Where Healthcare, Ethics & Money Meet
Do you have the special privilege of being on your company's benefit committee with the job of figuring out how to absorb or pass on this year's 22% increase? Or, try being the poor company controller who's whose insurance company just delivered an annual rate adjustment that is four times last year's profit? You would think with all the money spent someone would be happy, but these days the healthcare industry is wobbling under it's own weight.
Of all the issues driving the ever-expanding cost of healthcare, a lack of a coherent national consensus on health policy seems the most intractable to solve. The very success of medicine has made its practice morally complex with hard, unanswered questions. These issues cross moral, social, political and economic boundaries.
Examples include:
- Society's obligation to treat the sick and dying.
- What people want verses what people need based on medical necessity and odds of a successful outcome.
- When to treat and when not to treat.
- Who gets to make healthcare decisions and what criteria are used for those decisions.
- Who pays and what should be covered.
Although many of these questions drive deep divisions in opinion, there is one problem we all understand--money. Premiums are growing geometrically. As of 2001, the national average for monthly family premium had risen to roughly $600 a month ($7,200 per year). Based on current growth trends, by the year 2007, monthly family rates will have doubled to $1,340 per month or a whopping $16,075 per year.
Today, no national process exists to get all these issues on the table for discussion. Often the fights and skirmishes occur between professionals, which the general public never sees. One thing is clear, the stakes are huge and growing everyday. Healthcare touches every single person and is extremely personal. A national healthcare policy must match our hearts with cold science and hard economic realities.
1 You can't have it all and healthcare is no exception. If runaway healthcare dollars reduce education spending (it is happening in many states right now), where do you draw the line? Currently there are close to 41 million uninsured in the country and this number grows in direct proportion to rising costs. Many of these people have chosen to pay their gas and food bills over their healthcare premium. The result is, we still provide for most of their medical care through Medicaid and other programs. The expense has not gone away and eventually is cost shifted right back into the remaining insured's premium. If costs are not held in check only the rich will have insurance and the rest will be dependent on the government.
Question How can we ration care to slow expenses, so that a minimum level healthcare can be affordable to everyone? Who makes those decisions and what does a minimum level of healthcare mean?
2 My sister died of leukemia in 1994 after a five-year battle including two bone marrow transplants. Total billed charges were around $750,000. It was hard and at times, terrible beyond words, but she also had long periods of remission and quality time with her family. Those few years were worth every penny to us, especially her two teenage children. Most of the treatment she received has been abandoned for "better, more effective treatment". Some of those new "treatment procedures" came directly from learning on the earlier patients that died like my sister. For those uniformed, at the edge of death, healthcare is a constant experiment and we are the test subjects.
Question At what point should a treatment procedure be considered a standard medical procedure--1% survival rate, 10% survival rate, 2% cure rate, 25% cure rate? Do you know how those decisions are made today?
3 A few weeks ago my family doctor called regarding my 94-year-old aunt's hip fracture due to osteoporosis. My aunt has been bed ridden in a nursing home for the last five years and has severe senile dementia. The doctor informed me that it was his professional opinion that a hip replacement was not appropriate in my aunt's situation. To my surprise, I find out these kind of operations for the elderly happen often. Most of these costs are supposed to be paid for by Medicare. Many doctors are leaving Medicare because they say they can't afford to take Medicare's low reimbursements.
Question Should the government limit costly services based on age? Should we prioritize basic services and education for children over end-of-life procedures? Should government agencies, the public, family members, and/or doctors make these determinations?
4 I have seen countless miracles of people snatched from death's grasp due to medical prowess. I also have seen brutal treatment regimes carried out on people with no hope of a cure. I am convinced that if people really understood their choices and what those choices really looked like, a significant number of end-of-life hospitalizations would never happen. A large percentage of people die in the hospital surrounded by science and strangers in a frantic pursuit of more treatment. My father, who was rarely sick during his first 84 years, was diagnosed with aggressive, very painful, terminal cancer. There was no hope for a cure. Despite one doctor's recommendation for aggressive treatment, we chose hospice care where my father stayed in his own home during his last four months. As the pain worsened the caregivers provided morphine. He died with dignity in his own home. We want dedicated doctors searching for better more effective options. But, I can tell you that those last few months with dad were precious and the long conversations we had in the quiet of his own home, unforgettable.
Question Should terminally ill patients receive aggressive treatment even when there is no cure? Should providers be required to provide in-depth counseling to terminal patients providing detailed disclosure of options and outcomes? In these situations, should hospice be the first suggestion or the last?
Medical science can do amazing and wonderful things. It is also crossing into the frontier of the scary and unknown. Some of the things we will be able to do, we should never consider as an option. What we do with healthcare and how much we pay are on the table. Unless you want the government, politicians, doctors, insurers, lawyers or others to decide the issues for us, it is time to pay attention and voice your beliefs. But, before you yell too loud, think long and hard about the future and what it might look like.
James N. Clay, is Principal at The Resource Group, L.C. He can be reached at 913.339.0800 or by email at jamesclay@trglc.com.