Sunday, March 07, 2010

How to cope with runaway end-of-life health care costs

There was an interesting article this week on Bloomberg by Amanda Bennett entitled "End-of-Life Warning at $618,616 Makes Me Wonder Was It Worth It" which chronicled her personal saga with dealing with end-of-life health care for her husband. The article also appears as the cover story of Business Week entitled "Lessons of a $618,616 Death - Two years after her husband's death, Amanda Bennett's cover story examines the costs of keeping one man alive".

Ultimately she seems to conclude that spending all of that money was worth it since she believes that it bought her husband another 14 months of life beyond the three that his doctors expected:

... those 17 months included an afternoon looking down at the Mediterranean with Georgia from a sunny balcony in Southern Spain. Moving Terry into his college dorm. Celebrating our 20th anniversary with a carriage ride through Philadelphia's cobbled streets. A final Thanksgiving game of charades with cousins Margo and Glenn.

She also tells us how it was a very personal struggle for both her and her husband. In other words, different people might have dealt with the same situation in a different manner.

Was it really worth it? She tells us:

Would I do it all again? Absolutely. I couldn't not do it again. But I think had he known the costs, Terence would have fought the insurers spending enough, at roughly $200,000, to vaccinate almost a quarter-million children in developing countries. That's how he would have thought about it.

Lucky for her, she had good insurance:

Terence and I didn't have to think about money, allocation of medical resources, the struggles of more than 46 million uninsured Americans, or the impact on corporate bottom lines. Backed by medical insurance provided by my employers, we were able to fight his cancer with a series of expensive last chances like the one I asked for that night.

How expensive? The bills totaled $618,616, almost two- thirds of it for the final 24 months, much of it for treatments that no one can say for sure helped extend his life.

In just the last four days of trying to keep him alive -- two in intensive care, two in a cancer ward -- our insurance was charged $43,711 for doctors, medicines, monitors, X-rays and scans. Two years later, the only thing I know for certain that money bought was confirmation that he was dying.

Some of the drugs probably did Terence no good at all. At least one helped fewer than 10 percent of all those who took it. Pharmaceutical companies and insurers will have to sort out the economics of treatments that end up working for only a small subset. Should everyone have the right to try them? Terence and I answered yes. Each drug potentially added life. Yet that too led me to a question I can't answer. When is it time to quit?

This is a difficult issue. On the one hand we don't want the insurance companies (or the government) deciding when to "pull the plug on granny", but if it is really true that a significant number of Americans will incur upwards of $500K to $750K for end-of-life care, how is that expenditure to be financed? And people wonder why health insurance companies would dare to raise rates by 40%.

So, who is to pay for all of this? Ultimately, all of us do, one way or another.

In my view, sooner or later we as a society are going to have to draw a line and give a hard answer to that question of "When is it time to quit?" In Ms. Bennett's case, they quit only when no other options were available, at any price. I do not see that as a sustainable approach. As a society we need to come up with a robust model for when and how to "pull the plug" in terms of when to simply let nature take its course and fall back on simple palliative care. To my mind, the focus should be more on moderation and moderate measures and less on extreme and extreme measures. In my view, desperation should not have any role in any stage of health care.

Nonetheless, Ms. Bennett's article does put both a personal and human as well as financial face on the issue of end-of-life care.

-- Jack Krupansky


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