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The Death of a Pet: A Glimpse into the Human Future

For some years I have been writing about end-of-life care and, of late, focusing on the high costs of that care. I recently had a painful but revealing insight into what the future might look like on both costs and decision-making. It came about from an unexpected angle of vision, the care provided by a veterinarian in an emergency care center for pets.

Our much loved dog, Sunny, a 6-year-old Cavalier King Charles, otherwise in good health, began throwing up, ignoring her food, and displaying untoward lassitude. The symptoms got worse within a few days and we took her to a neighboring pet hospital, one that advertises a range of available technologies and treatments equal to that found in a hospital for humans.

We took her in the morning, left her there, and in the late afternoon were told that she had kidney failure, was unable to pass urine, and had other serious symptoms. The prognosis was not good, but it would take another day or so to see what difference treatment might make. She gradually went downhill the second day, a catheter failing to bring forth much urine and with increased signs of distress.

At the end of that first day, we were given a detailed set of cost projections. We were required to put up, via credit card, $2,600 as part of an estimated cost of $5,000 or so for two days of intensive care — a treatment plan that could come to $9,000 if it went on for more than three days. I had read about the high cost of upscale veterinarian care, but it had never occurred to us that we would have to face it.

Yet if the projected costs were jolting, something else was no less arresting: the time and care the chief veterinarian in charge of Sunny’s care took to explain exactly what was going on with Sunny, what they were doing, what the prognosis was — and how rapidly the costs would continue to rise if Sunny survived. She was equally frank about the fact that Sunny was not likely to make it and what it would cost us if she did. The veterinarian told us in a way that beautifully integrated money, medical candor, and compassion. It was, I thought as she was doing so, just what we might hope for from a doctor for our care, but by no means yet reliably available.

We agreed at the end of the second day that we would see how Sunny did overnight. If there was no improvement, we decided it would be best to put her to sleep (I don’t believe her doctor ever used the phrase “put her down”). She did not improve, required oxygen during the night, and passed little urine. Sunny’s doctor called us early the next morning to report the bad news, and I told her to stop. It was both a hard and an easy decision. Emotionally it was hard to say stop, but easy because it seemed the only reasonable decision, and the doctor readily assented.

What will stay in my mind in addition to the pleasure Sunny brought us in her relatively short life — she was always at our side or in our laps — was the doctor’s combination of sensitivity and telling the truth. There have been some important medical journal articles in recent months on the importance of restoring the ancient skill of prognosis, long in decline, to end-of-life care for people. Patients and families need to have some sense of what the future will bring, even if it is uncertain. They need to know the likelihood of death and also what may ensue if a very sick patient survives: what then? Our veterinarian said that if Sunny were lucky enough to make it she would likely remain in poor health, requiring considerable future medical care. Our doctors often fail to tell patients and families about just that disturbing likelihood. Seeing it well done by our vet underscored its value, for our pets and for us.

But my most telling glimpse into the human future came with the introduction of cost as an upfront consideration, something I believe will soon become common in our health care, perhaps even routine. For us, the $5,000 charge for Sunny’s care was bearable, but the prospect of the cost of successful treatment, had that been possible, would surely have given us pause. I am sure we would have said at some point that, financially, enough is enough, but I am not certain just when that might have been. I am convinced, however, that the future will force us to deal directly with the high, and in many cases insupportable, human costs of end-of-life care and to stop treatment for that reason. Sunny’s quick decline spared us that decision, which was a blessing in a way.

I was left with some troubling thoughts. Would it have been better if veterinarian medicine had not moved into the high-technology realm once reserved to humans? My wife and I both had dogs (and sometime cats) as we grew up. When they got sick they just died or were put down to save them from misery. I don’t recall anyone thinking that state of affairs was an evil. Are we better off now with that our pets have access to expensive, high-technology medicine — and are they? And how much better off are we as humans because of the way we now often die, sometimes lingering on for years, the beneficiaries, and sometimes victims, of a medicine equal to what our pets can now have? For me, those questions were left hanging in the air.

Daniel Callahan, cofounder and President Emeritus of The Hastings Center, is coeditor of the Health Care Cost Monitor. This essay originally appeared in Bioethics Forum.

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The Trial of “Death by Medicine”: An Interview with Lisa Krieger

On February 5, Lisa Krieger, a science and medicine writer for the Mercury News in San Jose, Ca, published a remarkably moving and insightful article about the protracted dying of her 88-year-old father. Suffering from advanced dementia he contracted septicemia, was admitted to the ICU of the Stanford Hospital, and then spent 10 days going miserably downhill. As Krieger put it, “The medical nightmare started, as they so often do, incrementally.”

While her father had made clear prior to his dementia that he wanted to die a “natural death,” what he got what he got was an unnatural “death by medicine,” as someone once put it. The total cost for the hospital stay alone was $323,000. Again and again Krieger had to make a decision about going on, as one crisis after another surfaced. With each new crisis, the doctors offered hope. There was, they said, “a decent chance we could turn it around.” They could not, and he finally died. But as the days moved along from one crisis after another, Krieger kept asking herself, Was it all worth it? “Should we have quit?” she wrote. And when?

I have come to think that the decisions about stopping life-sustaining treatments may have become harder, not easier, since the 1960s, when the reform movement was gaining momentum. Medicine has become increasingly skilled technologically in keeping the dying alive. Her father, Krieger noted, “thanks to modern medicine … lived decades longer than his father.” That same medicine gave him a miserable death. That is a dilemma of modern medicine we have yet to resolve.

I put some questions to Krieger, and here are her responses.

As you have reflected in the aftermath of your father’s death, what kind of advice might you now give to someone in a similar situation?

This is what I would have done differently: I would have asked for a road map. A plan. Even if it’s just a back-of-the-envelope flow chart. What are we doing, and why?

I would have asked earlier: “Where are we headed, with all this? What’s the view from 30,000 feet up? Let’s say he survives and makes it out these hospital doors. Then what?”

I wish someone had told me about the range of choices. Not just: “Do You Have a DNR? Treatment or not?” Rather: “We can do everything. Or we can do some things, but not others. Or we can do nothing, but keep him comfortable.” That conversation never happened.

I think it is possible to have a conversation about options in aggressive treatment and palliative care at the same time — early on, maybe upon entering the ER, or even when there is the initial dementia diagnosis. Not when things go south in the ICU. Because then you keep waiting for the perfect time to stop. There is no perfect time.

If at some point you should have forcefully said to the physicians, “Stop — no more,” how might we educate family members to learn how and when to say that?

I think people need to be told that stopping isn’t doing nothing. Stopping can be a gift. It’s a time to tell someone: “I love you and will always love you. Your memory – and what you’ve said and taught me – will live forever. I will tell my children, and they will tell their children.” You can’t say that if you’re busy fighting.

The hard part is getting the information you need to make that decision, so you can flick that emotional switch. I know doctors are busy. And their job is to diagnose and treat. They don’t want to offer a guess, or speculate, or peer into the future. But that’s what people desperately need, when the data-driven stuff isn’t helping.

I was so desperate for useful information. I buttonholed one ER doctor in a side hall. I found one ICU doc in the cafeteria. Fortunately, because I was living in dad’s ICU room, I could be part of the conversations when doctors were rounding. But I could tell that made them uneasy. I’ve got a biology degree and worked in hospitals before journalism, which helped a little. I really wanted to know where we were headed, some sort of prognosis.

This is what I needed to know: let’s just assume all this crazy treatment works – what does his future look like? Skilled nursing? What is long-term wound care like? How much pain and suffering will it entail? Will he be able to walk? What might his mental state be?

No one’s got a crystal ball, of course. But families need to know what they’re gunning for. So they can decide whether the end is worth the means.

Practically, how could that happen? In ER, I wish I had demanded some sort of ethics consult. (That’s admittedly a challenge: when someone’s crashing, there isn’t much time.) Maybe the ethicist would have given me the strength to say: “Even though we don’t have a precise diagnosis, this isn’t looking good. Maybe it’s OK to let him go, even without knowing everything.”

In the ICU, I could have used a neutral ombudsman to say something like: “Doctors will recommend a ventilator. This is why, and these are the implications.” Ditto for a feeding tube. Or: “Doctors will recommend surgery, and this is what that means for his future.”

I don’t expect doctors themselves to offer this interpretative stuff. They’re too busy saving lives. But families are clueless. Until we fix that, the default will always be to act.

I also think people might be more willing to quit if they didn’t fear guilt and second-guessing. There might be a cultural shift if more doctors simply said: “You did the right and merciful thing. It was hard, but you stepped up to the plate. For the rest of your life, you can be confident in the decision you made.”

A recent article noted that physicians do not want to die the way many of their patients do. Yet they will inspire hope with their patients even when they know better. How would you like physicians to talk with patients when it is clear families want hope — –bluntly, delicately, diplomatically?

Again, just information. Repeated as often as necessary. Because when you’re in shock, you’re not really hearing.

Maybe a good conversation-starter is the odds. (“This is a very tough one – in medical experience, only about X % of patients survive. Those that do survive face these challenges.” Something like that.)

Then describe what continued treatment would entail: “We can treat, but we want you to understand what further treatment will entail. Example. Example.” And what survival, in the remote chance it succeeds, would look like – from a quality of life perspective.

In word choice, there’s a way to shift the blame, and enable people to let go. Maybe saying, “Modern medicine is great, but it just isn’t good enough right now to fix this, no matter how hard we try. We’ve run out of good options. It’s just too tough a problem.” It takes it away from the right/wrong, try/quit, good/bad paradigm. It just means the tools weren’t up to the task. It’s like trying to dig a ditch with a pitchfork, and anyone will understand that.

Then describe what palliative care can provide – that it actually is doing something. That the loved one will not feel distress. That pain can be controlled. (I actually wonder how many people know what “palliative” means. It’s a pretty wonky term.)

And support the heck out of them. My readers said that doctors suddenly “abandoned ship” when they stop the rescue. They said they felt abandoned. And guilty. If we’re going to change the culture, we need to honor saying goodbye.

You article drew a large number of responses and was given a special section in a later Sunday edition of your paper. What was the range of responses, and did many of them report experiences similar to yours?

The response was stunning. My voicemail filled up instantly. I’ve gotten about 200 emails so far; some are pages long. It was as if people just wanted permission to talk about dying. I opened the door.

No one criticized me for letting go. Some blamed me for not quitting sooner. Almost everyone supported the decision to stop – then wanted to share their own experiences. 

What was amazing is that a lot of people could recount the precise details of long-ago deaths – and they’re still second-guessing themselves, decades later. There was a huge amount of guilt — believing they caused a loved one to suffer because of their choices.

It happens because people don’t have enough information, and support, to trust their decision.

Daniel Callahan is cofounder and president emeritus of The Hastings Center. His most recent book is Taming the Beloved Beast: How Medical Technology Costs are Destroying our Health Care System.

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Medicare Demonstration Projects: Not Ready for Prime Time

A Congressional Budget Office (CBO) report released last month brought discouraging news about the prospects for reducing Medicare costs by expanding Medicare demonstration projects – pilot efforts in disease management, coordination of care, and alternative payment systems.

The Affordable Care Act allows the Centers for Medicare and Medicaid to expand these projects on a national scale if they meet either of two standards: reduce costs while maintaining or improving quality of care, or improve quality of care without raising costs. The CBO report examined 10 major projects that have been independently evaluated and found that, by-and-large, they failed on both accounts.

Six out of ten demonstration projects focused on disease management and care coordination. They were designed to facilitate greater efficiency in care services for patients with particularly expensive chronic conditions. These projects utilized nurses and “care managers,” who were responsible for educating patients on caring for themselves at home and then following with up them.

These efforts were mostly ineffective at reducing hospital admission rates. For example, 19 out of 34 programs used in the demonstrations neither decreased nor increased hospital admissions by a substantial margin, defined as 5% or more.

The programs that were highly successful at lowering hospitals admissions shared one characteristic: care managers who had “significant in-person contact” with patients. However, these programs often failed to reduce costs sufficiently enough to offset the extra costs incurred to run them, such as paying for the care managers.

The other four demonstration projects employed value-based payments, alternatives to traditional fee-for-service systems that offer incentives – including physician bonuses — for improving the quality and efficiency of care rather than the number of services provided. But with one exception, these projects also failed to produce significant savings and had little impact on quality of care outcomes.

The one exception involved heart bypass surgery: lower rates for the surgery were negotiated by offering “bundled payments” to doctors and hospitals for all services associated with the surgery. This payment system reduced the cost of heart bypass surgery by approximately 10 percent.

The CBO report concludes with a list of several lessons we can glean from its analysis, such as “focus on transitions in care settings,” “use team-based care,” and “target interventions toward high-risk enrollees.” For instance, programs with the fewest hospital admissions tended to smooth transitions between primary care providers and specialists and target intervention methods such as chronic illness education, careful monitoring of health, and the encouragement of adhering to self-care procedures,] to patients who were at high risk for hospital admission.

The takeaway from the CBO report is that the Medicare demonstration projects need better ideas for maintaining quality while reducing health care costs before they can be used in a national scale. I wonder how much doctors, nurses, and other clinicians are consulted for their suggestions. Doctors such as Allan Ropper have expressed frustration with the disconnect between health reform and on-the-ground input from clinical workers. According to Ropper,

[F]ew published perspectives include the view from the factory floor. The usual platitudes of about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients.

Jim Sabin, who writes the blog Health Care Organizational Ethics, agrees. Among his three suggestions for what Medicare reform “really needs”, he writes:

Improvement-minded physicians, nurses, other health professionals, and administrators are the ones who know how to wring the waste, estimated to be as high as 30%, out of the care system. Competition won’t do it. Vouchers won’t do it. Only motivated health professionals can.

Cameron Waldman is a research assistant at The Hastings Center.

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Will Raising Taxes on the Wealthiest People Hurt the Economy? Probably Not

Warren Buffet has argued that the tax rates on the highest income earners should be increased because he pays a lower tax rate than his secretary. I agree that these tax rates should be increased, but not for the reasons that Mr. Buffet cites, which have mostly to do with the preferential tax rate on capital gains and dividends. Rather, I think that the taxes should be raised because these tax payers, myself included, have benefitted unfairly from the Bush tax cuts that were scheduled to expire at the end of 2010, and because increasing revenue is critical to achieving a balanced budget.

Republicans have staunchly refused to raise taxes, arguing that it will threaten our vulnerable economy. They believe that the highest income earners already pay a disproportionate share of our taxes – the top 5% of tax payers pay 59% of our federal income taxes – and to call on them to take on an even larger burden is unfair. Finally, since they want to shrink the size and scope of the government, they think that raising more revenues would be counterproductive. They would rather keep the pressure on spending reductions.

These latter two concerns are mostly a question of values and I don’t expect much, if any, reconciliation on this issue. But, the argument about economic growth is one that can and should be addressed.

The Republican position argues that a tax increase will diminish economic activity and a tax decrease will stimulate the economy, a claim first popularized by the economist Arthur Laffer. While I agree with this proposition in general, there is little to no evidence that it is true with respect to the tax rate on the highest income earners. For the not-mathematically-faint-of-heart, Peter Diamond and Emmanuel Saez argue persuasively that “Very high earnings should be subject to rising marginal tax rates and higher rates than current U.S. policy for top earners.” They suggest that a tax increase on the highest earners would not reduce economic activity.

I find the following chart of maximum tax rates and economic growth helpful in understanding how tax rates affect economic growth.

Source: Citizens for Justice

There was no noticeable effect on GDP when the top rate fell in the 1960s and 1980s, nor in the early 1990s when the top rate increased. Rather, I think that it is pretty clear from this chart that tax rates in this range have not had any effect on economic growth.

What about the assertion that a tax increase on high earners is going to disproportionately affect small business owners, who are the engines of job creation? The reality is that only 3% of business owners, regardless of the size of their companies, report earnings over $250,000. Furthermore, the average tax rate that they pay is only 20%. Are we really to believe that small businesses are going to close up the shop to avoid a couple more percent in taxes? The facts simply don’t support the assertion.

This country faces a serious budget crisis over the next decade. While progress must come from the spending side, most importantly in Medicare and Medicaid, it is delusional to think that we can prevent our debt from growing to dangerous levels without increasing revenues. It is time for the members of Congress to break ranks with their extreme factions and do the right thing for the country.

Frank Trainer, the former director of fixed income at Sanford C. Bernstein & Co., Inc., is a member of the Board of Directors of The Hastings Center.

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Global Competitiveness: How Other Countries Win

Republicans have long championed global competitiveness as an important political and economic goal, and the power of market competition as the royal road to get there. But, as two recent studies show, right under our noses are two little-noted facts that tell against that belief, most relevantly in the health reform debate.

One of them is that, by well-accepted standards of international economic competitiveness, every country that does best is also one that has both strong government-run or regulated universal health care systems and comprehensive welfare policies. The one exception to that pattern is the United States. The other fact is that nowhere in the world is there a health care system that controls costs by letting the market have its head.

The September release of the Global Competitiveness Report of the World Economic Forum for 2011–2012 (noted for its annual meeting in Davos), tells the competitiveness story. That report ranks the countries of the world for their competitiveness. Save for the U.S., every one of the top 10 are countries that have just those social policies most despised by American conservatives: Switzerland is first, followed by Sweden, Singapore, Finland, Germany, Denmark, the Netherlands, Japan, and the U.K. The U.S., once ranked first, has now dropped to fifth place. In addition to universal health care programs, the countries that rank highest for global competitiveness have notably strong social and welfare programs.

A recent study in the BMJ Quality and Safety, coauthored by one of us (Elizabeth H. Bradley), showed that the average ratio of social services to health care spending among most industrialized countries is 2:1, compared with 0:9 here. Social spending includes expenditures on housing, employment training, unemployment benefits, old age assistance, social security, and family support services. Furthermore, the countries with a higher ratio of social to health expenditures get better health outcomes, notably higher life expectancies and lower infant and maternal mortality rates. The evidence seems undeniable: good welfare policies produce healthier populations. 

Moreover, to rub it in a bit, those countries have much higher rates of personal taxation than our country, leading to a larger portion of their GDP going to government expenditures in (e.g., in 2008, 47.1 percent for Sweden vs. 26.9 percent for the U.S., and close to 50 percent for many of the other countries).

Representative Paul Ryan has become the Republican leader in singing the praises of competition in health care and the cutting of taxes. His latest foray in late September, following an earlier push for turning the Medicare program into a “premium support” plan – a variant in name only of government vouchers to purchase care – is a move well beyond Medicare reform. Taking up an idea once pushed by Senator John McCain, Ryan would eliminate tax breaks for employers who pay for their employee’s health care. Employer health care now covers some 60 percent of American workers. The net result would put the Medicare program and most other health care spending directly in the hands of consumers as supposedly savvy shoppers and insurance companies as competitive cost cutters.

It is a good thing he did not use the present competition of American insurers as an example of the power of choice and competition to lower costs. The Kaiser Family Foundation annual study of employer-sponsored health care found a 9 percent increase in family premiums for 2011, only 1 percent to 2 percent of which could traced to the addition of an increased age for young adults to stay on their parent’s insurance policies. The insurers are already competitive but they are also highly ineffective in keeping their prices down (not helped by the underlying costs of an expensive system).

Anyone who has recently priced health insurance plans can not fail to note how little they differ in offering similar benefits for comparable prices. The Federal Employees Health Benefit program, offering over 100 competitive insurer choices to government employees, while it saw a rare 3.8 increase last year in average premium costs, has historically been in the 7 percent annual cost increase range, and sometimes much higher.

More broadly, it is just about impossible to find more than a few examples anywhere in the world where competition has effectively controlled health care costs and generated better outcomes.

The only example market supporters can offer of late is the Medicare part D program for drugs. Competition has worked there, but considerably helped by the relative ease in effectively pressuring drug manufacturers to lower their prices, as can be seen in the great variations in drug prices for the same drug in different countries. And in any case controlling the costs of drugs, a single medical commodity, is a long way from controlling insurance company prices for entire health care systems.

The International Monetary Fund tried competition in developing countries in the 1980s and 1990s and failed. In 2006 the Netherlands led the way in Europe by enhancing the competition of insurance companies to better manage annual cost increases. That policy has also failed.

Most distressing, we continue to spend valuable time and political capital on jiggering the health care system to be more efficient and of higher quality. Many social programs are already languishing or targeted for budget cuts. Creative ideas about reforms of those programs are pushed aside and, ironically, even threatened by an increased focus on health care. A bypassing of social programs and a faith in competition as a cost-reducing, quality-enhancing, strategy is a mixture designed for failure. Health care itself will be hurt as will millions of Americans.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is President Emeritus of The Hastings Center and the co-author of Medicine and the Market: Equity v. Choice. Elizabeth H. Bradley is a professor of public health at Yale School of Public Health and the director of the Yale Global Health Initiative.

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How AARP Can Help, Not Harm

Two recent news items caught my attention, both of which left me wondering what the originators of them could have in mind. One of them was the announcement that Prime Minister Papendreou was calling a national referendum on whether Greece should accept the harsh conditions laid down by the other E.U. nations to deal with that country’s debt problem. The other was a political ad by the AARP calling for a rejection of any cuts to the Medicare and Social Security programs, as part of the U.S. deficit/debt crisis.

They both raised a similar question in my mind: was this a crafty move on their part, knowing they will lose, to simply strengthen their negotiating position? Mr. Papandreou surely knows from the recent Greek riots that a referendum is likely to come out against the E.U, just as the AARP must know that Medicare must be cut, an unpopular move or not.

I will leave the divining of Mr. Panandreou’s motives to E.U. savants, and focus on the AARP. Its leaders can read the papers and economic forecasts as well as anyone else, so what are they up to? To be sure, no government program threatened with a loss of money is happy about that: the common response is to point out all the harms that will result, most of them probably accurate. They then rally supporters, asking them to protest, to write to their congressman, and to rally their constituents to stand firm.

Sometimes these tactics work, but in this case they should not prevail. Even before the deficit/debt problem came to the fore, provoked in part by the recession, it was well known that Medicare would eventually be in big trouble. A combination of the retirement of the baby boom generation and steadily rising health care costs would guarantee that result. The Social Security program has a longer projected period of solvency and that period could be extended in relatively painless ways, such as raising the age of entitlement. But there are few painless possibilities for Medicare, and one would have to be more than a little crazy to take any such ideas with that as its aim seriously.

AARP should not oppose cuts. That is at least foolish and at worst a gross appeal to the elderly to put their interests before other groups and the economic welfare of the country.

Here’s what I suggest they do instead. First, work out a plan for benefit cuts that would make a serious budgetary difference, not just a gentle bending of the cost curve. Make use of direct cuts, cost-effectiveness (not just comparative effectiveness) guidelines, increased means testing, eligibility changes, and a tolerable degree of out-of-pocket copayments and deductibles.

Second, propose a range of comparable cuts to providers, physicians and hospitals most importantly. Doctors would make less, hospitals would make less, and pharmaceutical and device manufacturer would be paid less. Providers in general should feel the pinch equal to that of Medicare beneficiaries.

Third, an overriding aim of this effort would be to go directly after the background costs of American health care. Medicare is expensive because it is embedded in an expensive health care system—which means that Medicare can only be sustainable in the long run if the system as a whole is. The overall point of a revised AARP campaign would be to fight for fairness: the elderly are prepared to take their lumps as long as the lumps for everyone else are just. We are all in this together.

Daniel Callahan is President Emeritus of The Hastings Center and coeditor of the Health Care Cost Monitor He is author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

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An Ounce of Prevention: Controlling the Diabetes Epidemic

Epidemics used to be infectious, sweeping across cities and nations, immediately producing violent symptoms in their victims, and often followed promptly by death. They instilled fear in the public and the urgent need for a solution would be unanimous, unquestionably a public health priority. Modern epidemics, on the other hand, tend to be noninfectious and often sneak up slowly. Their symptoms may be mild for years and persist through old age, redefined as “chronic conditions,” until they finally kill their victims. Their incidence and fatality are often preventable.

One such epidemic is diabetes. It’s been creeping up on us for over two decades, and yet any sense of urgency in quashing it is still minimal, although it is growing. Diabetes is the seventh leading cause of death, costing billions of dollars a year, with no sign of slowing down and no sign of a cure. It poses a particular challenge in a time when cuts in health care costs are needed: should it be made an exception to the necessity of cuts in general?

Approximately 19 million Americans are diagnosed with diabetes and nearly 79 million adults are prediabetic, meaning that they have blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetic. The annual cost of diabetes is over $218 billion. The American Diabetes Association projects that the cost of diabetes and the number of people with the disease will at least double over the next 25 years.

Obesity, Aging, and Longevity

The diabetes epidemic parallels the obesity epidemic: 90% to 95% of cases of diabetes are type 2, which is caused partly by obesity. About 80% of type 2 diabetes patients are overweight or obese. Experts identify obesity and type 2 diabetes as two of the greatest public health problems of the coming decades in the U.S. and globally.

The prevalence of diabetes also increases with age, and the U.S. population is aging. But it is on the rise among young people, as well, mainly because of obesity.

Until the mid 1990s, children and adolescents rarely developed type 2 diabetes, which had been call “adult-onset” diabetes. Today, the Centers for Disease Control and Prevention estimates that type 2 diabetes is diagnosed in 3,700 children annually. Furthermore, a recent study found that the prevalence of prediabetes is almost 30% among overweight and obese children in high-risk communities across the nation. “High-risk” refers to groups that are disproportionately affected by diabetes, including Hispanics, blacks, and Native Americans. 

The diabetes epidemic is also, in a sense, a reward for effective treatment. People are living longer than ever with diabetes in large part because improved treatments. As the disease progresses, however, patients often need additional medications and increased dosages to keep their blood sugar within safe ranges. They also develop complications. Diabetes is responsible for more cases of blindness, renal failure, and amputations than any other disease and increases the risk for cardiovascular disease and stroke by two– to fourfold. 

Opportunities for Savings

Comparative effectiveness research at Johns Hopkins determined that metformin, a generic drug that has been around for more than 15 years, is as effective for reducing blood sugar levels as newer drugs, has fewer side effects, and is the cheapest oral medication (35 cents per pill, compared with as much as $6.42 per pill for newer drugs).

Nevertheless, the most significant savings lies in prevention. Type 2 diabetes is largely preventable. The Diabetes Prevention Program, the largest and most diverse prevention trial to date, compared the cost-effectiveness of the metformin and lifestyle intervention in preventing prediabetic adults from developing type 2 diabetes or delaying onset. Lifestyle intervention proved to be the most effective means of preventing diabetes, reducing onset by 58%. Metformin reduced onset by 31%. Researchers determined that the cost of lifestyle intervention implemented in routine clinical practice would be $13,200 per case of diabetes delayed or prevented over three years – a savings of $1,100 compared to medical intervention.

Last January, a study published in Diabetes Care found that 24 million of America’s prediabetics might benefit from pharmacological treatment (in addition to lifestyle modification) to prevent or delay development of diabetes. According to the study, the cost of 24 million new prescriptions of metformin, at current generic rates, would be about $1.15 billion per year, plus related medical expenses such as doctor’s visits and laboratory tests. 

That’s a lot of money, but it’s worth it in the long run. Though other modern epidemics, like cancer and cardiovascular disease, continue to surpass diabetes as the leading causes of death in the U.S., their incidences are on the decline, while the incidence of diabetes is on the rise. The diabetes epidemic is set to hit future generations harder than ever. Experts predict that today’s children could be the first generation to have shorter and less healthy lives than their parents.

In the midst of the economic crisis in health care it may seem implausible to increase health care spending to cover the upfront costs of diabetes prevention such as screening, treating prediabetics, and reducing obesity. The cost of prevention will be substantial, but the nature of the diabetes epidemic warrants this sort of investment because the future, if left to follow the current path, is sure to exceed the cost of prevention by far.

Brittany Rush is a former Hastings Center visiting scholar.

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The Medicare Trap: Can the Supercommittee’s Cuts Be Fair?

One way or another, the costs of the Medicare program must be cut. That likelihood can of course be averted in part by raising taxes, means testing, increasing copayments and deductibles, and raising the age of eligibility for benefits.

Given the political climate, a significant tax increase is not likely, and even the other possibilities are not likely going to be sufficient. That most dreaded option, by Democrats and Republicans alike, a direct cut in benefits, will be necessary. Can it be done equitably, with everyone sharing the burden in a fair way?

My straight answer is: probably not. The best that might be achieved will be to keep the inequity at a low, tolerable level – that is, insofar as one can speak of what sounds like an oxymoron, a fair inequity. The reasons for that outcome are not hard to find. All major actors in health care have good reasons – in their own eyes – why cuts should not be visited on them, and many of them are engaging in a form of hostage-taking to show the dangers of tampering with their reimbursements or benefits.

Doctors don’t want their Medicare or Medicaid reimbursements cut and threaten that they will stop taking patients in those programs if that happens. That threat has been successful every year for many years in persuading Congress to set aside its long-standing mandate for annual reductions in reimbursements.

Hospitals are no less receptive. Their threat is more indirect: we will not be able to handle the costs of caring for patients, already a problem for many hospitals on the margins of financial solvency.

The elderly and the public by a large majority, as shown consistently by public opinion surveys over a long period of time, do not want benefit cuts (and aren’t enthusiastic about higher taxes either). The implicit threat message to politicians is that they will not be reelected if they go after Medicare. And the elderly of course do not want cuts because they have paid their taxes over the years for it and feel entitled to Medicare benefits.

Even now what they get is often not enough. The elderly spend an average of between $3000 and $10,000 out of pocket a year, many being forced into bankruptcy. The theoretical, even high probability, danger that Medicare itself may eventually be destroyed if costs are not controlled does not have the nasty bite of benefit cuts, which will hurt current Medicare beneficiaries immediately and personally.

Equity would require that each of the affected groups, patients and providers alike, be burdened more or less simultaneously and in ways that, if not perfect, at least does not lead to outrage and a gross sense of unfairness. Why are they picking on us and not everyone else? That would be a reasonable question to ask if some were obviously hit harder than others. Even so, a kind of putative equality – everyone gets cut equally – does not obviate the possibility, even likelihood, that some groups will have greater problems than others in bearing the burden.

If the supercommittee of 12 cannot come to a consensus on balancing tax increases and benefit cuts, that will automatically trigger an across-the-board 2% reduction a year in Medicare payments. That kind of flat cutting, however the cuts will be calculated, is hardly likely to have the nuance necessary to get an equitable balance.

My solution: a parallel private committee, put together at once and bringing representatives of the major groups together, should be organized by one of the health care foundations or the Institute of Medicine. The supercommittee has to make its recommendations, or failure to agree, known by November 23. The parallel committee should have its work done by mid-to-late October to get its findings before the supercommittee while the latter still has time to act on its findings. The charge to the parallel committee should be straightforward: see if you can work out a fair plan to achieve some reasonable agreement on the equitable sharing of the cost burden.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

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The Fallacy of “The Real Problem is …”

It is time to recognize a new fallacy, maybe not a logical fallacy up there with the ad hominem argument but surely, I believe, a political one. It might be termed “the real problem” fallacy. I first thought of it years ago when I told people I was interested in working on ethical and policy problems of medicine, even starting a research center on that topic. “But how can you justify focusing on that,” one person responded almost indignantly, “when the real problem is the proliferation of nuclear weapons?” Another said with identical language that “the real problem” is “the Israeli-Arab conflict.” Well, maybe so, but we just ignored them.

Then, many years later, closer to my own field, Christine Cassel wrote in her 2005 book, Medicare Matters, that “rationing appears unjustifiable when there are abundant opportunities to economize by improving efficiency and effectiveness in the health care system.” Just this year, Judith Feder, a professor at the Georgetown Public Policy Institute, said that it was wrong to focus on entitlement reform when “the problem is overall health care spending.” And so on: the real problem, a chorus of discordant cost control voices cry out, with Medicare is fee-for-service medicine, or background costs, or great regional variations in cost, or commercialized American medicine; or excessive use of technology. 

Actually, one of them may indeed be the real problem (and my vote would go to the underlying costs of the system), but then why do I call it a fallacy? Its implication is that we have to solve a long-term underlying problem before we take on another one here and now before our eyes. Medicare has a critical cost problem right in front of us. We cannot wait until the almost intractable 50-year-year-old problem of waste and inefficiency has been vanquished. And we can hardly put off entitlement reform until we have done away with “excessive overall spending,” which could take generation or more to achieve, if at all.

Our health care system can be likened to a large and ailing schooner at sea in a storm. The wooden hull is rotting, dangerously taking on water, the weight of which is making the sails ineffective. The sails, as it turns out, are in shreds and must be repaired if the ship is to make it to port where the hull can be repaired. But patching the hull requires that men who should be working on the sails must have the boat stopped so they can swim under the hull to do the necessary work. Meanwhile, it is rumored that the nearest port may not be able to fix hulls or provide new sails – but that a much farther port, dangerously far, is well– equipped to do so. The consensus of the crew is that the real problem is the company that made such a boat, with a poor hull and bad sails; it should be sued.

The captain responds that the crew may well be right, but that is beside the point: the boat is sinking. Medicare is no less sinking. Whatever the underlying real problems, its reform must be begin at once, and by the most direct means possible (no falling back on bending the curve): cutting benefits and raising taxes.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

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Cost: News and Commentary

In Defense of the IPAB

The independent payment review board has been criticized for being a rationing tool, a form of “central planning” that will misappropriate funds, and even a death sentence to our health care system. Jonathan Cohn, in The Health Care Blog, praises it as a way to reduce spending and manage care more efficiently, partly by shifting decision-making power from lobbyists to scientists. The program is not perfect, he writes, and could be improved. At the very least, the dialogue around the IPAB should focus on how to develop it, not whether or not to eliminate it.

Physicians’ Role in Cost Control

James Rickert, an orthopedic surgeon, calls for physicians to make some sacrifices to help mitigate the increasing health care costs. Writing in the Health Affairs blog, he says that physicians, especially specialists, must be willing to take cuts in their income. Doctors are more knowledgeable about which types of treatments are most necessary and cost-effective, and they need to get more involved in these types of decisions. 

Pennywise and Pound Foolish?

It makes sense: cutting spending is the way to cut costs and provide long-term stability to budgets. But Joe Flower, writing in The Health Care Blog, argues that decreasing spending doesn’t always improve the bottom line, and often increases costs. He calls for reducing health care costs by improving efficiency across the board and eliminating unnecessary procedures, treatments, and tests.

Cost Control Trends

Six leading policy and industry experts weigh in on the most interesting ideas for cutting back on health costs. Some recent models include vigorous consolidation, better coordination of care, new financial arrangements among health care providers, and greater use of medical data to identify practices that lower costs.

Michael Gallinari is an intern at The Hastings Center.

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