Comments on: Ending the Cost Insanity: Some First Steps http://healthcarecostmonitor.thehastingscenter.org/henryaarron/ending-the-cost-insanity-some-first-steps/ Commentary and opinion on cost control as part of health care reform from The Hastings Center Thu, 08 Jul 2010 20:41:05 -0400 hourly 1 By: Geri Rodin http://healthcarecostmonitor.thehastingscenter.org/henryaarron/ending-the-cost-insanity-some-first-steps/comment-page-1/#comment-49 Geri Rodin Tue, 08 Sep 2009 11:41:24 +0000 Iun5ouFM3BGv7mqM8ivLAg_37c8b124a88e266a2341e43fd62fc961#comment-49 We "had" a great friend, late 80's who was so terribly ill there was just nothing that could be done. He was finally on life support. He had suffered great pain for over 10 years. When the doctors asked he and his wife if they should keep him on life support, he turned he head to his wife and said he would prefer to die. She agreed with HIS decision, and after 2-3 minutes of removing the life support, he passed away. He now is out of his ever lasting pain at this choice. My husband and I have living wills that issue these same signed statements. This is a very tough decision for many to make. This article was extremely pointed in making clear many of the problems of the doctors today in these cases. We “had” a great friend, late 80’s who was so terribly ill there was just nothing that could be done. He was finally on life support. He had suffered great pain for over 10 years. When the doctors asked he and his wife if they should keep him on life support, he turned he head to his wife and said he would prefer to die. She agreed with HIS decision, and after 2-3 minutes of removing the life support, he passed away. He now is out of his ever lasting pain at this choice.
My husband and I have living wills that issue these same signed statements. This is a very tough decision for many to make.

This article was extremely pointed in making clear many of the problems of the doctors today in these cases.

]]> By: M http://healthcarecostmonitor.thehastingscenter.org/henryaarron/ending-the-cost-insanity-some-first-steps/comment-page-1/#comment-48 M Fri, 19 Jun 2009 03:46:26 +0000 Iun5ouFM3BGv7mqM8ivLAg_37c8b124a88e266a2341e43fd62fc961#comment-48 I appreciated this article and agree with Isaac above on #6. I witness, nearly every day, the covert and overt threats from patients and families demanding various forms of intervention that are not likely to work to meet the patient and family's goals. I spend hours with these patients and families educating about the prognosis of terminal conditions to try to help them understand what is controllable with medical intervention and what is not. Bottom line is that when it comes to facing death, many, many people are not ready to do it and would rather hide behind the demand for the 4th opinion or the continuation of multiple intensive treatment modalities that every physician taking care of the patient will readily admit cannot change the patient's outcome. This is a substantial element of the spending problem- more than 25% of medicare dollars are spent in the last year of life. The number escalates exponentially as death approaches, as the system throws "all it's got" at the patient. At least in my environment, it is not about the greed of the physician wanting to continue to victimize the patient who does not want the intervention- the MUCH more common scenario is that the physicians feel held hostage by the threat of lawsuit if they put a foot down to say that putting a 98 year old, non-verbal, contracted dementia patient, or a 52 year old cachectic stage 4 non-small cell lung cancer patient who has failed multiple chemo regimens prior through repeated hospitalizations and ICU care/life support/code blue is actually poor quality medical care that is not the standard of care and will not be provided. The pendulum of autonomy has got to swing back a bit from the extreme place where it is now, lest the principles of justice and non-malfesience continue to be neglected. It must be a societal agreement, though, that we as a society cannot and should not demand low value interventions just to maintain the entitlement of American immortality, to "get all we can" out of the system, or to try to put off the tough, sad and trajic realities for one more day, week, month. There is a lot of data out there already about efficacy of some interventions- code blue data in the frail elder, the stage 4 cancer patient, and the multiply co-morbid hospitalized patient as a start. Physicians need to be able to make decisions about appropriate or innappropriate interventions based on the evidence, with support from the system at large that if they are following the standard of care they will not pay the astronomical personal and financial price of being named in a lawsuit if that decision makes the patient/ family angry. Until the system adjusts in this way, physicians will not take the risk of actually practicing evidence based medicine, behavior is not likely to change, and the treatment demands of patients and families who do not have medical licenses will continue to drive the system. It's not the whole answer, but in my world as a physician it is what we see happening. It's not a philosophical argument about an abstract concept, it is a physical reality in any ICU that any policy maker could walk into today to see for themselves. I appreciated this article and agree with Isaac above on #6. I witness, nearly every day, the covert and overt threats from patients and families demanding various forms of intervention that are not likely to work to meet the patient and family’s goals. I spend hours with these patients and families educating about the prognosis of terminal conditions to try to help them understand what is controllable with medical intervention and what is not. Bottom line is that when it comes to facing death, many, many people are not ready to do it and would rather hide behind the demand for the 4th opinion or the continuation of multiple intensive treatment modalities that every physician taking care of the patient will readily admit cannot change the patient’s outcome. This is a substantial element of the spending problem- more than 25% of medicare dollars are spent in the last year of life. The number escalates exponentially as death approaches, as the system throws “all it’s got” at the patient. At least in my environment, it is not about the greed of the physician wanting to continue to victimize the patient who does not want the intervention- the MUCH more common scenario is that the physicians feel held hostage by the threat of lawsuit if they put a foot down to say that putting a 98 year old, non-verbal, contracted dementia patient, or a 52 year old cachectic stage 4 non-small cell lung cancer patient who has failed multiple chemo regimens prior through repeated hospitalizations and ICU care/life support/code blue is actually poor quality medical care that is not the standard of care and will not be provided. The pendulum of autonomy has got to swing back a bit from the extreme place where it is now, lest the principles of justice and non-malfesience continue to be neglected. It must be a societal agreement, though, that we as a society cannot and should not demand low value interventions just to maintain the entitlement of American immortality, to “get all we can” out of the system, or to try to put off the tough, sad and trajic realities for one more day, week, month. There is a lot of data out there already about efficacy of some interventions- code blue data in the frail elder, the stage 4 cancer patient, and the multiply co-morbid hospitalized patient as a start. Physicians need to be able to make decisions about appropriate or innappropriate interventions based on the evidence, with support from the system at large that if they are following the standard of care they will not pay the astronomical personal and financial price of being named in a lawsuit if that decision makes the patient/ family angry. Until the system adjusts in this way, physicians will not take the risk of actually practicing evidence based medicine, behavior is not likely to change, and the treatment demands of patients and families who do not have medical licenses will continue to drive the system. It’s not the whole answer, but in my world as a physician it is what we see happening. It’s not a philosophical argument about an abstract concept, it is a physical reality in any ICU that any policy maker could walk into today to see for themselves.

]]> By: Isaac http://healthcarecostmonitor.thehastingscenter.org/henryaarron/ending-the-cost-insanity-some-first-steps/comment-page-1/#comment-47 Isaac Wed, 03 Jun 2009 02:19:35 +0000 Iun5ouFM3BGv7mqM8ivLAg_37c8b124a88e266a2341e43fd62fc961#comment-47 What's the use but here goes .... people in the medical business know how to trim spending. Wee need a surgical approach, not some broad "cookie-cutter" approach. 1. Start with the most egregious wasters ... publicly funded prescription drug seekers and drug traffickers. 2. Reduce abuse of the system such as colds and non emergency conditions in the ER. 3. No public health funds for illegals ... unless emergency 4. discourage poly-pharmacy by the doctors .. some patients are on 20 different meds 5. require a co-pay for care, if only 5 dollars. 6. Tort reform .... billions are spent each year on useless tests just to CYA... "cover our ass". 7. decrease use of antibiotics, another CYA, for viral conditions. 8. Increase REAL health education in schools. Make sure that while we are teaching kids to put condoms on bananas, we also teach them the difference between viruses and bacteria, basic and even advanced first aid, and some common-sense anatomy and physiology, wound cleaning, hygiene, etc. What’s the use but here goes …. people in the medical business know how to trim spending.
Wee need a surgical approach, not some broad “cookie-cutter” approach.
1. Start with the most egregious wasters … publicly funded prescription drug seekers and drug traffickers.

2. Reduce abuse of the system such as colds and non emergency conditions in the ER.

3. No public health funds for illegals … unless emergency

4. discourage poly-pharmacy by the doctors .. some patients are on 20 different meds

5. require a co-pay for care, if only 5 dollars.

6. Tort reform …. billions are spent each year on useless tests just to CYA… “cover our ass”.

7. decrease use of antibiotics, another CYA, for viral conditions.

8. Increase REAL health education in schools. Make sure that while we are teaching kids to put condoms on bananas, we also teach them the difference between viruses and bacteria, basic and even advanced first aid, and some common-sense anatomy and physiology, wound cleaning, hygiene, etc.

]]> By: Paul Hochfeld http://healthcarecostmonitor.thehastingscenter.org/henryaarron/ending-the-cost-insanity-some-first-steps/comment-page-1/#comment-46 Paul Hochfeld Thu, 21 May 2009 07:40:27 +0000 Iun5ouFM3BGv7mqM8ivLAg_37c8b124a88e266a2341e43fd62fc961#comment-46 Thanks for your insightful article. I have arrived at the same conclusion. For me single payer isn't so much about the savings that arise from getting rid of the insurance companies as having linkage between the entity that collects the money and the entity that has the responsibility/authority to control the costs. Insurance companies can only raise premiums (by 50% over the last three years) and deny claims (which they can fairly be accused of doing in the name of profits). If the single payer came to us three years in a row with double digit increases in our health tax, we would stay "No way! You gotta control costs." Then, and only then, will difficult decisions be made. This isn't about health care. This is about the broken political process in which The Industry manipulates the public process in order to craft public policy to sustain their profits. We aren't going to accomplish anything substantive until we get campaign finance reform. Instead we will get "reform" that is more of the same. Thanks for your insightful article. I have arrived at the same conclusion. For me single payer isn’t so much about the savings that arise from getting rid of the insurance companies as having linkage between the entity that collects the money and the entity that has the responsibility/authority to control the costs. Insurance companies can only raise premiums (by 50% over the last three years) and deny claims (which they can fairly be accused of doing in the name of profits). If the single payer came to us three years in a row with double digit increases in our health tax, we would stay “No way! You gotta control costs.” Then, and only then, will difficult decisions be made.

This isn’t about health care. This is about the broken political process in which The Industry manipulates the public process in order to craft public policy to sustain their profits. We aren’t going to accomplish anything substantive until we get campaign finance reform. Instead we will get “reform” that is more of the same.

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