In the debate over health reform, there has been an increasingly emotional argument over whether controlling medical cost growth will require rationing of care. The answer is: Of course it will. We ration care today, but do it in a profoundly irrational way. Reformers hope that health reform will allow us to do it in a more sensible manner, based on medical evidence. For instance, perhaps we'll treat back pain with physical therapy more frequently instead of surgery--a choice that may provide similar outcomes at far less cost.
However, when it comes to the frail elderly, I met a woman who put the issue of rationing health care in powerful perspective. As part of my research for my new book, Caring for Our Parents, I spent some time visiting a hospital ICU. During one visit, on morning rounds, I met "Mrs. Williams" and the doctors and nurses who cared for her.
This is her story: Mrs. Williams, who was in her mid-90s, had been admitted to the emergency room the night before with severe shortness of breath. A resident of a local nursing home, she was very ill. Although her mind was sharp, she had Stage IV lung cancer and congestive heart failure. Mrs. Williams had no family, but did have a living will.
After Mrs. Williams' breathing was stabilized, an ICU doctor, the unit's nurse manager, and a social worker met with her. They told her (in a much kinder way than I am recounting here) that her breathing problems would only get worse. They said she had two options: They could hook her up to a ventilator that would help her breathe. She might live another month or two, but would remain on the machine for the rest of her life and be unable to speak or eat. Alternatively, they could keep her comfortable but not take extraordinary measures. In that case, she would probably die within a day or two.
She chose the ventilator, and did live a few more months. She spent much of that time in the ICU, because no local nursing home had an available "vent" bed. She was eventually transferred to a skilled nursing facility, but was readmitted to the hospital two more times before she died.
The ventilator prolonged her life, but her quality of life was extremely poor by almost any standard. I don't know what it all cost, but my guess is well in excess of $50,000.
Very sick patients such as "Mrs. Williams" account for as much as 80 percent of Medicare spending. We could save a lot of money by allowing patients like her to die quietly and comfortably.
But who is going to make that call? Sometimes we make these decisions ourselves, perhaps with the help of loved ones or clergy. But imagine the uproar if Medicare determined it would no longer pay for vent care of a terminal patient. Or if a private insurance company refused. It is one thing to talk about rationing in the abstract. But when it gets down to it, these are hard, painful choices.
If we are going to get costs under control, we are going to have to confront these issues. If not, we will have no choice but to continue to raise taxes and insurance premiums to pay for this kind of high-tech end-of-life care.
Which is it going to be?