February 12, 2009

A Tale of Two Patients

The primary caregiver for her three grandchildren, 59-year-old Lola Sanchez tried unsuccessfully to go to the kitchen to prepare a snack for the four-year-old and found something was terribly wrong with her right leg. She managed to call an ambulance, but by the time the paramedics arrived, Mrs. Sanchez could no longer speak distinctly and her entire right side was paralyzed. Her blood pressure and her blood sugar were sky high. When she reached the hospital emergency room, she was in a coma. Two days later she was dead, a victim of a massive intracerebral hemorrhage, caused by untreated high blood pressure and inadequately controlled diabetes. Mrs. Sanchez had no health insurance.

In the intensive care unit of the same hospital, Samuel Wang, a 92-year old man with advanced dementia, lay curled up in an ICU bed, dependent on a ventilator to breathe. He had been brought in from a nursing home two weeks earlier with pneumonia. Mr. Wang, who could no longer speak or recognize his family, had aspirated—his food had gone into his lungs, a common occurrence in the final stage of Alzheimer’s disease. Because his family asked the physicians to “do everything” to prolong his life, he remained attached to the ventilator, receiving artificial nutrition through a feeding tube in his stomach. A pacemaker helped keep his heart going. One month after admission, he died after an unsuccessful attempt at cardiopulmonary resuscitation. Mr. Wang was enrolled in Medicare, which together with his supplementary medical insurance, paid the entire $125,000 cost of his hospital stay.

These two scenarios are far from uncommon. According to a recent Urban Institute report, 27,000 Americans died of preventable causes because they lacked medical insurance in 2006. Since most people like Mrs. Sanchez with high blood pressure are asymptomatic, they often do not visit the doctor if they are uninsured. But over the long run, untreated hypertension predisposes to stroke. In the same year, according to researchers at the Dartmouth Institute for Health Policy and Clinical Practice, Medicare spent $10 billion on non-beneficial care for elderly individuals with chronic disease such as Mr. Wang. Expenditures on diagnostic tests, physician visits, and hospitalization are three times higher in some areas of the U.S. than in others, without resulting in any better outcomes.

The current administration hopes to help people like Lola Sanchez by increasing access to care. Access is critical: fully 75 million adult Americans are uninsured or under-insured, resulting in the U.S. coming in last among 19 industrialized nations in the rate of preventable deaths, according to a new analysis by the Commonwealth Fund. But it is irresponsible to improve access, adding to the total government expenditure on medical care, without simultaneously addressing its cost. Currently, Medicare and Medicaid alone account for nearly 5% of GDP and Peter Orszag, Director of the Office of Management and Budget, has projected this will rise to 20% by 2050 unless we take dramatic steps to curb escalating growth.

In the move toward health care reform, cost has received short shrift except to stimulate exhortations to limit waste and inefficiency. Waste—ordering duplicate diagnostic tests because of a lack of an electronic medical record, or prescribing expensive brand name medications instead of far cheaper generic equivalents—makes a modest contribution to spiraling medical costs. The main culprit, according to most medical economists, is the American obsession with high tech medicine. Physicians, patients, and families believe that more is better. The faith in technology is further fueled by device-manufacturers, pharmaceutical companies and the media, as well as by our health care reimbursement system. As health care reform proceeds, we should focus on access, quality, and cost. That will mean using our technology selectively in those who have a reasonable chance of benefiting. It will mean changing the medical culture to ensure that patients nearing the end of life do not routinely undergo pacemaker insertion and are not regularly admitted to the ICU, but instead receive competent and compassionate palliative care.

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