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The case for rationing healthcare

Americans will have to decide what we can and cannot afford.

April 18, 2011|By M. Gregg Bloche

Several years ago, I was asked to speak on end-of-life issues at a retreat for Southern California physicians. A number of doctors there brought up one particular case: an 82-year-old woman who'd suffered a massive heart attack while visiting her daughter.

Her story captures the difficult choices that keep us from controlling healthcare spending. Unless we all confront those choices, the costs of medical care will consume us, stealing away an ever-larger share of our national wealth and driving federal budget deficits to catastrophic levels.

The patient was admitted to intensive care, then put on "pressors" — medications that boost blood pressure by causing muscle cells surrounding tiny arteries to contract. Her doctors quickly concluded that her prognosis was dismal. Aggressive doses failed to raise her systolic pressure above 70 (a worrisome sign). Too much heart muscle was nonfunctioning. Yet she remained awake, alert and chatty.

The woman's daughter was around when the doctors delivered their dire prognosis. The pressors were pointless, they said; the battle couldn't be won. Their prescription was to end aggressive treatment. The patient didn't obviously object to the doctors' plan, but her daughter, a social worker told me, "felt it was an assault."

The daughter began paying close attention to clinical details. She questioned the doctors about their intentions. The doctors, in turn, grew annoyed.

"Her daughter could not let go," one of them later told me, "even in the face of a bad prognosis. She was taking … an adversarial position, almost litigious. What I tried to clarify for her was that this was not an adversarial relationship."

But one of the doctors admitted to some thinking that wouldn't have reassured the daughter: "When we see dollars wasted, that's not a good thing. Nobody presents that to the patient." Keeping the mother alive, which required the high-tech monitoring and ministrations of the ICU, was most likely a waste because her chances for survival were so tiny. "The problem is that individual members only care about themselves, because they don't have the global perspective."

One cardiologist did present this perspective to the patient. According to colleagues, he came to her bedside, told her she didn't have enough heart muscle to survive, then said: "Have you ever stayed in a really expensive hotel, like the Plaza? You know how expensive a room is? Six to eight hundred dollars. Well, you know how expensive this room is? Ten thousand dollars."

The daughter threatened to sue, demanded new doctors and insisted that the staff go all-out to keep her mom alive. Four weeks later, the 82-year-old patient left the hospital on foot. For a year or so, until she died, she divided her time between her daughter' home, an assisted living facility and her own residence.

The doctor who'd complained to me about the daughter's "adversarial position" said her mother's survival astonished him. Yet he stands by the decision he'd have preferred: to take her off pressors and get her out of the ICU — in effect, to let her die. "If you say that the fact that this lady survived means we should do that type of thing for every patient — I'm not prepared to say that," he said.

And then he spoke the unspeakable: "We are subconsciously rationing care, whether we call it that or believe that's what we're doing.... If we didn't, the reality is that we would be facing an absurdity in which we made … near-futile efforts to save one life out of an enormous number of failures. We'd bankrupt our healthcare system."

We want our doctors to go all-out for our loved ones and ourselves. But as voters and consumers, we send a different message. We pick politicians who promise to cut taxes, and we demand low-cost insurance. We're telling government and the healthcare industry to hold the line on healthcare costs, even if it means sacrificing clinical benefits. And we put doctors in the middle of this contradiction.

In recent weeks, private insurers have revealed plans for double-digit rate hikes. Our medical bills are already close to a fifth of our national income, on track to reach one-third within 25 years. Soaring Medicare and Medicaid costs are the main reason for nightmarish federal deficit projections over the long term. Yet as Republicans and Democrats battle over the federal budget to the point of threatening a government shutdown, serious healthcare spending cuts remain unspeakable.

House Budget Committee Chairman Rep. Paul Ryan (R-Wis.) recently proposed to cut Medicare and Medicaid by shifting their costs to poor and middle-class Americans who can't afford them. It's an unconscionable approach, but it at least acknowledges the urgency of gaining control over federal healthcare spending. Neither President Obama nor congressional Democrats have put forth plausible proposals for doing so.

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