To start, I’m extremely ignorant about insurance and medicare. So perhaps this is a matter on which I merely need my ignorance fought. Second, my questions may be founded on misinformation, but here goes.
Was talking with a friend yesterday. His 72 year old brother had just undergone surgery for congestive heart failure. According to my friend, the device that was implanted had a price tag of $600,000. (Of course, who pays how much may be another set of questions.) I asked what the prognosis was, and my friend said 10 years. The alternative would have been a progressive decline. The brother is retired, and not independently wealthy.
This conversation really got me thinking about how much health care any individual ought to receive. Modern medicine can do amazing things - but I’m not sure how we could scale the costs to provide such services to everyone. I can imagine if I were 72 yrs old, and was offered $600k+ in health care for which I had to bear little of the cost, I’d take it. But I wonder if I would feel undeserving of such an expenditure.
I realize it is likely impossible to dole out treatment based on merit: for example, treat the artist and the brain surgeon, but not the homeless or unskilled worker. But could there be a way to put a maximum cap on healthcare received over one’s life - after which one is just made as comfortable as possible as they die?
I’m all for offering free “basic” (however you define that) care for everyone: vaccinations, pre-natal, lifestyle counseling, many meds… But I just don’t get how any/each individual could potentially receive hundreds of thousands of dollars of care - whether paid for by insurance or medicaid/care. I also know it is problematic to link disparate social issues, but I’d far prefer that that $600,000 be spent on education and job training for younger people, than to allow a septuagenarian lie on the couch and watch TV.
I’ll stop here, let you all tear me a new one, and decide if I have anything more to say besides apologizing for being such a poor excuse for a human being!
I agree with you, that these are questions that we’re currently wrestling with, and will continue to wrestle with.
In the US, at the moment, these things are largely determined by doctors. Sometimes those doctors are working in teams, but it’s still largely up to the doctors, how much time and energy they’re willing to spend writing appeals to your insurance company when their claims and preapprovals are denied, and (sometimes) arguing with ethics committees at their hospitals.
Some hospitals are more intervention happy than others. (Here in Chicago, if you want them to “do everything,” you should go to Northwestern or University of Chicago or Rush. If you want to be left alone to die, go to St. Bernard’s or Jackson Park. Something in between, Christ or UIC.) Big teaching hospitals and research hospitals are more likely to approve doctors’ plans for expensive treatments that may provide some limited benefit, because they also benefit their teaching and research programs.
Doctors, in turn, base their recommendation on their agency policies, analysis of risks vs benefits, the patient’s overall health status, and their own professional opinions, informed by journal articles, the guidelines and/or best practice statements of their professional organizations, consultations with other doctors and, occasionally, conversations with the patient about the patient’s own goals. Traditionally, there was a strong feeling that cost shouldn’t enter into the decision making process, but that’s changed in recent years as costs have risen. Good article about how some specialties are beginning to factor cost into their guidelines here: Cost of Treatment May Influence Doctors - The New York Times
Assuming it would be a good idea, it would be untenable socially (and as a result politically). People would see their loved ones die (or become infirm) while knowing that they could live in good health for another 15 years, if only they had the money to pay out of their own pockets. I know there’s already such a discrepancy, especially in the USA, but being flat out told “he’s going to die even tough we could save him easily because you’re too poor” and looking at the wealthy who are back on their feet after open heart surgery would just rile people up. People expect that we’re at least mosty equals when facing death.
Besides, if for some reason some arbitrarily cap had to be put in place, the one you propose would probably be the most poorly perceived. A child born with some medical condition could exhaust his “allowance” by the age of 10, can you imagine the ruckus? Or, less tragically, some medically unlucky but otherwise still productive guy at the age of 30.
You’d be better off by flat out refusing any medical procedure for anybody if it costs more than X. Or by denying expensive care to people after age Y. It would seem a bit more egalitarian hence a bit less infuriating.
By the way, I often wonder how non-wealthy people living in developing nations deal with the idea that the ailment they’re suffering from could be easily treatable if they where living someplace else or simply had a bit more money.
Well this family of 4 has to starve but I don’t even consider them because I get my $600,000 procedure to (possibly) live another 10 years.
Not that the above is an accurate scenario as that $600,000 burden would be spread among all young workers, but to say you would never consider the burden you place on others for health care you personally can’t afford is astonishingly selfish and (borderline) immoral.
My old private (PPO) insurance* had a ‘Lifetime Cap’ of $7,000,000 (or maybe it was $6Mil).
That seemed horribly arbitrary to me, but then again, I was not liely to ever hit it, so it was not a concern.
But it does answer the OP: let the Insurance Company decide where the cap is.
with which, prior to ACA, I was stuck - my ‘Pre-Existings’ meant that I’d never be able to buy any other insurance at any (even remotely viable) price.
How about we just offer the septugenarian $10,000 and a suicide pill?
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Really? You’re that selfish?
Well this family of 4 has to starve but I don’t even consider them because I get my $600,000 procedure to (possibly) live another 10 years.
Not that the above is an accurate scenario as that $600,000 burden would be spread among all young workers, but to say you would never consider the burden you place on others for health care you personally can’t afford is astonishingly selfish and (borderline) immoral.
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Why assume that the $600,000 goes to starving families or education? What if it goes to NASA or the National Endowment for the Humanities? Both of those provide a social benefit.
Lifetime (and annual) caps were made illegal by the ACA. So now insurances companies try to deny everyone equally, because they can’t rely on there being an end in sight.
Well, that’s certainly true. Lots of things that used to be billed as one big chunk are now billed piece-by-piece to take advantage of Medicare and health insurance reimbursement policies.
Philosophically, I abhorred W Bush’s proposal for personal medical savings accounts, because I felt it would be the most detrimental to those who are neediest. However, I see tremendous problems with a system such as Medicare, where the recipient has “no skin in the game.” What incentive is there for a patient to be circumspect in their consumption of medical treatment, if they know they are not going to be paying any portion of the bill?
Here is where my ignorance re: medicare comes into play. I have no idea what premiums for supplemental insurance are, but they would have to be awfully high to cover that population’s anticipated healthcare needs.
Also, I am not suggesting that every - or even most - doctor is unscrupulous in prescribing treatment/testing simply because it will be compensated. Fear of liability and unclear family directives play a huge part.
I guess I have a pretty low sense of my “worth” to society - and am likely blinded by my good fortune. I’m not sure exactly what extent of heroic measures I feel I am “worth.” In my 50s, I suspect I will feel I “deserve” less and less over the coming decades. I’ve never complained about the taxes I pay, as I support the provision of various governmental services. But I do have a sense of “fairness” as to what “benefits” I deserve. I’m very fortunate that I have never been destitute, nor have I had chronic disabling health conditions. And I’ve been employed, with health insurance all of my adult life.
I often encounter issues on which my values apparently differ from many/most. But it surprises me that, when most people seem to consider cost in just about all of their purchase decisions throughout their lives, that they seem to believe their should be no limit to the health care they receive. Sorry to say this, but just about everyone I have ever met just isn’t worth that much!
[Tongue firmly in cheek] - Maybe we should give everyone a couple of million when they are born, for them to spend/save/invest as they wish - with the expectation that that covers their lifetime health care. When it is gone, they are euthanized!
What proportion of people do you think would push for additional and unnecessary, uncomfortable, time-consuming and potentially hazardous medical treatments?
I’m not aware of people undergoing treatment for the heck of it.
I live in a country where I can get all the medical treatment I need and not need to pay for it at point of delivery. I don’t know of anyone who actively seeks treatment they don’t need.
Might it happen? In a few limited cases of course, people are wierd but I’ll happily have my tax dollars put consumed by a small amount of wasteful behaviour if it means the system as a whole endures.
Yeah, I can’t say that I’ve ever had a patient decide not to take their medicine because when they get sicker, their doctor visit won’t cost them out of pocket. I’ve had several who don’t take their medicine because they can’t afford to pay for it out of pocket, though…
My understanding - based on nothing more than having read several articles on the subject lately - is that in the US, considerable improvement could be made regarding communicating the quality of life that will result following treatment, and continued costs (financial and otherwise.)
I personally have great difficulty with the provision of most care beyond palliative for individuals with advanced dementia.
Also, there is a significant issue regarding DNRs and other directives. Once someone is put on a resuscitator, it can be very difficult to take them off. Once that pacemaker is implanted, it is going to keep beating for the battery’s decade-long life. And these decisions may not be being made by the patient.
Since Medicare pays no more than 80% of the physician’s charge for covered treatments, the patient clearly has skin in the game.
OK, you’re clearly aware that Medicare recipients probably need supplemental policies. They come in a variety of different price/coverage ranges - none of them cheap. And, depending on how one’s health changes, what works for someone one year may not be adeqaute the next.
That’s because very few of the other purchase decisions one makes don’t carry the possibility of dying if you cheap out.
When my nephew was 40 he suffered a lightning infection that led to multiple organ failure. His family decided on no heroic measures but SURPRISE, he recovered. His time in the hospital, even without all the end-of-life heroic measure, easily was more than $2 million. He’s healthy now, and employed, but of course, he’ll need a somewhat higher level of medical care than the typical person his age for the rest of his life. So at what point should we say “you’ve cost society enough now”?
Generally, patients are exempted from insanely high costs. At some point it becomes ridiculous to recover money from patients. Of course, before that happens, we (healthcare enterprises) do make at least some effort to get your house and savings. A savvy patient can generally negotiate her way around that, but that’s a different story.
It’s a bit of a canard to pretend there should be no upper limit on the healthcare spend for a given individual. Neonates (esp the premature) and the dying are the two groups who most often have spectacular bills.
In our “someone else should pay, and society should be generous to all independent of ability to pay” culture, it’s kind of fun for me (as an observer of people) to see the reactions to excessive cost. They are quite rare. More commonly people like having a lot spent on them b/c it makes them feel more worthy. Kind of an increase in personal significance achieved at a pooled cost.
Right now no one has an incentive to care about health costs. No healthcare enterprise wants to shrink. No insurance company wants to sell a cheaper product. No one wants to be the one whose care is diminished for a savings which benefits the common good. And for us healthcare workers, the whole thing is full employment, even when the economy is bad. So we are likely to mention the topic right up until cost cutting cost us our job. Then the most important thing is DOING EVERYTHING POSSIBLE.
Bottom line: Please give healthcare an unlimited check. When you are done, please raise some more money. When you are out of money, please borrow from your children. Let’s do this for as long as possible.
Many thanks,
Chief Pedant
Fully employed, and likely to stay that way as long we can avoid the Death Committees
Did not realize you are a physician. Good to hear your perspective. Do you mind generally describing your practice area?
Very well put. With respect to the health care providers, I’m astonished at how little healthcare money actually ends up in the pockets of doctors, nurses, therapists, etc. Earlier this year, I underwent a pretty significant orthopedic surgery - I was shocked at what a small portion of my bill went to the surgeon. IIRC, his fee was less than the plates and screws that were implanted.
In my OP I referenced a $600k device. How much of that price is allocated to R&D? How much to liability? How much to profit? Moreover - how much did who actually pay?
2.7 million Americans with Hep C. $100k in treatment for each of them? ($200k if a second course is needed.) Sorry I am such an ogre, but if you show me someone in their 50s who has never held a longtime job, who may have been in and out of incarceration, and who may have lengthy history of substance abuse - I don’t see it as automatic that that person is worth $100k. Of course, I don’t know how you would be able to draw any such lines. Maybe instead of $100k in treatment, we could offer folk $25k in cash, for a waiver of any future right to other than palliative care! Or maybe $50k, followed by a bullet when it is spent!
kunilou So medicare pays 80%, and supplemental insurance is pricey. That insulates the poor and the wealthy. The poor have no assets to attach, and the wealthy have no problems paying for supplemental. Actually, I suspect supplemental is not out of reach for many middle class folk, provided they planned for retirement.
I wonder how the younger generations are going to react, when the older generations keep living longer and longer. It is all fine to say each life should be sustained - but at what cost?
