Monday, November 23, 2009

The High Cost of Dying

This Sunday, the 60 Minutes story The Cost of Dying raised some crucial issues on the containment of health expenses for Medicare, the single payer health insurance for US citizens over 65.

Last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients' lives - that's more than the budget of the Department of Homeland Security or the Department of Education. And it has been estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked.

This is entirely different from the horror stories of private insurers denying procedures that have cut short the lives of people who were otherwise young and vital. In this case, we have a government insurance plan whose leniency allows doctors and hospitals to pad the bill by ordering endless procedures on patients without any real benefit in the way of life extension.

Here is one example from the story.

Meredith Snedeker's 85-year-old mother spent her last two months shuttling between a nursing home and community hospital in New Jersey, suffering from advanced heart and liver disease.

Dorothy Glas was a former nurse who had signed a living will expressing her wishes that no extraordinary measures be taken to keep her alive. But that didn't stop a legion of doctors from conducting batteries of tests. "I can't tell you all the tests they took. But I do know that she saw over 13 specialists," Snedeker told Kroft. Asked what kind of specialists, Snedeker said, "Neurological, gastroenterologists. She even saw a psychiatrist because they said she was depressed. And she told the psychiatrist, 'Of course, I'm depressed. I'm dying.'"

When (60 Minutes) reviewed the medical records, (they) discovered that there weren't 13 specialists who attended to her mother: there were 25, each of whom billed Medicare separately. The hospital told 60 Minutes that all the tests were appropriate, and an independent physician said this case was fairly typical. "You think they were running up the bill to make money? Or running up the bill or giving her all these tests because they really thought it might help her? Or to cover their…rear?" Kroft asked.

"Yeah, to cover their rear," Snedeker replied.

Among the tests conducted was a pap smear, which is generally only recommended for much younger women, not an octogenarian who was already dying of liver and heart disease.

Maybe it was both to run up the bill and cover their rears.

I have a personal experience to share here.

It was almost 30 years ago that my father was dying. We planned to have him spend his last days at home but some complications arose that required us to have him taken back to the hospital. Although he was in a coma by then, neither I or my mother wanted him to die alone so we took turns staying by his hospital bed, she during the day and me at night.

For someone who was obviously only a few days away from dying, it was curious to see the parade of doctors who came by all though the night to visit and sign the chart in front of his bed. I didn’t pay it much mind until I saw the bills from the doctors and hospital a month or so later. There was the list of visits and charges from each of those doctors — an incredible number of them who listed visits in the last few days of his life. And to add insult to injury, there were doctor visits listed for one and two days after his death!

When critics of Medicare bring up its financial difficulties, they overlook that since most people don’t die before reaching age 65, the private insurers in effect pass off almost all of the end of life care issues to Medicare. It would certainly make sense to have a discussion about limiting testing and procedures to where a patient can realistically be made better instead of prolonging an inevitable death with no quality of life. But then we would surely get the demagoguery in the form of “death panels” and “pulling the plug on Grandma” that is presently practiced by those demonstrating against health care reform.

Whether we like it or not, to make Medicare financially solvent over the long run, we do have to exert better control over what is being paid out to stop the abuses of those providers who are taking advantage of the present system to pad their profits through either unnecessary procedures or just outright fraud which alone is estimated at about $60 billion a year.

Finally doing something about all of this waste and fraud would go a long way toward our being able to afford health insurance for those millions in the US who have had to go without it.

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