Addressing Health Care Costs: Palliative Care

Dan Weintraub wrote a thought provoking column yesterday. It that touches on issues he rightfully says have been neglected in this health care debate. We have done a lot of talking about insurance, but not much about the costs of health care that are not administrative. He argues for a look at more fundamental reforms. Nothing could be a bigger shift than a move to a single-payer system, but we can try something new that is not SB 840.

Health care costs are rising mainly because of demographics and technology, and neither trend is going to change any time soon. As a state (and nation), we are getting older, and older people use more health care. All of us also tend to demand the latest tests, procedures and drugs, which cost more money.

Unlike other products, from computers to air transportation, medicine seems only to get more expensive over time. The health care industry has few if any incentives to reduce costs through the use of innovation and technology. That means legislation that focuses mainly on expanding access to insurance is likely to miss the mark.

The health care industry is bloated. They look for the most profits, not the best way to treat their patients. The most well known example are the drug companies. They make their drug development decisions based on profit margins not societal benefit. It is just one of many failures of the free market system and a reason for more regulation not less.

David Gibson, a physician and health care consultant, agrees that nothing will change without a major restructuring of the health care industry itself. American doctors, he says, on average earn twice as much as their counterparts elsewhere in the industrialized world, and their salaries drive labor costs throughout the system. In addition, the rising number of medical specialists appears to be pushing costs higher, especially at the end of life.

"We reward the wrong skill sets," Gibson says. "More Medicare patients die in high cost intensive care unit beds here in California than in any other state. The reason -- the default decision for specialists is to use high-tech inpatient resources, rather than community-based options such as hospices, for terminal care."

Can these problems be solved by passing new laws? Maybe not. Not every problem can be fixed by more government intervention.

Much of the industrial world has some version of a single-payer system and that is helping clamp down salaries to a more reasonable level. This is also another example of the rich getting richer, while average wages have remained at the same level. It is a problem that exists across all industries.

Weintraub is correct, not every problem can be solved through legislation, but the current system is fundamentally flawed and the whole industry needs a kick in the pants that only the government can provide.

The issue of palliative care deserves more attention and discussion. It is as much of a moral as it is a fiscal issue. We need to find a more fiscally responsible and socially acceptable way to deal with end of life care, particularly of the elderly.

David Gibson brings up an important issue, the high cost of treating end of life care in a hospital rather than a hospice. The rules of most insurance providers including Medicare are to blame. They force terminally ill patients to choose between hospice and advanced medial treatments. The NYT had an excellent article a few weeks ago on the issue.

Forcing patients into this either-or decision has prompted many who might benefit from a hospice program to instead opt for expensive hospital care that may end up costing Medicare and other insurers far more.

But now, some hospice programs and private health insurers are taking a new approach that may persuade more patients to get hospice care for the last months of life. These programs give patients the medical comfort and social support traditionally available through hospice care, while at the same time letting them receive sophisticated medical treatments that may slow or even halt their disease.

Hospice care is intended to help patients and their families better cope with the end of life by providing social services and special care.

Experts say that if the new approach catches on more broadly, more patients who would benefit from hospice care will actually enter hospice programs — and enter them earlier. And more patients, they say, could avoid the costly, crisis-ridden final weeks in a hospital that often still represent the American way of death.

In 2005, only about a third of the 2.4 million people who died in this country were in hospice care. Perhaps twice that many patients should have been in hospice programs, according to specialists in the field. And even many of those who entered hospice care did so only at the very end of their illnesses, spending a week or less in a program that ideally would have helped them cope with the final six months or year of life.

It should not be an either or decision. Hospice care would be enormously beneficial for these patients who do not want to give up chemotherapy or dialysis. They would have access to nurses and doctors who are experts in palliative medicine to relieve pain and increase quality of life. This approach also encourages people to avoid the expensive ICUs that many people spend their last days in at up to $27,000 a day.

Part of Sen. Wyden's health care proposal would end the Medicare requirement that forces patients to forgo other coverage to get hospice care. It is something the legislature could thing about addressing as they look to reform the private health care system here in California. We need to get smarter about how we treat people and this is one of many topics that should be discussed.