Wednesday, September 23, 2009

The Validity of the Dartmouth Atlas for Health Care

Some authors have asserted that the waste in our health care system based on the Dartmouth Atlas of Health Care is incorrect. The Dartmouth Atlas uses Medicare data from different regions in the United States comparing the cost of care. The assertion is that if high cost regions spent the same as low cost regions for all patients the savings would amount to about $700 billion per year. Critics question this for many reasons:

1) Medicare data does not include non-Medicare patients for which the results could be quite different.
2) Many expenses for Medicare patients are paid for out-of-pocket and supplemental insurance and thus would not be included in the Dartmouth Data.
3) Medicare reimbursement rates vary by region with some low cost regions receiving high cost region reimbursement because of political influence.
4) Hospitals with more private well-insured patients can more readily cross-subsidize their losses from the Medicare reimbursement schedule and thus are less likely to prescribe more procedures.

So does the Dartmouth Atlas of Health Care using Medicare data reflect on how medicine is practiced for all patients or does it give a false sense of what can be saved by having all regions become low cost? Fortunately there is a completely different assessment of the spending for health care per person in the United States versus many other countries. The McKinsey & Company December 2008 Health Care Report compared the amount spent/person versus gross domestic product. Their conclusion, “The U.S. spends far more on health care than expected even when adjusting for relative wealth”. The estimated excess was about $700 billion. It is to be noted that these other countries have better health outcomes than those in the U.S.

Thus the conclusion is inescapable: doctors in other countries take better care of their patients at significantly less cost. They rely more on history, physical diagnosis and clinical judgment and less on expensive tests. I believe the time has come for physicians in this country to assume their share of the responsibility for our excess health care expenditures.

Tuesday, September 1, 2009

Towards a Rational End-of-Life Policy

We have recently witnessed an intense controversy over end-of-life counseling. Deep inside the Congressional House Health Care Reform Bill was a section paying physicians to have end-of-life discussions with patients at least every five years. To be generous it was meant to be helpful. To be cynical it was an attempt at cost saving. Opponents to the proposed legislation exaggerated its intent using inflammatory rhetoric which made headlines but added little to nothing constructive towards a thoughtful discussion of a very sensitive topic.

The medical advancements available to maintain bodily functions (such as heart beat) beginning in the 1970’s caught our entire society ill-prepared. Two famous cases illustrate this point.

1) In 1975, 21 y/o girl Karen Ann Quinlan suffered anoxic brain damage (not enough oxygen), causing irreversible and complete loss of her cerebral cortex. The cerebral cortex is the humanized part of the brain responsible for consciousness, thinking, awareness, speech, purposeful movement, and all other human traits. She was kept “alive” by artificial means. Karen’s father wanted to remove a breathing machine realizing she was irretrievably lost as a person. He was vigorously opposed by her physicians, the local prosecutor and the New Jersey Attorney General. This opposition was most unfortunate considering Karen’s loss of humanness. Physician opposition to removing the respirator help created the image of physicians as irrational purveyors of technology regardless of the potential for benefit. This does not absolve agents of the state who were also complicit in this irrational use of technology. It took the New Jersey Supreme Court to give the father authority to remove the respirator.

2) A similar crisis arose in 1983 when 25 y/o Nancy Cruzan also suffered anoxic brain damage and irreversible loss of her cerebral cortex because of an automobile accident. She was kept “alive” in a state hospital via artificial nutrition although her parents, realizing recovery was impossible, wanted cessation of all therapy. The conflict which arose between the state and the parents was resolved by the U.S. Supreme Court which in 1990 ruled that a competent person could refuse artificial means to sustain her/his life. A corollary to this is that a competent patient can refuse any or all therapy. Shortly thereafter friends of Nancy testified that she would not have wished this kind of treatment. Life support was removed and she ceased to exist shortly afterwards.

Later, in 1990, Congress, as part of budget legislation, passed the Patient Self Determination Act that became the authority for states to initiate advanced directives. Missing from the act was the phrase, “Within the boundaries of good medical practice”. Thus the imperative of knowing the medical feasibility of any desired treatment was missing.

There is a voice missing from this abbreviated synopsis. What is the opinion of physicians and their medical societies on this issue? Their silence was and still is deafening! Should not the fact that complete and irreversible loss of all human functions enter into the decision process, especially when there is medical certainty that for this individual there is no chance of recovery?

Unfortunately cost considerations are mentioned by some when discussing this issue. However, many more important principles are at hand.

1) It is unethical to have a human body decompose in a hospital bed with absolutely no chance of recovery in the name of medical care.
2) The doctors, doctors-in-training and nurses become desensitized to human suffering perhaps lasting their entire careers if they participate in de-humanizing non-beneficial care!
3) Training young physicians and nurses to have the skills to provide futile care takes away from learning more important humane skills such as tolerance, kindness, empathy and physician-patient communication.
4) Families while experiencing great stress are forced to make decisions regarding the continuation of care in situations where further care is only prolonging death.
5) Advanced directives created at any time in the past and without physician input as to what is feasible are at best problematic and at worse deceiving. I suggest that a new admitting form be routine at every hospitalization to determine patient desires and medical feasibility.

In summary, for this nation to develop a rational end-of-life policy it must be based on human need, realistic expectations and devoid of any financial considerations. It must be policy that if there is any chance of recovery there should be no consideration of cost.