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Thursday, January 19, 2012

Changing End-of-life Care

When I told my colleague, dear friend, and mentor, Gordon Moore, about this new blog, he showed me the draft of a proposal he had written for Medicare reform. Gordon and I have worked together and exchanged ideas regularly for more than 30 years, so it's not surprising that we agree that we in the Medicare generation are key for reforming the program and reducing its costs. He gave me permission to print what he'd written and to tweak it for length:
To my fellow Medicare recipients, 
I am a retired general practicitioner, now on Medicare.  Like many of you, I am feeling guilty and at the same time defensive about the claim that Medicare expenditures threaten the economic well-being of America.   Defensive because I feel I have earned the right to have good medical insurance as I get older.   But guilty because I know that the growth rate of Medicare does, indeed, threaten the future of our children and grand children.
As I watch the partisan fighting in Congress, I have become increasingly dubious that our government will be able to solve the problem of Medicare costs.  Both sides have staked out positions that block compromise. We are in a stalemate that threatens the nation’s future.
I have concluded that only we Medicare recipients are capable of stepping up to the plate and resolving this dilemma.   I am reminded of Pogo’s famous comment that ‘we have met the enemy and he is us.’
So how could we solve this problem? One answer is that we individually volunteer to remove Medicare expenditures that are wasteful. The greatest waste is in end-of life care.  We spend almost 30% of the Medicare budget on care that ends with death in a year or less.  As a doctor, I saw time and again the relative futility of aggressive medical care in the last months of life.  Not only did I know that such care was vanishingly unlikely to prolong life by any meaningful length, but I also watched the quality of life plummet as aggressive medical care led to hospitalization, loss of function, and prolonged pain and suffering. 
I promised myself that, like Elizabeth Edwards, at a certain point when my doctor calculated that the odds of meaningful survival were low, I would choose to be at home with my family, to receive hospice services for comfort only, and die in dignity. 
How would we know that the time had come to make such a choice?  As a primary care physician, I almost always knew the odds that intensive care would no longer help.  And yet I was relatively ineffective in helping many of my patients accept that conclusion.  Part of the problem is that most doctors find it hard to accept that there is nothing more that they can do to produce a cure.  And for most patients and families, insurance makes care seem “free,” so why not do “everything”?
But we are discovering that this care isn’t free.  It’s just that we are asking our children and grandchildren to pay for our expenditures by reducing the prospects for their own lives.  I’m very uncomfortable with the idea that our end of life care is hurting the generations that follow us, especially “care” that is associated with a miserable quality of life and maximum distraction when our real need is to be comfortable and at peace to come to our own terms about dying.   
So I have been thinking about whether we could start a campaign to reduce the expenses of our own end of life care.  If most or all of us committed ourselves to ask our doctors to inform us when the odds of recovery or significant prolongation of quality of life had dropped below a specific figure (like 1 in 5 or 1 in 10) and if we further committed to asking that all but supportive comfort care be stopped, we could make a significant dent in Medicare’s risking costs.  
But this prospect makes me confront a major barrier to my own participation - that the savings would disappear into relieving our sovereign debt.  That would feel like paying taxes - at best it's a duty, at worst it's taking the money from my sacrifice and using it for many things with which I disagree. 
 As I thought about this, I came to the conclusion that were I to relinquish my ‘right’ to unlimited expenditure at the end of life, I would want it put to a good purpose that would be sufficiently specific to make me proud and others grateful.  
My proposal is that we earmark these savings to make the generations that follow healthy and productive, to make it possible for them to achieve the quality of life that my generation has been able to enjoy.  
To do this I propose that we form a National Health Fund to which our individual contribution, calculated actuarially, be made when we forgo high cost/low yield end of life “care.” This fund would be used in the best way we know to assure healthy productive young people capable of contributing to our common good – to combine public health, education and personal care in initiatives to address the major behavioral factors that lead to illness and disability – obesity, lack of exercise, violence, and smoking.  There is little we could do in personal medical care that would deliver as much improvement in the health of our nation.
We Medicare recipients are capable of improving care and reducing costs.  We can be the generation that says ‘it’s not all about me.’ We can lead the way to a new level of civil discourse about the future of America.  Our parents did this for us with their sacrifices during the Great War; isn’t this crisis the war that we can fight to make this country better for our children?
I want to (a) thank Gordon for letting me publish his vision of Medicare reform and (b) invite other readers to send me their best ideas!

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