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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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AnnieMertvincentC. BrownSacramento Printing Recent comment authors
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Annie
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Annie

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’.

Mert
Guest

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.

vincent
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vincent

“…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

DrThom
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DrThom

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… Read more »

C. Brown
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C. Brown

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… Read more »

Sacramento Printing
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I’m going to miss Ford, I wanted to go see him and I’m even in Sacramento

DrThom
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DrThom

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.

Barry Carol
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Barry Carol

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… Read more »

DrThom
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DrThom

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… Read more »

pgbMD
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pgbMD

“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… Read more »

PCB
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PCB

“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… Read more »

Barry Carol
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Barry Carol

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+)… Read more »

Eric Busboom
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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… Read more »

Chris
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Chris

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… Read more »

Barry Carol
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Barry Carol

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… Read more »