I try to keep my day job out of my column, but sometimes the political scene requires I bring the MD and PhD to bear. With the House effort to repeal the Affordable Care Act making headlines this week, it seemed a good time to talk about a few of the system’s dirty little secrets, on the off-chance that the Republican leadership remembers that they once promised to repeal and replace.
Let’s start with a biggie. Medicare prevents preventative health care. No one planned it that way, but it’s often true.
According to the Centers for Disease Control and Prevention (CDC), the leading cause of death in 2010 was heart disease (some argue cancer has caught up). For men, the first heart attack occurs at age 66. Medicare, an important and efficient system, starts picking up most of the tab at age 65. If you’re an insurance company, you have every incentive to enroll people, skimp on their preventative care, and let Medicare pick up the tab when bad things happen. For women, who have their first heart attack at age 70, it’s a no-brainer. This may not be as important as you thought because preventative health care may not save money.
Yes, good diabetes control could save us some hospital admissions for ketoacidosis, and yes, treating heart disease can help people live longer healthier lives. Both are important benefits of preventative health care, but let’s not kid ourselves about the money. Even patients well served by preventative medicine will consume health care dollars during those “extra” years, only to eventually pass of the same expensive heart attack. Or perhaps a cancer, after expensive chemotherapy, which demonstrates that health care is affordable. Immortality isn’t.
In 1996, more than $37,000 was spent in the last year of life for people 65 and older, versus $7,000 in other years. More recent studies show that we are spending nearly 1/3 of our health care resources in the last year of life; in no small part because nearly two-thirds of Americans die in a hospital or nursing facility. “But they want to keep fighting,” you say. Perhaps not. A Time/CNN poll in 2000 found that 70 percent of Americans would rather die at home. In fact, what we should really look for are interventions that save money and make patients happy, like death panels that save lives.
Gov. Sarah Palin coined the phrase “death panel” to caricature the idea that health care reform might include footing the bill for patient-initiated end-of-life care discussions. In Palin’s universe of misleading hyperbole, this somehow led to mandatory consults and eventually government bureaucrats sneaking into the ICU to pull the plug on gramma. Not so much. Even then, data showed that having conversations about end-of-life care as part of a daily ICU protocol increased patient and family satisfaction and decreased costs. Later studies have shown that patients with terminal lung cancer actually live longer if seen by a palliative care specialist. Which is why tort reform is important.
I’ve seen studies concluding that defensive medicine in the face of litigation doesn’t add that much to the national health care tab. I don’t buy it. Not as a practitioner, and certainly not as a watcher of late-night commercials asking, “Did you have [horrible outcome] after your doctor prescribed [some medication]? Call the law firm of [I’ll sue them].” I don’t want a system where bad doctors can’t be held to account; but I think we can agree on some simple things. For instance, shouldn’t doctors prescribing an FDA-approved drug for an FDA-approved indication be insulated from litigation? (We’re not.)
My lawyer friends tell me that such insulation for doctors could cause a chain of evidence/liability problems in suing drug companies. I say that’s just the kind of thing that Conservative congressmembers are well-suited to fix legislatively. They might find a few unexpected allies if they stop taking show votes against President Obama’s best honest effort and actually try to assist in making health care more humane and affordable.
