of the Manhattan Institute, I raised the point that Ford had not one but two angioplasties at the Mayo Clinic—and that as he was likely to die soon anyway that money would have been better spent on pre-natal care for an uninsured woman who was featured on ABCNews that week.

David Cutler recently estimated that adding an extra year of life for the elderly cost $145,000.

So consider Ford’s last few months of life. He was admitted to hospital last January for pneumonia. Then spent much of July in hospital in Vail; then went to the Mayo Clinic for not one but two angioplasties in August. Then went back into hospital in California in October, and now has died in December. All that time he was obviously going to die within a year or so, and all that time he was at least 92 years old.

My guess is that over the last 12 months of his life well in excess of $100,000 was spent on his health care. And that money probably extended his life by three months at most. Now for all we know they may have been the most wonderful three months ever for him and his family, but I’m inclined to think that if he’d died in the summer, his family would have been equally fine with it, and the nation wouldn’t have felt any differently about him. But the cost of extending life an extra year in this type of case is probably around $400,000.

How can that possibly have been money worth spending? The answer is that it cannot have been. And that is where the money is in our system which could pay for all the pre-natal care for uninsured mums, immunizations for sick kids, and procedures for uninsured 50 year olds that we “can’t afford.”  And frankly it’s probably better and more humane care to provide palliative care at home than to put sick old people through yet more invasive and painful procedures.

So the sooner we start having that conversation the better. And if that conversation comes out of Gerald Ford’s death, then at least that spending on the last months of his life might have done some good.

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23 replies »

  1. Reading over these comments way after they were discussed.
    The conclusion is that the so-called debate should be about how to give the healthcare market back to the people so that some of you nazis will never get in the position to be put in charge of anyone’s end of life decisions. That is what you are worried about, having to pay for some 70-90 year olds healthcare – ‘Eh, you’ve lived long enough. Die so that my taxes can go for some transgender to get his privates whacked off’.

  2. Come on man that money is worth spending if you have it even for 1 days. life is very precious, even if you live 93 years already.

  3. “…money would have been better spent on pre-natal care for an uninsured woman…”
    So would the money that is used to run this anti-freedom blog.
    Freedom- i can pay whatever i want, whenever i want, for whatever medical services i want
    Fascism – i can NOT pay for a CT scan, but I can have a
    “free” one done in three months that was paid for by the tax payers

  4. C
    I couldn’t agree more. Any individual has the right to choose to live as long as his body permits and to ask a physician to provide interventions demonstrated to be of benefit in the clinical situation he or she finds himself in. A physician, though, has absolutely no moral or ethical obligation to offer futile or unproven therapy. She does, however, have to duty to explain the risks and benefits of any intervention which can be offered. The difficulty lies in the fact that there has never been a controlled study that has ever demonstrated benefit from angioplasty in a 93 year old with pneumonia, none. All the evidence is from anecdotal case series, the most unreliable type of clinical evidence. The intervention needs to be presented fairly and I fear in this case it was not.
    So many interventions with inargueable benefits are not pursued due to the financial incentives of our system. No one is asking the elderly to die and get out of the way, but I am suggesting that by appropriately describing the true risks and benefits of interventions like those described above, there would be less utilization of these costly futile therapies and, perhaps, more resources which can be used in an effective manner.
    The art or medicine lies in caring for the patient, the science lies in the treatment. Without both of these components, the practitioner turns from Physician to charlatan
    TED

  5. I can’t believe that we’re even talking about denying elderly citizens the right to live as long as possible. The majority of these people were law abiding, decent and honest individuals who deserve to live as long as possible. If an uninsured mother cannot provide for her child(ren) why did she have them in the first place knowing that she did not have the money to support them. I’m tired of having to worry about people who don’t work and rely on society to bail them out of difficult situations. I was a single parent for years and worked hard to support my children even if it meant that I had to deny myself something to clothe and insure them.
    What happened to respecting our elders, and gaining knowledge from their experience? Kids today don’t even want to spend time with older peopleunless they come from a close knit family. Our society has deteriorated to the point where it’s a crime to age. One day we will all be in that situation. I wonder if those who oppose saving the elderly will have the same opinion when their time comes. Gerald Ford deserved to live as long as possible, and that is true of every other elderly person who needs care to extend their life, even if it’s just for a year. It’s time we take a good hard look at our values.

  6. Barry
    Unfortunately, you are not mistaken.
    I recommend that people find and stick with a personal physician who is in private practice independent of the employ of any vertically integrated “system”.
    Such an individual will have knowlege of who is influenced by finances and who is less so. I personally have been fortunate enough to cultivate a group of intellectually honest specialists far more talented than I who have the courage to have that difficult conversation.

  7. Dr. Thom,
    What you say makes perfect sense to me. However, as a practical matter, it seems that laying out both the hope and the risks that an intervention might entail is a more difficult conversation than just emphasizing the hope or possible upside even if the doctor knows that the prognosis is not very good. Second, doctors generally have no personal financial incentive to save the system money. In fact, they are more likely to be rewarded financially for doing more, not less. In the case of Stage 4 cancer patients, for example, my impression is that cancer specialists generally not only don’t level with patients, but often continue to treat when the prospects are clearly poor and even ignore or override living wills that call for nothing heroic to be done. Am I mistaken?

  8. Of interest to me is that, aside from antibiotics for pneumonia, not one of the interventions described has been demonstrated to provide any benefit in Mr. Ford’s clinical situation in blinded controlled studies. In addition, every one of them is associated with known harm.
    As physicians, we have no obligation to offer therapies with no proven benefit and in fact have an obligation to discourage interventions where the benefit is unknown but the downside is quantifiable.
    Too many interventions are undertaken in the elderly on the basis of “well, it was a net positive in a 40 year old, so we might as well try it in an eighty year old” Just as children are not little adults, the elderly are not just old ones.
    I wonder if the angioplasty was presented as “there is no evidence that this will help, but there is evidence that it will harm” It might have been, but based on my experience with interventionists, I bet not.
    I deal with many families who also would do anything to keep their loved ones with them for a little longer. When presented with the science behind the options available to them, most opt for minimal intervention.
    I don’t want to sound too high and mighty, but when dealing with the elderly, we must divorce ourselves from the economics driving our system and stay intellectually honest with ourselves and our patients. That simple intervention will go a long way to alleviating the situation described above.
    Thomas Davis MD

  9. “But if Ford’s end of life care was paid for by the Ford family or Ford’s private insurer, then those expenses are not Society’s concern; Ford can spend his money on anything he’d like to, and extending life is probably at the top of nearly anyone’s list of expenses.
    Society cannot morally restrict a person’s choices in medical care unless the person is spending society’s money.”
    I agree with you, but from what I understand, Medicare patients are not allowed to spend their own money on care unless they are seeing the rare physician that has completely opted out of Medicare (definitely not at Mayo). Additionally, it is illegal to sell whole healthcare insurance to Medicare eligible patients. However, they can purchase additional coverage on top of the Medicare coverage. Maybe the strict Medicare laws need to be changed. Please correct me if I am wrong.

  10. “The fact is that we can generate more healthcare than we can pay for, and we have to draw the line somewhere.”
    Barry,
    I find this a provocative statement. I wonder how many reading here believe it. I think it even goes beyond end-of-life care.
    Consider it restated:

    If everyone had easy access to his/her doctor for every possible medical condition, and if the doctor followed current practice standards, we would spend more on health care than we could tolerate (And it’s inevitably going to get worse).

    (I have a sense that those working in health care appreciate this more than others, but it’s just a sense.)
    Examples:
    -Sex life not perfect? Take these pills.
    -Memory not perfect? Take these pills.
    -Life tough right now? Take these pills.
    -Too much energy at school? Take these pills.
    -Joints bothering you? Get new ones.
    -Hard to lose weight? Have surgery.
    -Labor not for you? Get a c-section.
    -Cholesterol numbers a little off? Take these pills.
    -Heart doesn’t squeeze perfectly? Get a defibrillator
    -Need a cardiac stent? Try our fancy new one.
    -Headache bothering you? Get an MRI.
    -Worried about cancer? Get an MRI/CT.
    -Worried about your prostate? Keep checking PSAs until you (inevitably) find something.
    and on and on….
    (I know people suffer legitimate debilitation from many of the medical conditions hinted at above. My point isn’t to marginalize anyone. I’m simply questioning how broadly we define “debilitation” and “medical condition.”)
    How far can we go with this? How many prescriptions/scans/surgeries will the average person have 30 years from now at the rate we’re going? How necessary will it all be? Are the benefits worth the costs?
    Who decides?
    Pete
    (As an aside, HSAs and out-of-pocket plans, whatever you think of them, address this head on,which is part of their appeal. You define “necessary” yourself and allocate resources accordingly, at least in theory. )

  11. Society cannot morally restrict a person’s choices in medical care unless the person is spending society’s money.
    Exactly correct and exactly the point. In the case of probably 95%+ of spending on end of life care, it is society’s money, and we risk crowding out other important and worthwhile priorities as spending on healthcare, especially healthcare at the end of life continues to escalate.
    I think there is an important distinction between the following two scenarios under which care may be denied or withheld at the end of life. Scenario 1: Two Medicare beneficiaries are the same age (say, 90+) and both need angioplasty. In one case, the doc, in conjunction with the hospital ethics committee, decides that the patient is too frail and the procedure isn’t done. In the other case, they decide the patient is reasonably likely to comfortably survive the procedure, and it is done. Both are judgment calls. I assume there is no living will in either case. Scenario 2: Congress passes legislation covering a whole series of procedures that Medicare will not pay for beyond a certain age including angioplasty in this age range. Now we have an insurance coverage issue equally applied to all. If the doc and the hospital perform the procedure, they will not be paid unless the patient or the family can self-pay. Society, through its elected representatives made some decisions recognizing that resources are finite and we cannot afford to pay for everything for everyone.
    A favorable byproduct of the legislative approach to determining what Medicare (and Medicaid) will and will not pay for is that middle age and other family members, who may not yet have come to grips with their own mortality, can be comforted by the fact that everything possible was done for mom or dad (consistent with the patient’s living will if one existed) within the system.. They do this sort of thing routinely in the UK and, perhaps, elsewhere, and I think the UK qualifies as a “civilized society.”
    If we ever get a system of taxpayer funded universal health insurance, explicit rationing of end of life care is virtually certain to be part of the package. The fact is that we can generate more healthcare than we can pay for, and we have to draw the line somewhere.

  12. Whose money was being wasted? The American people would only have paid for Ford’s angioplasties to the extent that such things are covered by Medicare. What Medicare covers and to what extent is a valid concern of American society.
    But if Ford’s end of life care was paid for by the Ford family or Ford’s private insurer, then those expenses are not Society’s concern; Ford can spend his money on anything he’d like to, and extending life is probably at the top of nearly anyone’s list of expenses.
    Society cannot morally restrict a person’s choices in medical care unless the person is spending society’s money.

  13. Also my first post here. Excellent discussion. Pete, I love your well thought out response. We all value health care for a 93 year old. The difficulty comes up when the 93 year old himself values it more highly than his insurance company or the federal government (as a proxy for society). How we settle that disagreement is the real problem. My great fear is that the longer we wait to have these discussions the harder and “hotter” the discussions will be. I’ve said to many people that I fear that in 2020 my kids and their generation will be forced to declare that “health care for everyone over 80 is hospice care”. I don’t want to put my kids into that dilemma.

  14. PCB,
    Excellent post. A couple of comments.
    First, my understanding is that only about 25%-30% of Americans have living wills and/or advance medical directives at this time. I would be interested in any information that others might be aware of as to how those break down between (a) don’t do anything heroic if the intervention(s) would be futile vs (b) “do everything.”
    I think it would be extremely useful if the society, through its elected officials, could arrive at a consensus as to an upper limit percentage of GDP that it is prepared to spend for healthcare recognizing that resources are finite, and there are many other things of value that people may prefer to spend those resources on instead.
    Personally, I would be comfortable with charging people higher Medicare or other insurance premiums if they want everything done for them at the end of life just as we routinely charge smokers more for life insurance.
    As for rules set by government, I would support things like age cutoffs – no dialysis beyond age X or no cardiac bypass or angioplasty beyond age X unless the patient or his or her family can self-pay or has purchased private supplemental insurance (if it were available) that would pay. I would also support using QALY metrics or something like it to determine whether or not to pay for new ultra expensive specialty drugs that are coming to market.

  15. First post on this blog I’ve been reading for a few months now.
    I agree with Matthew that this is a discussion that we should be having. Just the brief responses here make it clear it will be difficult to have such a discussion, especially on a larger scale in important decision making forums.
    In the ideal world of medical insurance theory, I would have private insurance that I have chosen to purchase and finance with my own resources. My chosen package would be one that reflects my health care values. If I felt that “everything” should be done for me at the end of my life, no matter what the cost/benefit ratio, then I would pay huge premiums because I may well consume huge resources at the end of my life. It would be my choice and I (or my family) would pay for that choice, reflected in our premiums.
    In the nation we currently live in, however, the taxpayer is paying for my insurance. I am drawing from medicare’s pooled resources that need to cover everyone. (above 65 y/o for this discussion) Unless these resources are unlimited, some decision maker will have to decide that some care is not “worth it.” We (society) can decide politically to have medicare be like the “Rolls Royce End of Life Care Policy” I mention above, but we will end up spending more of our GDP on health care than most are comfortable with. We can only divert so many resources away from other things we value.
    Ideally, I would feel a moral obligation not to draw a disproportionate amount out of the pool when care is futile or provides little predicted benefit. What do we do when this isn’t the case and “all that can be done” is demanded, no matter what the cost?
    Some process needs to limit care if resources are limited. Debating that process is where I think Matthew wants to go.
    The responses here do not inspire confidence in getting there, at least not anytime soon.
    Pete

  16. John,
    I understand and respect your position on the end of life issue. What I would really like to see as a starting point, however, is universal adoption and execution of living wills and advance directives so the individual can provide guidance in advance to both providers and family members as to what care the person wants and doesn’t want as the end of life approaches. They could be updated or renewed annually as they are in Canada (according to Peter). Without the living will, providers often feel that they have no choice but to do everything possible while family members often disagree about what course of action should be pursued. The bottom line here is that the family member would make the decision (it could easily be to “do everything”) but the expense and suffering related to unwanted care would be avoided.
    I think it would also be instructive to study how the other major developed countries deal with this issue. To what extent do those societies accept whatever the process is? What did they go through to ultimately develop and implement a consensus approach? I suspect there is a lot we could learn from others on this subject.

  17. “If he was 93, I think it might have been more humane to not put him through that”
    Then that would be your family’s decision.
    IMO, you are caught ethically far off base to place yourself in the position of making that decision for other families.
    And it is not ethically better to shift the burden of such a decision to some other party- such as a government agency.

  18. “letting nature take its course in the case of the frail and very sick elderly.”
    Barry, you and I agree on a great many issues and I certainly agree with you that end-of-life care is expensive and probably not optimally managed.
    But it’s my opinion that older, infirm people do not have a duty to die in order to save money for younger, healthier people. I also do not accept that younger and healthier people have a duty to help older, infirm people die, by deliberately withholding medical care or medicines – or food, for that matter. I believe that to say “letting nature take its course” is a circumlocution that admits many dangerous and regrettable future acts. Based on all that you have posted here and elsewhere, I believe your position on end-of-life care is proposed with only the best of intentions. But actually giving someone the power to make decisions that would curtail end-of-life care, is to create a monster that I doubt could be controlled.
    Because, someday, a duly authorized representative of our government will surely say to your children or my children or anyone’s children: “[S]he’s useless now. Therefore stop feeding her and do not provide him any more health care.” And that decision will have the force of law. It’s a chilling prospect.
    Also, BTW, there is nothing special about the elderly. Health care, food, nurturing, etc could as easily be withheld from anyone who is deemed by the proper authorities to be “very sick” and “beyond hope”. The definitions of those terms would be made by . . .who exactly? If some significant part of the health care cost problem can be solved simply by “allowing” unhealthy people to die, what happens to incentives to develop additional cures? What then makes us different from the insurance companies whose underwriting practices so many complain about?
    My opinion is that if we move toward “letting nature take its course” we would pay for it by surrendering our claim to be a civilized people.

  19. I know this is a deeply deeply emotional subject. Which is why we’re not talking about it nationally. And perhaps we never can.
    And to John’s point, of course we as a society are wasting money all over the place (Iraq, imprisoning non-violent drug offenders, insert your favorite here).
    What I am saying is that there is a real cost — and not just a financial one– to performing heroic procedures at the end of life that gain only a small amount of extra time.
    My father had a quadruple bypass aged 63 and is still going strong 7 years later and will likely be around at least another decade more. That to me passes the sniff test as being a “good value” medical intervention. But it was a brutal experience for him. If he was 93, I think it might have been more humane to not put him through that, and to have given him palliative care at home. It would certainly have saved society some money.
    And if we want to cover the pre-natal care for the uninsured mother, then the money HAS to come from somewhere. Can we really justify spending MORE on health care?

  20. In regards to your posting Matt, one would need to look at it from Betty Ford’s perspective. My wife was the “light” of my life. I would have done “anything” to keep her alive. And my wife wanted to stay here as long as she could, for me. Even after knowing all the negligence that was done to her, and that she would not survive, equal amount of money was spent to keep her alive. I cherished those extra twelve months. Betty Ford had many more years to live with her spouse than I did, but I’m sure the bond was equally persuasive.

  21. John,
    I think there is a considerable difference between proactively imposing the death penalty (killing) a prisoner and letting nature take its course in the case of the frail and very sick elderly. Just because we have the technical capability to perform a surgical intervention doesn’t necessarily mean that we should. At the very least, I think we should require the elderly to execute living wills and advance medical directives to provide guidance to both providers and family members as to what care they want and don’t want as the end of life approaches. As I’ve said numerous times before, I believe this should be part of the process of signing up for Medicare (or Medicaid) or entering a nursing home or assisted living facility. It could be renewed or changed each year if desired. In a world of finite resources, we have to try to find savings somewhere. Let’s start with a thorough and careful reevaluation of our approach to end of life care.

  22. “How can that possibly have been money worth spending?”
    There are convicted murderers imprisoned all over the country who are being kept alive, fed, clothed, and housed at great public expense. Might one with equal logic ask how that can possibly be money worth spending when there are honest citizens who are in need?
    Is it because we are a civilized society and reject the death penalty? Then I don’t understand how one who opposes the death penalty e.g., for murderers and rapists, can at the same time favor the death penalty for the merely old and infirm. I also don’t understand how a deliberate public policy to withhold medical care from the old and infirm is any demonstration of a civilized society.

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