I am not a policy expert, but I know a thing or two about medicine. So
consider the following case I recently did. (The reader should realize
that this is a pretty typical case, more common than not. Number$ below are all approximate.)
83 year old Mexican woman with end stage renal disease, on dialysis 3
times a week. She has also hypertension, diabetes, obesity (5' 6'';
92 kg), hypercholesterolemia, and much much more. She doesn't speak
English, and probably Spanish, because she is demented. So now she has
sick sinus syndrome. The cardiologist and family want to implant a
pacemaker.
Consider the cost of what we did for her, for the family, and for you,
dear taxpayer. We have implanted a $6000 device. Then we had a $600
anesthesia charge, $1500 surgeon's fee. $2000 OR fee, $400 radiologist
fee. All that was followed by one day of ICU, then telemetry, then
regular hospital stay ($10,000 or more). Then rehab, nursing care, etc,
etc. So, we are talking $50,000 - $150,000 total charge for a
person who is not really a person anymore. (And who did not work a day
in this country to pay into the system, but that is a different matter.)
The questions are:
Would the family do the same if they would be required to pay at least
10% of the total charge? Or would they put grandma in the bedroom and
give her comfort, like people have done for thousands of years?
Do we really need that universal healhcare thing, or do we need more
personal financial responsibility on the part of patients or their families?
You are saying to let the patient die because she never paid a cent into the system. Do you have her work record.
Universal healthcare is a must. Let the people have it and then iron out the flaws as we go along.
I believe you went overboard. A 83 year old Mexican woman with end stage renal disease, on dialysis 3 times a week. She has also hypertension, diabetes, obesity (5' 6''; 92 kg), hypercholesterolemia, and much much more, is not a typical case. If she ever existed.
Why do you mention "mexican" are you trying to insinuate something?
It is very typical case. This woman has to be comforted by her family, and then, after she was treated compassionately, she will be dead. This way the taxpayer will not pay for this nonsense.
I agree that universal health care is not the option, and a 10% plan would probably help immensely. Still, the old "if it was your family member" adage rings pretty strongly in this case. No doubt it seems pointless to implant a pacemaker into a person who no longer knows who they are, but if that person was a loved one of yours, and you had the possibility to keep her around for a few more years or months, most people would make the same decision. The 10% may help curb the economic problems that exist in health care, but in return people will just be more disgusted with the system having to pay $15,000 to keep their families healthy.
<i>No doubt it seems pointless to implant a pacemaker into a person who no longer knows who they are, but if that person was a loved one of yours, and you had the possibility to keep her around for a few more years or months, most people would make the same decision. </i>
I guess there are many people who think that viewpoint is selfish. The woman most likely is in pain pretty much constantly, doesn't know who she is and thus suffers mental anguish, and you want to keep her alive so that family can see her body continue to deteriorate?
I've lost my two closest grandparents in the past 5 years--my grandmother was quite cognizant as she lived her last days in agony, my grandfather was 5 years into an Alzheimer's diagnosis. In both cases there were "heroic measures" that could have been taken to stave off their deaths for a bit. Measure that were not taken...because they only would have prolonged the agony. Trust me, these were not easy experiences, and I in no way support euthanasia...but this is NOT euthanasia...it is allowing nature to play itself out.
I agree, this is a very frequent example of what happens when the familly and/or the physician do not exercise common sense and judgment. Who made the decisions here?
The family should be told how much it is going to cost. Nothing is free!!. This is NOT a good argument to endorse Universal Health Care, or payor, at all. (flawedl logic here).
One can certainlly document that the providers do not agree with further treatment due to quality of life issues....dementia, etc with consultation by a uninvolved third party. (ethics committee of the hospital?)
who was the captain of the ship?
who was advocating for this therapy?
was an informed discussion even attempted?
Before you can parse out "blame," more info needed. If docs were passive and just rubber stamped the "usual routine," to me, this is neither an economic nor family related issue, but a physician one.
First of all, regarding mexica's remark about whether or not this is typical I must agree with Dr D. It doesn't matter what race, color or religion you are, it is a typical case. I also think the only reason it was stated she was Mexican is because later it would have to be explained about the patient speaking English or Spanish. After 30 years in the operating room, I've seen this same scenerio repeated over and over again.
To Agree and Disagree
I, myself was in this exact position in 2004 with my father. He had parkinson's disease, his heart, even with an AICD devise, functioned at less than 15%. His dementia was worsening, he couldn't do anything he loved to do anymore. He was eating less and less. Because of his parkinson's he was having trouble swallowing. He had a lung infection, ended of in the hospital in the middle of March 2003. His physician wanted to intubate him and refused to make him a DNR. Both my step mother and I refused to allow the intubation. He survived, but we fired the physician and put him into hospice care. He died, peacefully on May 16,2004 at the hospice facility. My point to this post is yes if it was my mother, grandmother, father, sister whomever, I would make the same choice.
I think, far to often, people don't think of the person suffering but of themselves. Even 30 years ago, we did not have the medical advancements we do now, but to often they are abused.
Great comment. The other difference between you and that family is that you can be more reasonable as an experienced professional. This pt's family (and many other families like that) are given a choice, thanks to our politically correct atmosphere. Doctors and nurses can't make these decisions anymore. In reality, for a lot of people their decision making is clouded by a misunderstanding of the situation and the emotional state that they're in, making them unable to make real life-and-death decisions, especially when it comes to a high tech end-of-life care. They have the hope, we have the tech, they don't need to pay: so they tell us to go ahead. And we, like the sheep,follow.
This set of care decisions is obviously not appropriate. But, ya know it's just easier to go along and/or opt for a higher level care to avoid the extra work, to to not "get in trouble (get sued?)."
Patients come in all the time to the ED who are hospice patients and are actively dying. The families, who have never done this before, feel guilty, and get scared by what people do when they are dying. They panic; they lose their nerve and call 911.
The EM docs (I'm one), roboticly intubate, place foleys, central and art lines, and get 'em on pressors, in the blink of an eye. This is done because 1) this is what we do on the residency-trained, reptilian-level - to get this patient stabilized and dispo'd; when they arrive upstairs in the ICU with a distraught/angry family member with a DNR/DNI document in-hand - it's somebody else's problem (whew, dodged another one). 2) to avoid engaging in a sticky, complicated, emotion-laden, values-driven, unresolved situation that might call for some deep thinking, some courage, and some people skills.
Every life is precious. Not every set of vital signs is precious though. Life and vital signs are NOT synonymous! To confuse the two is to lack wisdom. We sometimes settle for vital signs for a time in order to get a patient back to life. To set vital signs as the goal of medicine and surgery is to just not get it. We are each entitled to death with dignity and reasonable comfort. It is a sin to put somebody else through procedures that are uncomfortable and even painful, with variable risk, and equivocal, or worse, doubtful benefit just so one or more adults who can't face facts doesn't feel so guilty. For a physician to be party (active or passive) to these dramas is unethical and unprofessional.
I don't get how UHC follows from this, but since you bring it up, your construction of UHC as free, and bottomless, is a straw man.
Nothing says that UHC can't have fees, even full-cost fees for services deemed to be without material benefit, unreasonable, unethical, or futile. Medical tort reform, then, would be a whole big part of it.
UHC would cover a finite, reasonable, efficacious set of care, procedures, durables and pharmaceuticals, etc. It's not the sky-is-the-limit, if-you-get-lucky system it is now. Nothing will stop anybody from buying coverage for above-and-beyond care. But, everyone will have access to an agreed-upon level of reasonable, basic health care. This one's easy - it will decrease costs overall because then people won't show up in the ED so ravingly sick for such unnecessary, costly and ineffective-band-aid care so much.
What it would do is take away a lot of insurance execs', lawyers' and shareholders' yacht payments, second homes, oops, people's first homes, their kids' college tuition, why it'd cost some people big - their current jobs, their and their family's lifestyle. So, you don't think they'd fight tooth and nail, that they'd resort to scare tactics and lies to keep their thing, that's wokin' for them, going?
Let's be honest, the arguments against UHC are largely political and ideological; they are mostly self-interested, class-interested and thinly rhetorical. They are not protecting us from the scourge of communism, or socialized medicine; they just want a slice of the action. They are not making, baking or saving the pie. They want a slice of the pie.
Back to our story at hand, in the big picture, UHC will force our cowardly, collective hand and make us face our collective and individual mortalities. We will have to grow up because it won't be individuals and families exercising their autonomy in separation from the whole. We will all get the bill for this kind of childishness of maintaining vital signs at all costs.
The education that physicians should be leading, needs to be ongoing in the society. We all (citizenry) need to see the costs and the results of these decisions. They have been protected too long from the ugly truth that we see everyday. They're grown-ups just like us.
Fears of slippery slopes is not a reason to postpone dealing with the hard work of having to figure this stuff out as a society. The Brits used to ration dialysis. This forced some hard decisions and larger reallocations to address this issue. We may have to give something up, like being the world's policeman. Whatever solution we come up with, it will cost money and it will force open assessment of priorities and the allocation of resources. Having individual insurance companies sequester their proprietary information and then variously ditch "uninsurable" patients onto the public sector resulting in a blurry hodgepodge of individual problems, robs the entire society of the entire data set. In UHC we could actually see what is actually going on in toto, not just anecdotes and random crises.
The Mexican thing - a cheap, racist shot. The passive-aggressive ("I didn't mean that; you're putting words in my mouth") dark-side rhetoric is tiresome. There are plenty of 83-year-old white women who never "worked a day in their life to pay into the system." English-speaking is not a valid criterion for continuing or not continuing care. You know it and I know it. It's not a mistake. It's not random. It was chosen and written on purpose. To claim otherwise is disingenuous.
I wonder if we made people pay a sum based on ability to pay if that would change the way people made these kinds of health care decisions (listen to the howls, now). I work in Detroit. A percentage is not really a barrier to the middle and upper classes, because $10,000 is one thing patients and families in the next county; it is a whole other, insurmountable "might as well ask for a million dollars" thing to the people I treat.
So, that fee proposal is really not about the "fairness" of a percentage. If you want to make people stop and think twice, then develop a policy that makes everyone stop and think twice to the same degree; not something that sounds "fair," but is really a back door to squeezing out the poor, even some more, so that the "good poeple," the deserving, relatively-rich can get yet another helping. A little justice and caritas would be fitting here. "Woe unto you,...you hypocrites.... you brood of vipers...."
brimcmike:
This person already has UHC, and as the case shows, there is a big problem with it. It is called lack of re$ponsibility.
It is a fallacy of ambiguity to state the UHC is synonymous with bottomless pit spending on futile cases. Insurance companies and gate keepers do it all the time when they deny claims or pre-authorization. The case-by-case basis of it renders this current process effectively policyless.
We have these bottomless pit cases because we don't have a single system that openly sets policies and limits on what is funded, and openly states that beyond that limit you're on your own.
Everybody gets the basics. Not everybody gets everything.
That's how it will work.
brimcmike,
Its a little harsh to throw accusation of racism when mentioning the person's life history was appropriate for the econo-political discussion here. Sadly, medicine is not separate from finances and politics, and wishing it were otherwise won't change it.
What nobody seems to ask is why a middle class family had to send their child to a cheaper summer camp because they had to instead pay for the life support of a person who is not coming back. How about the cheaper and more inferior helmet that they bought for the child to save a few bucks? Why is it that they have to compromise on their child's safety, having deposited tens of thousands of dollars into the system, while someone else, who has not contributed anything, is wasting their resources away?
I say the child gets the priority. I say that the middle class family should be getting a little more respect.
I also say that to have some kind of government committee decide what is the sufficient treatment that the state will pay for, is also absurd. People need to make the hard decisions, and take financial responsibility for them, instead of laying them at the feet of others.
There's a saying that goes like this: "For free even vinegar tastes sweet". And that is one of those rules that any socialist-style project always ignores.
I'll have no truck with the supposed miseries of the middle and upper classes. I grew up working class. I'm the first person in my family to complete college, and beyond. Making an argument that someone with multi-dimensional privilege and affluence had to take a down grade on an unimaginable luxury so that somebody at equally unimaginable disadvantage could also have a shot at what the upper classes take for granted is a quite petty and insular, not to mention chillingly uncharitable.
Saying that healthcare for the poor makes you put your children at
physical risk reveals either you have some galactic-sized blind spots
about your priorities and spending, or you're poorer than you can admit
to yourself and probably need to spend under you means for a while
until you get a handle on things, maybe even save a little.
I can't remember ever having received an invoice for someone else's health care changes. If you mean our burdensome taxes make you buy substandard safety equipment for your child's brain housing group, I would invite you to look at your other uneccesary expenses, e.g., those big screen TVs, multiple SUVs with concommitant gasoline bills, various expensive toys and trinkets, lessons, tutors (let's see I made it into a University of California med school while being a tutor to rich kids, certainly not having one), etc. You know the competitive potlatch stuff, proving you have money and status by showing you have money to burn and waste on ostentation and extravagance in order to shame your neighbors, associates and rivals
Vain, wasteful spending was certainly not a value of the Founders of
this country. If you have come to believe that wasting your money on
things you don't need is a core American value, you have been sorely
tricked by people who want your money.
If you have money to burn on stuff you don't need, or on stuff you don't even actually want, but think you gotta have, why not instead get a grip on your values, prioriites, decision-making and behavior and give some of it to charities for the poor and destitute?
So it really is about financial re$ponsibility. If you're not poor yourself, your woes are not the fault of the poor.
`Scrooge and Marley's, I believe,'' said one of the gentlemen, referring to his list. ``Have I the pleasure of addressing Mr Scrooge, or Mr Marley?''
``Mr Marley has been dead these seven years,'' Scrooge replied. ``He died seven years ago, this very night.''
``We have no doubt his liberality is well represented by his surviving partner,'' said the gentleman, presenting his credentials.
It certainly was; for they had been two kindred spirits. At the ominous word ``liberality'', Scrooge frowned, and shook his head, and handed the credentials back.
``At this festive season of the year, Mr Scrooge,'' said the gentleman, taking up a pen, ``it is more than usually desirable that we should make some slight provision for the Poor and destitute, who suffer greatly at the present time. Many thousands are in want of common necessaries; hundreds of thousands are in want of common comforts, sir.''
``Are there no prisons?'' asked Scrooge.
``Plenty of prisons,'' said the gentleman, laying down the pen again.
``And the Union workhouses?'' demanded Scrooge. ``Are they still in operation?''
``They are. Still,'' returned the gentleman, `` I wish I could say they were not.''
``The Treadmill and the Poor Law are in full vigour, then?'' said Scrooge.
``Both very busy, sir.''
``Oh! I was afraid, from what you said at first, that something had occurred to stop them in their useful course,'' said Scrooge. ``I'm very glad to hear it.''
``Under the impression that they scarcely furnish Christian cheer of mind or body to the multitude,'' returned the gentleman, ``a few of us are endeavouring to raise a fund to buy the Poor some meat and drink, and means of warmth. We choose this time, because it is a time, of all others, when Want is keenly felt, and Abundance rejoices. What shall I put you down for?''
``Nothing!'' Scrooge replied.
``You wish to be anonymous?''
``I wish to be left alone,'' said Scrooge. ``Since you ask me what I wish, gentlemen, that is my answer. I don't make merry myself at Christmas and I can't afford to make idle people merry. I help to support the establishments I have mentioned: they cost enough: and those who are badly off must go there.''
``Many can't go there; and many would rather die.''
``If they would rather die,'' said Scrooge, ``they had better do it, and decrease the surplus population. Besides -- excuse me -- I don't know that.''
``But you might know it,'' observed the gentleman.
``It's not my business,'' Scrooge returned. ``It's enough for a man to understand his own business, and not to interfere with other people's. Mine occupies me constantly. Good afternoon, gentlemen!''
Seeing clearly that it would be useless to pursue their point, the gentlemen withdrew. Scrooge resumed his labours with an improved opinion of himself, and in a more facetious temper than was usual with him.
It is your job as the doctor to provide care to the patient and to do everything in your power as a medical professional to keep this person alive, as long as you have the consent of her family with certain matters. It is not your job to walk a fine line with violating HIPAA regulations by broadcasting this all over the internet and it is certainly not your job to worry at the time of treatment about what type of insurance she has.
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