Sunday, August 16, 2009

End of Life

There has been a lot of discussion lately about the cost of care during the end of life period.

I wonder when you start counting the end of life period especially if you don't know when the end occurs?

In the recent house bill there was a provision, since removed, that reimbursed doctors who provided end of life counseling.

Some senator or congressman I read said that having counseling like that at the end of life was too late and it needed to happen 20 years earlier. Thought that was interesting.

I noticed an article in the Wall Street Journal that reported some rather old statistics. The article referenced a 2001 study. That's 8 years ago and I suspect things might be different now but I didn't really find more recent data (which is not to say it doesn't exist).

However, I paid more attention to the graph than the statistics after I noticed it.

But back to the stats: The 2001 study reported that each year about 5% of Medicare beneficiaries die and that spending in the last year of life accounted for 27.4% of total Medicare spending. So that last year of life is definitely expensive.

I think that was true in my parents' case but only if I include the cost of caregivers I hired and paid for myself. I never did know really what hospice cost so I can't comment on it.

Just last Friday though an attorney friend told me that he really thought we all needed end of life counseling in order to cut medical costs because that's where the most money is spent. It is kind of like robbing banks I guess.

That same idea definitely is repeated in the WSJ article.

There's even mention of a report by The Urban Institute that concluded about $10 billion per year could be saved with "better managed end-of-life care." How this would be done:
"The savings would result from training aimed at discouraging doctors from providing care simply because they would get paid for it, and from having teams at hospitals help terminally ill patients manage their pain once they chose to stop treatment, among other things."
Well there is talk about the cost of the health care plan being about $1.5 trillion over 10 years or some $150 billion per year. So $10 billion per year savings would be about 7%. Really doesn't seem like that much when you think about it that way -- at least to me.

About then I noticed the graph.

My next thought was a brief memory flash of that 1973 movie, "Soylent Green." It is set in the year 2022 in New York City where 40 million people live. There are government assisted suicide ("going home") centers ("clinics"). Soylent is a giant company in cahoots with the government that makes processed food because real food is long gone.

The newest Soylent product is a wafer called Soylent Green.

Turns out that it is made from humans who have "gone home."

I wonder if the "green" comes from the idea of recycling life?

You do have to admit that according to that Kaiser graph we could save a lot of money if all of us 65 and older just went "on home." Or maybe we should make it 3 score and 10.

We could save even more if we moved the age down to say 60. Then you wouldn't even have to pay social security at all. That would solve the social security problem, go a long ways to fixing the medicare problem, eliminate a lot of trouble with old age diseases including Alzheimer's and Parkinson's, and probably help the unemployment situation.

It is interesting to me that the cheapest years are 5 to 17. But really it is pretty much the same until age 45. Save a lot if you cut off at 45.

I started thinking about the cost for a family of 4 let's say: Father and mother in their 30's and 2 children say 5 to 17. It works out to about $7,500 per year. If I applied it to my family (me and my wife) then it works out to just about $10,000 per year. That's interesting because that's quite a bit less than my health insurance costs my business. My parents did not spend anywhere near $8,776 per year until they were about 85.

Then I began thinking about how much is an extra hour of life worth? Or an extra day? Or an extra week? Or an extra month? Or an extra year?

Depends I guess on whether it is you or someone else and whether or not there's pain or unawareness or depression or all sorts of other parameters.

It's quite a bit easier I suspect if it is someone else and someone you dislike to boot. If you like them then its probably harder.

What do you tell someone in end of life counseling? "Wow, you're about to die and really there's no sense in prolonging your life. Why don't you just go ahead and check on out now and save us all quite a bit of trouble and don't be so damn selfish."

Probably not that crude. Would be smoother -- more like Soylent Green I imagine or some of the dialogue in 1984. "Wouldn't you like to just lie down here and enjoy the pretty pictures of Earth they way it used to be and have a nice, long, deep sleep?"

Of course there's no problem really if someone has an advance directive that specifies no heroic measures be taken to prolong life. No problem because that's the consensus of the majority.

But what about the person that goes against the majority and either has no directive or actually has the gall to specify his or her desire for longer life? What then?

Does not society have the right, indeed, the obligation, to force that person to accede to the best interest of society?

Probably we would have some kind of boards established like the old draft boards I remember from the Vietnam War era. Everyone will get a card with a designation. Some people we need to keep around longer.

I'm going back to reading 1984 now.


Lori1955 said...

It's been ages since I read 1984 but Soylent Green, I remember very well. Scary stuff. I wonder just when it was that we stopped valuing life.

~Betsy said...

Thought provoking post as usual, Terry.

rilera said...

Terry, that chart doesn't even factor in the care that we all gave our loved ones as caregivers. We caregivers save billions in money and received very little support. But I know we would do it all again out of love for them.