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April 09, 2007

The costs of cost control and end of life care

Paul Levy, over at Running a Hospital, is mulling over the war cry of the interventionist: Too much is not enough!

My favorite example from the Dartmouth Atlas project which Paul discusses is the angioplasty/stent epidemic at a cardiology practice in Ohio (4x national rate of stenting). That would never happen today, though, post-COURAGE, right?

As far as end-of-life care goes, why not establish case rates as insurers do for the beginning of life?  It is SOP to pay providers a fixed fee for prenatal care and delivery.  As in any such system, some cases are "winners" for the payors and the others are "winners" for the providers (to be crassly commercial). I know, I know, easier said than done, and when do you draw the line/pull the trigger?  The Medicare hospice benefit is just a baby step in that direction.  Bottom line, once you raise chronic disease and terminal illnesses, we're talking about personal and ethical issues, not "just" health care financing.

But assuming we can talk about this and maybe even get somewhere, what about shifting the assumptions that get us bolloxed up?: e.g., assume hospice or comfort care election unless specifically stated otherwise -- and if aggressive care is elected by the patient or delegate, include a requirement that a physician certify that the care is not futile before it is continued, just as a physician certification is required before  a patient may qualify for Medicare hospice benefit; assume consent to organ transplant unless specifically stated otherwise; etc.

Paul, it's never too late to wade into this river.

-- David Harlow

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Interesting thought for an opt-in policy for aggressive care rather than an opt-out, although I would imagine this would not fly politically and some might say it smacks of 'money is more important than lives.'

All of this is very interesting when discussed at a policy level but how to communicate a emotion-less policy to a patient or family member becomes very difficult, especially if you do not have public support.

Funny you should make the BOL (beginning of life) and EOL (end of life) analogy for insurance reasons because I often compare the EOL to the BOL in my practice as a hospice & palliative medicine physician. The uncertainty inherent in each is one of the most obvious similarities, but there are many others. And now you have given me a new thought for comparison.

Christian Sinclair, MD
Pallimed: A Hospice & Palliative Medicine Blog
www.pallimed.org

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