Thursday, December 15, 2011

Bach: When Care Is Worth It, Even if End Is Death

In the 12/12/2011 New York Times, Dr. Peter Bach discusses, "When Care Is Worth It, Even if End Is Death".

First, Dr. Bach lays out the "conventional wisdom" currently being promulgated by the cost-cutters:
You've probably heard that we spend a lot of money on patients who die. It's true: about one-tenth of the money spent on direct care goes to people who die each year. Among Medicare patients, the figure is much higher, about one-quarter.

You may be shocked by those statistics. What health care system would squander so many dollars on patients who don't benefit? Or maybe you’re saddened. No humane system would subject patients to painful interventions and procedures that serve no purpose.

The idea that we waste money on terminal patients has caught on; the simplicity of the conceit makes it appealing to policy makers. And the data to support it keep coming, because it is easy for researchers to measure how much is spent on patients before they die.
Then he points out the following "inconvenient truths":
Providing care means reducing the chance they may die -- not eliminating it. My supervisor noted this the moment he saw my patient...

Put another way, the policy conceit that spending money on patients who die is a waste overlooks the core purpose of health care -- to prevent or forestall illness, disability and death among patients at risk of those outcomes.

It also overlooks a key correlation in health care. When people get sicker, they need more intensive -- and expensive -- health care services. But when they get sicker, they are also more likely to die. When I met my patient, I took him to the intensive care unit, the second-most-expensive place per minute in any hospital. The other place he went, twice, was the operating room -- the most expensive place.

Healthy people, who are unlikely to die, are also very unlikely to find themselves in those settings. Thank goodness.

Thus, spending will always be concentrated on people who are the sickest. When one examines spending on patients who die, dollars will be concentrated there, too.

I am not saying that every health care dollar is well spent. But five carefully done studies have now shown that hospitals that spend more on caring for sick patients have better outcomes than those that spend less. So some of the spending is improving health.
(Read the full text of "When Care Is Worth It, Even if End Is Death".)

It's impossible to ascribe "value" for a health care dollar in the abstract. As author Ayn Rand once noted, the concept of "value" presupposes "to whom and for what". No government central planner can determine what is the appropriate value to a particular patient for a dollar spent on his health care.

One of the biggest problems with ObamaCare is that it presumes that health care "value" (and thus what constitutes "appropriate" vs. "inappropriate" care) can be best determined by bureaucrats, rather than by those whose very lives are at stake.

As a corollary, payment for health services is also the responsibility of those who wish to receive them. If someone desires health services because it would be of value to them, they should pay for it from their own funds, through contractually-promised voluntary agreements (such as private insurance or mutual-aid groups), or via private charity. They don't have the right to demand that others write them a blank check for services they deem valuable.

(NYT article link via Dr. Kathleen Brown.)