This concentration of total cost on a small segment of the total population is reflected in another common aspect of medical spending: the concentration of treatment, and cost, in the end of a life span. For most people, the vast majority of all the health care they’ll ever get comes near the hour of death. Hundreds of billions of dollars each year are spent treating Americans who are in the last weeks, or days, of life.
The old Marx Brothers’ joke—“I wouldn’t dare go to the hospital—people die there all the time”—is essentially true. Many people die in the hospital—in many cases, just after they’ve incurred a hugely expensive round of surgery, treatment, and medication. About one-third of Americans undergo operations in the last month of life.
If these issues were subject to hard, cold economic theory, a health-care system would probably distribute spending differently. The large sums it costs to keep a sedated cancer patient with dementia alive in a hospital bed from age 94 to 95 could presumably be directed instead to provide, say, a kidney transplant for a 40-something victim of renal failure, or a young woman who is too depressed to care for her baby. That money could be used for pre-natal care for uninsured mothers, setting the stage for both mother and child to have a healthier and happier life. Or, those funds could be used to provide health insurance at reasonable cost to the 29 million Americans who have no health coverage today.
The issue of allocating medical spending is most acute in the United States, because we spend far more on treatment and medication than any other country. All the other developed democracies on the planet guarantee health care for everybody (citizen or alien), and yet they spend, on average, about half as much per capita as the U.S.
But all over the world, health systems are struggling with the same concentration of cost that plagues the U.S.
So Britain created an organization to make rules for how its healthcare money is spent. It’s formally called the National Institute for Health and Clinical Excellence, but everyone knows it by its acronym: “NICE.” This outfit issues guidelines to the regional medical authorities on what should be covered, and what shouldn’t. Should a 94-year-old get a hip replacement? Should a terminal cancer patient be given a course of medication that costs $40,000 and extends life an average of four months? (In Britain, the answers are, generally, “No.”)
In one widely-reported case, the NICE guidelines said that a pub waitress—a mother of three—who contracted breast cancer should not receive the drug Herceptin. After all, NICE noted, the medication costs about $36,000, and doesn’t usually help with that woman’s particular form of cancer. Since there is only a finite amount of money in the National Health Service budget, the agency said, it would be smarter to spend those thousands on a treating another patient with a better chance of recovery.
Americans who are not health-care economists tend to resist the concept of QALYs and DALYs because they lead the system not to pay for one person’s health care in order to pay for another’s. This is considered “rationing” of health care, and rationing is generally condemned under a variety of names, most memorably as “death panels.”
In fact, though, every nation rations health care every day. No country—not even the richest oil sheikdoms—can afford to pay for every advanced surgical procedure and every costly drug that modern medicine knows how to provide. Accordingly, health-care systems are constantly making choices—rationing—about which treatments to pay for.
One approach to this quandary that seems promising, both for the individual patient and for the health-care system overall, is the concept of “death with dignity,” as reflected in the Hospice movement. Hospice was initially a British idea that has spread to France, the U.S., and other advanced democracies. It’s a system that emphasizes caring, not curing, that replaces the all-out battle against death. In essence, the surgeries and the IV tubes and the breathing machines are replaced with a calm acceptance that one’s time is coming.
A patient in Hospice avoids the operating room and the hospital ward, spending the final weeks or days of life at home or in a quiet facility, often with a regimen of drugs to control the pain of disease. In the U.S., most of the people who commit to Hospice are elderly, but it’s a path that terminally ill patients sometimes choose in their 20’s or 30’s. For the ailing individual, and for friends and relatives, it provides a more tranquil opportunity to reflect and say goodbye than the hurly-burly and confusion of a major hospital. For a health-care system, it can be a massive money-saver.
As other countries have found, there’s no simple solution to the problem of concentrated health-care costs. But one step that could clearly help in the U.S. would be a commitment, at long last, to provide health care for every American. All of the rich countries that guarantee health care for everybody have better health outcomes at much lower cost than the U.S. This is not a coincidence: a comprehensive system of universal care will always be cheaper and more effective than the haphazard, crazy-quilt network of overlapping and costly payment systems America is stuck with today.
And when everybody is covered, the health-care system can probably make fairer decisions about where the money should be spent. If America is going to pay $3.4 trillion for health care, after all, we ought to make sure that every American benefits from that colossal expenditure.
More at Source: How We Spend $3,400,000,000,000 – The Atlantic