As we all were painfully reminded last week, it’s hard to change the U.S. health-care system.
The failure of the Republican-led effort to repeal and replace Obamacare proves that whatever lawmakers try to do about health care, someone doesn’t like it. The fundamental problem is simple: Americans want to consume more health care than we collectively want to pay for.
And since health care costs money — lots of it — most changes either give people less of what they want, or jack up costs. Moreover, cutting expenses doesn’t only deprive consumers (many of whom vote) of something they consider important. It usually also reduces revenue for at least one powerful industry group, whether doctors, hospitals, insurers, pharmaceutical companies, or another recipient of the $3 trillion-plus Americans spend annually on their health.
Deliver better health care, make patients more satisfied, and save money.
But there is one exception to this rule, one place where it’s possible to deliver better health care, make patients more satisfied, and save money: Care at the end of life.
The opportunity exists because — unfortunately — we deliver a tremendous amount of non-beneficial end-of-life care that increases suffering without likely benefit, at enormous cost. Far too often, dying patients are admitted to hospitals and automatically placed on an end-of-life “conveyor belt,” without being fully informed of where it is leading. This typically involves greater pain and isolation, and a medically intensive death that most people wouldn’t choose.
I’m not talking about patients who have a reasonable chance of benefiting from treatment. Most of us would agree that they should receive the full-court press to return them to health and functioning. I’m referring to the many situations where every health professional involved knows the patient is dying. Treatment won’t prevent death, and (contrary to popular belief) quite often won’t even delay it. Instead, such treatment increases suffering, and piles of evidence shows that most properly informed patients opt out of intensive, non-beneficial care.
So we have the happy situation — rare in health care — where informed patients want better care that actually costs less. Indeed, the potential cost savings are significant. The U.S. spends about $300 billion annually on people who die. Medicare alone spends nearly four times as much on each recipient who dies compared with those who don’t, and nearly 30% of Medicare funds are spent on beneficiaries in their last year of life. We’d expect the last year of someone’s life to have higher medical costs than most other years, but it’s clear that much of that cost meets the definition of waste: spending with no benefit. Worse, there’s often likelihood of harm.
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End-of-life care doesn’t necessarily mean that people get less treatment. Informed patient-centered decision making, palliative care designed to make patients more comfortable, hospice — all of these are active treatments, sometimes even aggressive ones, but they center on patient needs and preferences. These approaches consider the whole human being rather than focusing narrowly on medical management of organ systems.
Does it work? Emphatically, yes. There’s compelling evidence that structured education and counseling programs empower patients to make decisions they believe are best for them, and they usually choose less medically intensive treatment.
Even after factoring in the additional cost of education and counseling, these efforts are big money savers. That’s why many health plans and hospital systems offer such programs; they make both their customers and their accountants happy.
There’s another reason that this approach really can succeed. Unlike most initiatives that could reduce health-care spending, no powerful, concentrated industry segment loses money with better end-of-life care. In fact, the major political opposition is likely to come from conservatives who fear government “death panels” that they believe aim to send granny to an early grave.
This barrier can be overcome with sufficient education and clarification. Multiple studies have found that terminal cancer patients live longer when their symptoms are managed with palliative care approaches versus being treated with chemotherapy. (Some death panel!) Optimal care of the dying maximizes patient autonomy, a key conservative principle. Moreover, it saves government money through patient choice — exactly the argument Republicans made to promote their health care legislation. With appropriate safeguards to prevent coercion, conservatives should be able to support efforts that allow people to make their own decisions, increase health-care quality, and save costs.
That said, to get traction, this idea must be promoted as promoting patient autonomy and offering better care, not saving money. Americans are highly suspicious of any attempt to shave cost at the expense of their health. Yet poll after poll show that most people want candor from their physicians about their prospects, want to pass away at home rather than in the hospital, and don’t want to die hooked up to machines. The American Society of Clinical Oncology recommends that patients with advanced cancer receive palliative-care consultation early in their disease so they can make informed decisions. The appeal here is about better care. At the same time, across the population there will be substantial savings.
So whether you’re primarily concerned about quality care, lower costs, or individual self-determination, this cause is for you. I won’t claim that fixing end-of-life care will solve our health-care quality or cost problems. It won’t have the sweeping impact that either the Affordable Care Act had or the GOP replacement aimed for. But in a political environment where major progress seems hard to come by, this may be our best near-term shot to improve U.S. health care.
Mark Zitter is chair of the Zetema Project, a diverse group of health care leaders informing the national health care conversation through expert debate. He chairs a series on end-of-life issues for the Commonwealth Club of California.
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