The case for rationing health care
Americans want doctors to go all out for their loved ones and themselves when facing illness, writes M. Gregg Bloche, but, as voters and consumers, they send a different message of cutting taxes and a desire for low insurance premiums. Doctors are stuck in the middle of this contradiction.
Los Angeles Times
SEVERAL years ago, I was asked to speak on end-of-life issues at a retreat for Southern California physicians. A number of doctors there brought up one particular case: an 82-year-old woman who'd suffered a massive heart attack while visiting her daughter.
Her story captures the difficult choices that keep us from controlling health-care spending. Unless we all confront those choices, the costs of medical care will consume us, stealing away an ever-larger share of our national wealth and driving federal budget deficits to catastrophic levels.
The patient was admitted to intensive care, then put on "pressors" — medications that boost blood pressure by causing muscle cells surrounding tiny arteries to contract. Her doctors quickly concluded that her prognosis was dismal. Aggressive doses failed to raise her systolic pressure above 70 (a worrisome sign). Too much heart muscle was nonfunctioning. Yet she remained awake, alert and chatty.
The woman's daughter was around when the doctors delivered their dire prognosis. The pressors were pointless, they said; the battle couldn't be won. Their prescription was to end aggressive treatment. The patient didn't obviously object to the doctors' plan, but her daughter, a social worker told me, "felt it was an assault."
The daughter began paying close attention to clinical details. She questioned the doctors about their intentions. The doctors, in turn, grew annoyed.
"Her daughter could not let go," one of them later told me, "even in the face of a bad prognosis. She was taking ... an adversarial position, almost litigious. What I tried to clarify for her was that this was not an adversarial relationship."
But one of the doctors admitted to some thinking that wouldn't have reassured the daughter: "When we see dollars wasted, that's not a good thing. Nobody presents that to the patient." Keeping the mother alive, which required the high-tech monitoring and ministrations of the ICU, was most likely a waste because her chances for survival were so tiny. "The problem is that individual members only care about themselves, because they don't have the global perspective."
One cardiologist did present this perspective to the patient. According to colleagues, he came to her bedside, told her she didn't have enough heart muscle to survive, then said: "Have you ever stayed in a really expensive hotel, like the Plaza? You know how expensive a room is? Six to eight hundred dollars. Well, you know how expensive this room is? Ten thousand dollars."
The daughter threatened to sue, demanded new doctors and insisted that the staff go all-out to keep her mom alive. Four weeks later, the 82-year-old patient left the hospital on foot. For a year or so, until she died, she divided her time between her daughter' home, an assisted-living facility and her own residence.
The doctor who'd complained to me about the daughter's "adversarial position" said her mother's survival astonished him. Yet he stands by the decision he'd have preferred: to take her off pressors and get her out of the ICU — in effect, to let her die. "If you say that the fact that this lady survived means we should do that type of thing for every patient — I'm not prepared to say that," he said.
And then he spoke the unspeakable: "We are subconsciously rationing care, whether we call it that or believe that's what we're doing. ... If we didn't, the reality is that we would be facing an absurdity in which we made ... near-futile efforts to save one life out of an enormous number of failures. We'd bankrupt our health-care system."
We want our doctors to go all-out for our loved ones and ourselves. But as voters and consumers, we send a different message. We pick politicians who promise to cut taxes, and we demand low-cost insurance. We're telling government and the health-care industry to hold the line on health-care costs, even if it means sacrificing clinical benefits. And we put doctors in the middle of this contradiction.
In recent weeks, private insurers have revealed plans for double-digit rate hikes. Our medical bills are already close to a fifth of our national income, on track to reach one-third within 25 years. Soaring Medicare and Medicaid costs are the main reason for nightmarish federal deficit projections over the long term. Yet as Republicans and Democrats battle over the federal budget to the point of threatening a government shutdown, serious health-care spending cuts remain unspeakable.
House Budget Committee Chairman Rep. Paul Ryan, R-Wis., recently proposed to cut Medicare and Medicaid by shifting their costs to poor and middle-class Americans who can't afford them. It's an unconscionable approach, but it at least acknowledges the urgency of gaining control over federal health-care spending. Neither President Obama nor congressional Democrats have put forth plausible proposals for doing so.
How might we "bend the curve" of rising costs without forcing doctors to break with Hippocratic ideals? Percentage points can be trimmed by better coordinating care and providing it more efficiently. But the main driver behind rising costs is indiscriminate adoption of new technology.
We must make it much harder for high-cost clinical wizardry to become part of our expectations. We should distinguish between decisive advances — biological breakthroughs that make large therapeutic leaps possible — and technologies that dazzle but deliver only marginal results. We can do this by demanding proof that pricey services add value before permitting health-care providers to tap insurers for payment. And we can harness intellectual property law to encourage therapeutic leaps by giving longer-lasting patents to more effective tests and treatments. We should also stop paying providers more for using technology than for listening and talking to their patients.
But as a society, we also have to set limits when it comes to individual treatment. We can't afford to spend without restraint in the ICU, in pursuit of tiny chances. We must — and this is the hardest part — decide what we can and can't afford. We have to let politicians and policymakers grapple truthfully with these issues rather than punishing them for "killing Grandma" when they speak of making hard choices about health care.
We accept cost-benefit trade-offs in other realms: We base airline and occupational safety regulations on dollar figures for the value of life. Similar clarity must replace the vague terms (like "medical necessity") that insurers use to veil health-care rationing. Clear limits, applicable to all, can help us come to terms with the need to say "no" without shattering our trust in medicine.
Bedside rationing on the sly won't do.
M. Gregg Bloche, a physician and a professor of law at Georgetown University, is the author of "The Hippocratic Myth." He wrote this for the Los Angeles Times.