Money & Medicine: Reflections on the message

Tags: money, medicine, end-of-life, care, pbs, health care reform, advance directive

We have known for years that the payment system for health care services provides incentives for hospitals and physicians to run more tests and perform more procedures. Debuting this week, a PBS special “Money & Medicine” examines not only runaway health care spending, but also the danger patients face from over-diagnosis and over-treatment.

“If you add up medical errors, drug interactions, and hospital-acquired infections, medicine itself is the third leading cause of death in this country,” one expert says in the film. And another, “I’m paid more when I harm my patients; I’m paid more when I do more, even when it’s not beneficial.”

Contributing to the estimated 30 percent of U.S. health care spending—$800 billion a year—that pays for unnecessary services, the filmmakers identify several forces at play. First, briefly, the providers:  “One person’s waste is nearly always another person’s income, and income turns into strong political defenses of areas that are classic waste.” Next, the patients: Patients’ demands are changing the behavior of providers. And particularly in end-of-life care, the family can demand “full court” care regardless of the odds.

And, finally, the system itself: “The big entitlement programs, with the vast amount being Medicaid and Medicare, they’re on auto-pilot. They automatically increase year by year. By 2050, they’ll be consuming more than 70 percent of the total federal budget. Oh, wait a minute, so will interest on the debt. We can’t afford it.”

Said more succinctly, “when payment incentives are aligned towards more care, when [providers’] worries about defensive medicine are aligned towards giving more care, and when their patients seem to want more care, it keeps driving in the same direction towards more, more, more.”

The filmmakers frame the discussion by comparing two world-renowned hospitals, UCLA Medical Center in Los Angeles and Intermountain Medical Center in Salt Lake City. Patients at UCLA have far more office visits and receive many more diagnostic tests for similar conditions than Intermountain, but don’t experience better outcomes.

Intermountain improves patient outcomes and decreases the overall cost of care by applying evidence-based standards to their process and relying on team-based care. They say there’s a shift happening in medicine: Hospitals are moving away from each physician acting as a standalone expert, “god-like in their powers,” toward a team of physicians managing the complex knowledge necessary to deliver the best care to a patient.

The film highlights four areas—inappropriate elective induction and elective C-sections, end-of-life care, imaging, and aggressive cancer screening and treatment. The most striking portrayal of waste is told in the examples of excessive end-of-life care. TAFP has quoted many times before that a third of health care dollars are spent in the last two years of life, and the film presents situations where care and its related costs are driven by the emotions of family members. It stops short of blaming families completely as even the hospital executive says he would demand whatever is needed if the case involved his own family, but it certainly places responsibility away from the usual suspects.

And as other viewers will find, I sympathized with the doctors instead of the family. One exasperated critical care physician describes the prognosis for a patient as “extremely poor.” He explains to the family that recovery to meaningful neurological status where the patient will be able to recognize them or communicate in any way is zero. The doctor explains what would be required to keep the patient alive, which opens him up to additional injury, and asks the family that if he, the patient, were able to speak, what would he want? One family member says, “He would want to live.” Another agrees, saying to the doctor, “I want him to live. Whatever you can do.”

“It is enormously troubling to focus our resources on patients in his condition who really have no reasonable chance of recovery to a level of function that most of us would find acceptable,” the physician says to the camera. The ICU was designed as a place where patients would receive treatment to be able to leave, but it is now often the last stop, he says.

Texas is unique among other states when dealing with so-called futile care. Though it has come under fire in subsequent legislative sessions, the 1999 Legislature adopted the Texas Advance Directives Act, which authorizes a health care facility to discontinue life-sustaining treatment 10 days after giving written notice if the continuation of this treatment is considered futile by the treating medical team. California doesn’t have this legislation. Neither does Utah, but Intermountain employs the care team to speak to the patient and/or the families to help them make more informed health decisions.

Paramount to the issue comes through a message briefly introduced in the film: A discussion about care at the end of a patient’s life can’t happen in a rescue care situation. Health care professionals are trained to keep patients alive in an emergency situation, and they do this well. This discussion must happen when the patient is able to express his or her wishes, and it must involve his or her family and a trusted primary care physician.

That moves the emotion away from family versus physician. “It’s not rationing to get rid of stuff that’s bad for you. It’s not rationing to get rid of care that won’t benefit you. It’s rational.”

Watch Money & Medicine online at www.pbs.org/programs/money-medicine.

– kalfano

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