A quandry involving Medi-Cal, going from paying badly to not at all

[Nathans_Dad]

Originally Posted by Moses

Obama's grandmother was terminally ill with cancer when she got a total hip replacement. She died 2 weeks later. Medicare paid the bill. She didn't get special treatment because of Obama, absurdities like this happen every day.

Tell me about it. Just a few months ago a woman was brought into the ER with terminal cancer. Family brings her in because she fainted. Turns out her pulse was in the 20s. Family insists that everything be done, cardiology puts in a pacermaker to the tune of $80k, lady dies 3 days later.

Your medicare dollars at work.

The latest gem from medicare is that patients and families can dispute their discharge from the hospital. If they think they just aren't ready to go home, they get 48 hours to stay AFTER the doctor discharges them so medicare can review the chart and decide if they really should go home or not.

And these are the clowns who want to run national healthcare...

[mikester]

Originally Posted by tabs

There will be rationing of health care, if you are sick and old they will say sorry you are old and sick and not worth saving. As your productive life is over. You want someone to tell you that?

The cost of new medical technology is high...in the old days the doc used to tell ya take an asprin and if your still alive call me in 2 weeks. That was cost effective.

Ben Franklin said 250 years ago that 9 out of 10 men kill themselves in one way or another...eating, drinking, smoking, not taking care of themselves or just plain risky behavior...so what has changed in 250 years?

Hmmm a practice here or a practice there...Hmmm what a decsion to make...Obama is gona be saying to you..."You work for me now!"

The Doctors on this thread have already eluded to the fact that this SHOULD to some extent happen.

You're 80, terminal and need a hip replacement.

Sorry...

[Noah930]

Originally Posted by jyl

"Don't let them ration healthcare" is a argument that I hear a lot. But it sounds like some sort of cost-benefit analysis may indeed be needed, from what I'm reading here. If so, how can this be made politically feasible, and how can it be implemented? Who decides what treatment will be paid for, and how it is decided? Or can you do it through purely economic means (e.g. some sort of lifetime cap on benefits per person)?

Take a look at your own state. Oregon Health Plan (OHP) caps all sorts of treatment. Some conditions are covered, and others are not. If you've got that problem, and you're on OHP, you're SOL.

Aside: I remember when one indignant patient exclaimed to the secretary: "I've got great insurance! I've got OHP!" I didn't say it, but thought to myself, that's like saying: "I've got a great job. It's called unemployment."

[Noah930]

Originally Posted by mikester

The Doctors on this thread have already eluded to the fact that this SHOULD to some extent happen.

You're 80, terminal and need a hip replacement.

Sorry...

Yes and no. You want a hip replacement (in that type of scenario) on government dime? You're SOL. You want a hip replacement and you've got private funds or private insurance to cover it? Then you're in business.

[Tobra]

Originally Posted by Moses

I practice in San Ramon, California, basking in the glow of his gracious magnificence; Howard Sokoloff, DPM

having met the guy on numerous occasions, that is pretty funny

Originally Posted by jyl

"Don't let them ration healthcare" is a argument that I hear a lot. But it sounds like some sort of cost-benefit analysis may indeed be needed, from what I'm reading here. If so, how can this be made politically feasible, and how can it be implemented? Who decides what treatment will be paid for, and how it is decided? Or can you do it through purely economic means (e.g. some sort of lifetime cap on benefits per person)?

there is no politically feasible way to do this, big reason why nothing ever happens

I remember when they first started talking about this in Oregon. There were people protesting in front of the hospital in Salem, Oregon. I recall when later, that OHP deal published their list, ranking diagnoses, at the end of the list was baby born without a brain.

[Moses]

Originally Posted by Tobra

having met the guy on numerous occasions, that is pretty funny

He is actually a terrific guy. Very talented surgeon. We're lucky to have him in our medical community. He is pretty east coast, though.

[Pazuzu]

Originally Posted by Nathans_Dad

Tell me about it. Just a few months ago a woman was brought into the ER with terminal cancer. Family brings her in because she fainted. Turns out her pulse was in the 20s. Family insists that everything be done, cardiology puts in a pacermaker to the tune of $80k, lady dies 3 days later.

I might have missed your point...would you have had it any other way? I can see a doctor fighting a hip replacement, but not fighting a pacemaker, or fighting a machine to help someone with a 20bpm pulse.

[Nathans_Dad]

Yes, I would have had it completely the opposite way.

The woman had terminal cancer. She was going to die from it. Putting in a pacemaker to extend her life of being in pain and bedbound not only makes no sense from a money perspective, it makes no sense from an ethical perspective.

Unfortunately, our medical system is driven by the patient/family. If the family wants everything done, despite the fact the doctors disagree, then everything gets done.

This woman should have been made comfortable and allowed to die. Instead we subjected her to an invasive procedure and a 3 day ICU stay with multiple blood tests and such.

Get it now?

[jyl]

Moses and the other docs here have explained, I think, that the large majority of a person's lifetime healthcare expense comes in the last year of life.

Can you docs think of some reasonable and workable restrictions that Medicare can put on treatment to avoid unwarranted healthcare procedures in the last year of life? Something like no (or only partial) payment for drugs costing more than X if clinical trials shows less than Y months' increase in life expectancy, no (or only partial) reimbursement for procedures costing more than X if the person is not expected to live more than Y months, etc? (Assuming the patient would be free to buy private insurance with no such restrictions, or to pay out of pocket.)

I'm thinking of rules that would be clear enough that all the discretion, and all the burden, wouldn't be dumped on the shoulders of the doctor on the spot who is facing the patient and family.

Of course, there is the issue of whether something like this could be sold to the voters. But surely the first issue is whether workable rules can be written in the first place.

[Porsche-O-Phile]

Originally Posted by mikester

The Doctors on this thread have already eluded to the fact that this SHOULD to some extent happen.

You're 80, terminal and need a hip replacement.

Sorry...

The problem with this is then insurers will be classifying everyone (or certainly more people than should be) as "terminal" in order to avoid paying out on treatments that really would help their quality of life, which is what medicine is supposed to be about.

There's no easy/quick fix to this. The problem is very complex and made worse by the fact that there's so much greed and money tied up in it now - there used to be a time when doctors simply did what they could in order to help people. Now big business has gotten into the mix with its predictable greed, lawyers, procedures, bean counters and other baggage, which has complicated things enormously.

[einreb]

Originally Posted by Nathans_Dad

Tell me about it. Just a few months ago a woman was brought into the ER with terminal cancer. Family brings her in because she fainted. Turns out her pulse was in the 20s. Family insists that everything be done, cardiology puts in a pacermaker to the tune of $80k, lady dies 3 days later.

er doc buddy of mine gets this all the time. 'grandma' has congestive heart failure, etc, etc... family wants 'no expense spared'... break all her ribs to restart the heart, run all sorts of tests, etc. no money to pay for it... grandma dies in a few days anyway.

The er/primary care thing is a wild cultural issue. One kid has the flu, so they go to the er, while they are there... whole family gets checked out for various 'ailments'.

[sjf911]

Originally Posted by jyl

Moses and the other docs here have explained, I think, that the large majority of a person's lifetime healthcare expense comes in the last year of life.

Can you docs think of some reasonable and workable restrictions that Medicare can put on treatment to avoid unwarranted healthcare procedures in the last year of life? Something like no (or only partial) payment for drugs costing more than X if clinical trials shows less than Y months' increase in life expectancy, no (or only partial) reimbursement for procedures costing more than X if the person is not expected to live more than Y months, etc? (Assuming the patient would be free to buy private insurance with no such restrictions, or to pay out of pocket.)

I'm thinking of rules that would be clear enough that all the discretion, and all the burden, wouldn't be dumped on the shoulders of the doctor on the spot who is facing the patient and family.

Of course, there is the issue of whether something like this could be sold to the voters. But surely the first issue is whether workable rules can be written in the first place.

A 5-10% co-pay on all expenses including hospital that is recoverable from the estate. Suddenly, grandma will just need to be made comfortable.

[Pazuzu]

Originally Posted by Nathans_Dad

Yes, I would have had it completely the opposite way.

The woman had terminal cancer. She was going to die from it. Putting in a pacemaker to extend her life of being in pain and bedbound not only makes no sense from a money perspective, it makes no sense from an ethical perspective.

Unfortunately, our medical system is driven by the patient/family. If the family wants everything done, despite the fact the doctors disagree, then everything gets done.

This woman should have been made comfortable and allowed to die. Instead we subjected her to an invasive procedure and a 3 day ICU stay with multiple blood tests and such.

Get it now?

No. That post seems anathema to the doctor's entire belief system. I guess I misunderstood doctors.

[Nathans_Dad]

Originally Posted by Pazuzu

No. That post seems anathema to the doctor's entire belief system. I guess I misunderstood doctors.

Firstly, it is not anathema to the doctor's "belief" system (there is no belief system for doctors).

Secondly, yes you do misunderstand the mission of doctors and of the healthcare system in general.

It is NOT the job of the doctor to prolong life at any cost. If a patient has a terminal condition and invasive and/or life saving procedures will neither improve their quality of life nor reverse that terminal condition, then those measures should be withheld and the patient should be kept comfortable and allowed to expire peacefully. To do otherwise simply prolongs suffering without benefitting the patient in any way.

Take the example I cited. This patient had metastatic, untreatable cancer. She was weak and bedbound at home. Her mental status was minimal at best. Family brings her into the ER with a pulse of 20. Instead of being kept comfortable and allowed to die in a few hours, she is admitted to the ICU, a pacemaker is placed, she goes into progressive kidney failure (which was already started when she came in), is intubated and put on a ventilator at family's insistence and finally dies 3 days later.

What did we accomplish besides prolonging her suffering? Is prolonging her suffering the right thing to do in your opinion? Is it not more humane to allow her to pass peacefully without tubes coming out of every orifice?

This is basic medical ethics, people who believe that doctors exist to prolong life at any cost are exactly the reason why we have the situations detailed in this thread.

[jyl]

Would it work to give the hospital's senior doctors the power to withhold treatment if they determine it is not cost-effective or appropriate (maybe these are two different things), and immunize them from liability for that decision? In other words, if the doctor(s) have the power to decide, will their decisions eliminate most of this overtreatment that you docs are identifying? Or will it also be necessary to change the doctor/hospital's financial incentives, so that there is not an economic incentive to overtreat grandma? (am not saying there is one, maybe the doctor/hospital is not financially rewarded for the pointless $80k pacemaker, I don't know).

I guess what I am trying to understand is if the overtreatment problem in this type of situation can be controlled by doctors, or if doctors are part of the problem.

[Moses]

Originally Posted by jyl

Would it work to give the hospital's senior doctors the power to withhold treatment if they determine it is not cost-effective or appropriate (maybe these are two different things), and immunize them from liability for that decision? In other words, if the doctor(s) have the power to decide, will their decisions eliminate most of this overtreatment that you docs are identifying? Or will it also be necessary to change the doctor/hospital's financial incentives, so that there is not an economic incentive to overtreat grandma? (am not saying there is one, maybe the doctor/hospital is not financially rewarded for the pointless $80k pacemaker, I don't know).

I guess what I am trying to understand is if the overtreatment problem in this type of situation can be controlled by doctors, or if doctors are part of the problem.

I worked at a hospital in England for a year. They had a medical ethics committee. If the committee determined that there was no reasonable expectation of recovery, the patient got palliative care only. No exceptions. If worked quite well. A lot of patients were evaluated then referred to hospice. They handle end of life issues with kindness and sensitivity. We could learn a bit from them.

[Rick Lee]

This brings my 87 yr. old grandmother to mind. For at least the last 12 yrs., she's been in and out of the hospital on a regular basis, had a pacemaker implanted, this or that bypass, constant pains, weaknesses, then it all goes away. Must cost a fortune. But she still leads a very active life, still drives, goes to her bridge club, lunch with old lady friends, etc. Looking at her age and medical history, it might seem crazy to keep doing costly procedures on her. But she's had 12 more years of a pretty active life since all this started.

[jyl]

My 98 y/o grandfather, who was quite healthy for his age but mentally not so much, went to the hospital w/ some sort of respiratory condition, developed pneumonia, deteriorated and was comatose in 3 days. I flew back to NJ, met with aunts and uncles and cousins at hospital. We listened to the options (but no recommendation) given us by the doctor, then decided not to prolong his life. He had lived for 99 years by Chinese measurement, his last conscious days were with all his family, and we felt his chances of leaving the hospital were very low and his chances of enjoying his life at home again were almost nil. And he'd accomplished his goal of living to 100, because a year previous we'd thrown a big party and told him it was his 100th.

[Moses]

Originally Posted by jyl

And he'd accomplished his goal of living to 100, because a year previous we'd thrown a big party and told him it was his 100th.

What a wonderful thing to do!

[Nathans_Dad]

Originally Posted by Rick Lee

This brings my 87 yr. old grandmother to mind. For at least the last 12 yrs., she's been in and out of the hospital on a regular basis, had a pacemaker implanted, this or that bypass, constant pains, weaknesses, then it all goes away. Must cost a fortune. But she still leads a very active life, still drives, goes to her bridge club, lunch with old lady friends, etc. Looking at her age and medical history, it might seem crazy to keep doing costly procedures on her. But she's had 12 more years of a pretty active life since all this started.

While this case may well be appropriate for a discussion of truly rationing care based on age, it doesn't apply to the cases Moses and I are talking about, which are examples of truly futile care.

Jyl, there are medical ethics committees at every hospital. Unfortunately their hands are tied, mainly due to concerns over lawsuits in the event care is withheld. Hospitals and hospital systems are prime targets for lawyers since multi-million dollar judgements are possible. This causes hospitals to be completely averse to involving themselves in any way that might cause a conflict with a family.

I have had several cases in the last year in which I have called in the medical ethics committee over concerns about futile care. In each case the ethics committee sat on their hands, mainly because the patient is usually obviously going to die within a few days or a week anyway and it is easier (and less risky) for the hospital to just let the family continue on the course and allow the patient to eventually die rather than risk upsetting the family by doing the right thing for the patient.