When care is worth it, even when the end is death

You’ve probably heard that we spend a lot of money on patients who die. It’s true: about one-tenth of the money spent on direct care goes to people who die each year. Among Medicare patients, the figure is much higher, about one-quarter.

You may be shocked by those statistics. What health care system would squander so many dollars on patients who don’t benefit? Or maybe you’re saddened. No humane system would subject patients to painful interventions and procedures that serve no purpose.

The idea that we waste money on terminal patients has caught on; the simplicity of the conceit makes it appealing to policy makers. And the data to support it keep coming, because it is easy for researchers to measure how much is spent on patients before they die.

. . . [C]aring for the sick means caring for people who may die. Providing care means reducing the chance they may die — not eliminating it. . . . [T]he policy conceit that spending money on patients who die is a waste overlooks the core purpose of health care — to prevent or forestall illness, disability and death among patients at risk of those outcomes.

It also overlooks a key correlation in health care. When people get sicker, they need more intensive — and expensive — health care services. But when they get sicker, they are also more likely to die. When I met my patient, I took him to the intensive care unit, the second-most-expensive place per minute in any hospital. The other place he went, twice, was the operating room — the most expensive place.

Healthy people, who are unlikely to die, are also very unlikely to find themselves in those settings. Thank goodness. Thus, spending will always be concentrated on people who are the sickest. When one examines spending on patients who die, dollars will be concentrated there, too.

. . . The more nuanced reality is that some aggressive treatment delivers value and is appropriate, even though some patients who receive such care die; other treatment is too aggressive and should be curtailed no matter what the short-term outcome. . . . The important thing is that it’s not all of one and it’s not all of the other.

Today the medical profession lacks a shared understanding of which patients are which. That gap must be addressed. It will be an excruciating task, and it will be politically noxious. Someone will again accuse officials of forming death panels. But leaving the distinctions to individual doctors leads to inequities, harm to patients, distrust in medical care and lawsuits; ignoring the problem should not be an option, either. NY Times