From the New York Times “Economic View” column by Daniel Altman:
[H]ow can Medicare’s ballooning costs be contained? One idea is to let people die earlier.
For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent, said Dr. Gail R. Wilensky, a senior fellow at Project HOPE who previously ran Medicare and Medicaid. Thus end-of-life care hasn’t contributed unduly of late to Medicare’s problems. But that doesn’t mean it shouldn’t be part of the solution. “If you take the assumption that you want to go where the money is, it’s a reasonable place to look,” Dr. Wilensky said.
(Hat Tip: Macroblog.)
Aside from the questionable morality of this proposal, there’s another basic problem here: How do you know, for sure, when someone is at the “end-of-life”?
I’m sure everyone has heard stories like this; here’s the latest from my personal collection: A colleague of mine at my previous job was been diagnosed with a “fatal” form of leukemia over five years ago, given months to live if that, and retired from his previous job to die. He was treated, recovered, got another job (where I met him) and aside from his cancer-in-remission seems healthier than I am. He had a relapse, took two months off to get an experimental treatment, and came back hardly the worse for wear. He takes some (probably rather expensive) pills to keep the cancer from coming back, but that and monthly checkups are the only thing impinging on his quality of life.
Yet, at two points in the last five years, he could have been determined by the above-proposed Medicare rules to be at the “end of life” and thus ineligible for the chemotherapy and advanced medication that saved his life. And you know what? They would never have known they were wrong, since by denying someone life-saving medical care, you make the “end of life” determination self-fulfilling.
Even more dramatically, Rus Cooper-Dowda was determined in 1985 to be in a “persistent vegetative state” much like Terri Schindler Schiavo. She could actually hear a group of doctors (including her husband, who was a doctor) discussing when to “pull the plug” on her:
In February of 1985, I woke up in a hospital bed in Boston, MA. I couldn’t see very well and I couldn’t move much — but boy could I ever hear!
I heard a terrifying discussion then that I will never, ever forget.
Around the end of my bed were a “school” of doctors in their white coats, planning when to disconnect my ventilator and feeding tube. I immediately started screaming, “I’m here!!” No one but me heard me.
They did notice my sudden agitation. They heavily sedated me. For a time, everytime I woke up I would make as much noise and move as a much as I could to show them I was “in there.”
And they would, in response, heavily sedate me…
I then started spelling the same word in the air, “Don’t! Don’t! Don’t!….”
The doctors decided that the letters I was spelling in the air were repetitive seizure activity and just happened to occur most often when they were in my room discussing killing me…I even took to writing them backwards to make it easy for them to read…
But, the nursing staff began to believe I was really and truly with them.
One, in particular, starting bringing in a clip board and a broken pen when she talked to me. She would put ink on my fingers, the clip board under my right hand and then ask me yes and no questions in the beginning.
With her I secretly progressed to answering in sentence fragments. However, by doctor’s orders she was not allowed to document in my file what she was doing and that I was giving meaningful responses.
But…she did save my inky answer sheets and recorded the questions she asked. She got into a lot of trouble for that.
Yet, it earned me a final conference where the doctors had to prove to the nursing staff for political reasons that all my communication was just agitation and seizures.
At that meeting, my then husband, who was a doctor siding with the other doctors who wanted to let me die, held that clipboard which was my lifeline up in the air in front of me. He was not going to make it easy.
The purpose was to prove that the nurses were basically hallucinating and that I was really and truly brain-dead.
To prove I could not communicate, he then put ink on my fingers and asked while laughing, “There isn’t anything you want to tell us, is there?”
In response I spelled out, “D-I-V-O-R-C-E Y-O-U!” The laughter got very nervous then. The doctors called for medication because I was obviously having a sezure.
Then they said I couldn’t breath on my own — and I could. Then they said I couldn’t learn to eat again on my own — and I did. Then they said therapy wasn’t important — and it was. Then they said I would be dead within a year — in 1985 — this is 2003…
They also said I would never have meaningful mental function again — yet I earned another Master’s degree only a few years later.
Here’s the real medical corker though — They also said at the time that I was permanently sterile. That was a cause of great grief for me then as I had very much wanted to bear and raise a child.
But, it turned out my son, who is here at this service today, was born at the end of that year.
It turned out that I was actually pregnant at the very moment they were telling me I was sterile — a simple test at the time could have established that.
She ended up surviving, divorcing him, raising her son, and getting a job as a teacher of disabled children — from which she was fired for giving an interview on her experience in connection with the Terri Schiavo case.
These are anecdotes, but there is actual data to support the notion that this is not an uncommon occurrence. Writing in the New England Journal of Medicinein 1994, Ezekiel J. Emanuel and Linda L. Emanuel point out:
Expenditures at the end of life seem disproportionately large. Although the precise numbers vary, studies consistently demonstrate that 27 to 30 percent of Medicare payments each year are for the 5 to 6 percent of Medicare beneficiaries who die in that year. The latest available figures indicate that in 1988, the mean Medicare payment for the last year of life of a beneficiary who died was $13,316, as compared with $1,924 for all Medicare beneficiaries (a ratio of 6.9:1). Payments for dying patients increase exponentially as death approaches, and payments during the last month of life constitute 40 percent of payments during the last year of life. Identical trends and ratios have been found since the early 1960s.
Many people believe that these expenditures are for the care of patients known in advance to be dying. The time of death is usually unpredictable, however, except perhaps when the patient has advanced cancer. There is no method to predict months or weeks in advance who will live and who will die. Consequently, it is difficult to know in advance what costs are for care at the end of life and what costs are for saving a life. Only in retrospect, after a patient’s death, can we identify the last year or month of life.
This article was written during the debate over the Clinton health care plan, which, if I remember correctly, called for a cessation of all care except pain control once two doctors had determined that a patient had less than six months to live. Combine this with the provision that made seeking care outside the proposed national system a crime punishable by 10 years in jail (or a $10,000 fine or both), it is quite possible that under that plan, a person could have been told he had six months to live, somehow find treatment outside the system and live another 10 years — but spend them in prison.
By the way, if we take this proposal to it’s logical conclusion, we can save even more money. If 28% of Medicare expenditures are spent on the 5% of beneficiaries who die each year, eliminating them can save, at most, 28% of the budget. But 100% of Medicare expenditures are spent on the 100% of beneficiaries who are alive each year. So the clear solution is: Kill anyone who becomes eligible for Medicare. (This is similar to a policy enacted in the Anthony Trollope novel, The Fixed Period.)
- Ezekiel J. Emanuel and Linda L. Emanuelm, “The Economics of Dying — The Illusion of Cost Savings at the End of Life.” New England Journal of Medicine 330:8 (February 24, 1994) pp. 540-54.
- Anthony Trollope, The Fixed Period. (Summary)