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Old 03-23-2012, 09:51 AM   #101
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Yes. And that the value of the services changes with frame of reference. I can sit here and objectively "know" that $200,000 buys more happiness and "good" if it is used to buy basic meals, vaccinations, textbooks, or other items rather than surgery and supportive care for an 80 YO cancer patient. But if that cancer patient is a loved one and this is the (very miniscule) chance to get another few years of life, and the family isn't ready to let go, and the money is "someone else's" then the situation is different.
How about a 60 year old cancer patient? Equally as worthless to society as an 80 year old.
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Old 03-23-2012, 09:55 AM   #102
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Folks, this thread is getting dangerously close to "baiting for an emotional response" which is a violation of the Community Rules. Let's try to keep this on track without incendiary or emotionally charged rhetoric so we can keep the thread open. Thanks!
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Old 03-23-2012, 10:36 AM   #103
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Folks, this thread is getting dangerously close to "baiting for an emotional response" which is a violation of the Community Rules. Let's try to keep this on track without incendiary or emotionally charged rhetoric so we can keep the thread open. Thanks!
I apologize for the last post. Let me try to be more thoughtful. Who should be making these value decisions? In the past it was the Dr. along with the patient and family members. And yes emotions drive up costs and lead to some improper decisions. But aren't you a little scared that these decisions are being made by an administrator who benefits financially by not spending money on the patient? If you consider solar energy, for instance, even though it is now not cost effective, by investing in it we develop new technologies that may someday be more efficient than what we use now. Many of our life extending drugs, procedures, and technologies were developed by keeping 80year old patients alive. Our youth has benefited from this learning process.
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Old 03-23-2012, 10:48 AM   #104
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I apologize for the last post. Let me try to be more thoughtful. Who should be making these value decisions? In the past it was the Dr. along with the patient and family members. And yes emotions drive up costs and lead to some improper decisions. But aren't you a little scared that these decisions are being made by an administrator who benefits financially by not spending money on the patient?
Well, that's the conundrum in a nutshell. I may not like it and maybe I'd prefer other alternatives, but I recognize that our financial resources are finite and there are situations where tough, even gut-wrenching, choices have to be made because we can't afford nearly infinite spending for everyone who might live a few more weeks with heroic measures.

I admit might change my tune if I were in that situation and it's easy to say now, but *right now* if I were terminal and I had (at best) a few weeks or a couple months left to live without expensive intervention that would do little more than give me a few more weeks or marginal-quality life, I'd rather see the cost of such heroic measures go to providing care for the poor and underinsured that actually had a chance to cure conditions that will give them many more years. Just give me palliative care, keep me out of pain and let me go.

For obvious reasons, we'd rather not think about things like a cost-benefit analysis when it comes to health care -- we'd like to think no amount of money is too much to save a life or prolong a life and we believe that our lives are priceless and "money is no object" -- but in the real world, as much as it sucks, that's not feasible. Health care, IMO, needs a utilitarian approach; the most good for the most people with available financial resources.
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Old 03-23-2012, 10:56 AM   #105
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Other countries, such as Japan, Switzerland, and France, do not appear to find this such a struggle. Is there perhaps something about the US that makes this issue more of a challenge?
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Old 03-23-2012, 10:59 AM   #106
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I apologize for the last post. Let me try to be more thoughtful. Who should be making these value decisions? In the past it was the Dr. along with the patient and family members. And yes emotions drive up costs and lead to some improper decisions. But aren't you a little scared that these decisions are being made by an administrator who benefits financially by not spending money on the patient?
I think in reality the situation is who is going to be making the decision, a bean counter in an insurance company, or a bean counter in a govenment bureaucracy? No matter what happens moving forward, only in the case of the wealthy is the decision going to rest in the hands of the Dr. and the patient or family. I'm not happy with the situation, but like Ziggy I recognise that in a world of finite resources there will be choices made that people won't like. The easiest (not best) way to live with the decisions is to keep a significant distance between the person making the decision and the human face of the result of the decision.
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Old 03-23-2012, 11:08 AM   #107
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Well, that's the conundrum in a nutshell. I may not like it and maybe I'd prefer other alternatives, but I recognize that our financial resources are finite and there are situations where tough, even gut-wrenching, choices have to be made because we can't afford nearly infinite spending for everyone who might live a few more weeks with heroic measures.

I admit might change my tune if I were in that situation and it's easy to say now, but *right now* if I were terminal and I had (at best) a few weeks or a couple months left to live without expensive intervention that would do little more than give me a few more weeks or marginal-quality life, I'd rather see the cost of such heroic measures go to providing care for the poor and underinsured that actually had a chance to cure conditions that will give them many more years. Just give me palliative care, keep me out of pain and let me go.

For obvious reasons, we'd rather not think about things like a cost-benefit analysis when it comes to health care -- we'd like to think no amount of money is too much to save a life or prolong a life and we believe that our lives are priceless and "money is no object" -- but in the real world, as much as it sucks, that's not feasible. Health care, IMO, needs a utilitarian approach; the most good for the most people with available financial resources.
I agree in general with you. Here is where I disagree with the utilitarian approach. Money to pay for for vaccines, routine visits for the flu, a few stitches, is why we should all have jobs. Money for surgery is why we should have insurance. I don't think we should be spending Bobs pacemaker funds on Jim and Sues birth control pills. If we want to treat healthcare as a business then let's do it by golly! How about a healthcare budget for healthcare and a humanitarian budget for social issues. We have those budgets so intertwined that we can no longer see the forest for all the trees.
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Old 03-23-2012, 11:54 AM   #108
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How about a 60 year old cancer patient? Equally as worthless to society as an 80 year old.
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I apologize for the last post. Let me try to be more thoughtful. Who should be making these value decisions? In the past it was the Dr. along with the patient and family members. And yes emotions drive up costs and lead to some improper decisions. But aren't you a little scared that these decisions are being made by an administrator who benefits financially by not spending money on the patient? If you consider solar energy, for instance, even though it is now not cost effective, by investing in it we develop new technologies that may someday be more efficient than what we use now. Many of our life extending drugs, procedures, and technologies were developed by keeping 80year old patients alive. Our youth has benefited from this learning process.

And you don't think other countries make that decision

My wife's first husband got cancer at 40YO... stage 4... can't remember what kind... he lived in another country... they sent him home to die... which he did within two months...


We DO have a finite amount to spend... and from all indications we are spending a lot more than any other country with little to show for our extra spending... is the extra spending end of life care? CYA medicine? Docs ripping off the system? I wish someone could figure it out and get it fixed because, as a country, we can not afford the system we currently have....

PS... the schools also say we need to spend more to educate our children, and the police say they need to spend more to protect the citizens and the X need more etc. etc... you see where this is going... everybody needs more and we can just not afford it all... we have to make tough choices of what we want as a society...
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Old 03-23-2012, 01:37 PM   #109
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And you don't think other countries make that decision

My wife's first husband got cancer at 40YO... stage 4... can't remember what kind... he lived in another country... they sent him home to die... which he did within two months...


We DO have a finite amount to spend... and from all indications we are spending a lot more than any other country with little to show for our extra spending... is the extra spending end of life care? CYA medicine? Docs ripping off the system? I wish someone could figure it out and get it fixed because, as a country, we can not afford the system we currently have....

PS... the schools also say we need to spend more to educate our children, and the police say they need to spend more to protect the citizens and the X need more etc. etc... you see where this is going... everybody needs more and we can just not afford it all... we have to make tough choices of what we want as a society...
If I would have made the comment about the 60 Y/O cancer patient 50 years ago ( and sent it by smoke signal ), I would not have felt compelled to apoligize for it because that was the average life expectancy. Certainly, I agree that all of our economic problems can be fixed if we can significantly lower our life expectancy. And that can be easily attained by not treating the significantly ill, regardless of age.
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Old 03-23-2012, 02:25 PM   #110
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All interesting and provacative replies. No easy answer. I just think we all should have the right to live long enough to see the Cubs win the World Series.
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Old 03-23-2012, 02:42 PM   #111
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Yes. And that the value of the services changes with frame of reference. I can sit here and objectively "know" that $200,000 buys more happiness and "good" if it is used to buy basic meals, vaccinations, textbooks, or other items rather than surgery and supportive care for an 80 YO cancer patient. But if that cancer patient is a loved one and this is the (very miniscule) chance to get another few years of life, and the family isn't ready to let go, and the money is "someone else's" then the situation is different.
I'm not exactly sure what point your driving at, or what solution you might prefer, but I'll tackle a couple of different thoughts I had.

1) Under any reasonable health care scheme, a $200,000 expense is going to be insured. So however we choose to proceed we're going to be "spending someone elses money" in the scenario you've outlined.

2) If the "someone else" happens to be the public, then the public has a right to deterimine whether such expenditures are wise. If the "someone else" happens to be a private insurance company, I suspect they will also only pay for treatments they deem appropriate.

3) If either the public or insurance company deems those expenditures unwise, there is nothing preventing the family from spending $200,000 of its own money on the treatment.
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Old 03-23-2012, 02:43 PM   #112
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Folks, this thread is getting dangerously close to "baiting for an emotional response" which is a violation of the Community Rules. Let's try to keep this on track without incendiary or emotionally charged rhetoric so we can keep the thread open. Thanks!
Thank you for the helpful guidance!
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Old 03-23-2012, 03:03 PM   #113
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.... I just think we all should have the right to live long enough to see the Cubs win the World Series.


Just what kind of life expectancy are we looking at?

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Old 03-23-2012, 03:09 PM   #114
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If I would have made the comment about the 60 Y/O cancer patient 50 years ago ( and sent it by smoke signal ), I would not have felt compelled to apoligize for it because that was the average life expectancy. Certainly, I agree that all of our economic problems can be fixed if we can significantly lower our life expectancy. And that can be easily attained by not treating the significantly ill, regardless of age.

From the tone of your reply, you missed my point... I did not say anything about 'significantly lower our life expectancy'... and I do not see anywhere in my post that even suggested it...

But if the cost of keeping someone alive (at whatever age) for a few weeks to a few months is 'high' (and I am not defining what level that is), then why should society bear that cost It does not significantly reduce our life expectancy if someone lives in a hospital room for two more weeks on machines.... what we are talking about (at least I am) is SURE death... there will be no long life no matter what we do...

As I assume you are a doc, you should know that there are things that medicine can not cure... and no matter how much is spent, the patient will die soon...

And yes, the 'one' is where the problem is... is this person deserving of an expensive treatment or not... most would say 'yes'.... but when you multiply that by 1,000.... or 100,000... can we afford the total cost... what other things could be done with that money that would make society as a whole better.... where do we draw the line in costs of medicine
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Old 03-23-2012, 03:09 PM   #115
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But aren't you a little scared that these decisions are being made by an administrator who benefits financially by not spending money on the patient?
Which is why doctors and hospitals are also required to hit specific quality metrics to receive any bonuses.
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Old 03-23-2012, 03:41 PM   #116
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From the tone of your reply, you missed my point... I did not say anything about 'significantly lower our life expectancy'... and I do not see anywhere in my post that even suggested it...

But if the cost of keeping someone alive (at whatever age) for a few weeks to a few months is 'high' (and I am not defining what level that is), then why should society bear that cost It does not significantly reduce our life expectancy if someone lives in a hospital room for two more weeks on machines.... what we are talking about (at least I am) is SURE death... there will be no long life no matter what we do...

As I assume you are a doc, you should know that there are things that medicine can not cure... and no matter how much is spent, the patient will die soon...

And yes, the 'one' is where the problem is... is this person deserving of an expensive treatment or not... most would say 'yes'.... but when you multiply that by 1,000.... or 100,000... can we afford the total cost... what other things could be done with that money that would make society as a whole better.... where do we draw the line in costs of medicine
Sorry, didn't mean to offend. Im not a phycisian, but rather a dentist. I have no special insight except that I am well schooled in human nature. This forum is nowhere near a microcosm of society. People on this website are informed and intelligent. I think that many people assume cost containment is going to be restricted to those on their death bed. Two extra weeks of treatment on the death bed are far less expensive than decades of treatment for diabetes or decades post care for congenital heart defects or any other chronic conditions. Acute care is predictable and cost effective whereas chronic care is not. So where is the most favorable cost savings going to come from? If we want to have an honest discussion then I think we need to expand our thinking from treating an 80 year old with terminal illness and consider what to do with the 10 year old with pulmonary disease. Or better yet, the money we spend on knees and hips. A clear picture from those changing our healthcare sysyem is not being given. Is that because they don't know or because they don't want us to know. Before we jump on the bandwagon, we should demand a precise picture.
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Old 03-23-2012, 06:13 PM   #117
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So where is the most favorable cost savings going to come from?
In the recent CNN documentary on health care they touched on this but didn't go too deeply into actual metrics. 50% of the money spent on healthcare is spent on 5% of the patients. (I'm sure someone will correct me if I got the figures wrong). Many of those top 5% of patients don't consume lots of expensive treatment just to extend their lives for a few weeks or months, but have chronic illnesses causing them to come back to hospital time and time again.

A town in New Jersey (I think?) was highlighted as tackling this by identifying these patients and assigning case workers to visit them and see if they can improve their care outside of hospital at a fraction of the cost.

While in England last year I watched an episode of an ER reality program covering a typical 24hrs in the ER of a hospital. One thing that did happen was a repeat patient who was then assigned to a care worker. They interviewed the care worker who talked about what approach she and her team would take, and also talked a little about some of the many successes she and her team had in providing alternative treatments outside of the much more expensive ER's. Again, nothing in depth on this episode as this type of program attracts viewers who want to see the unsual, like people with 2 bums, rather than the routine stuff.
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Old 03-23-2012, 07:26 PM   #118
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In the recent CNN documentary on health care they touched on this but didn't go too deeply into actual metrics. 50% of the money spent on healthcare is spent on 5% of the patients. (I'm sure someone will correct me if I got the figures wrong). Many of those top 5% of patients don't consume lots of expensive treatment just to extend their lives for a few weeks or months, but have chronic illnesses causing them to come back to hospital time and time again.

A town in New Jersey (I think?) was highlighted as tackling this by identifying these patients and assigning case workers to visit them and see if they can improve their care outside of hospital at a fraction of the cost.
It was indeed Camden NJ, that segment caught my eye too. The stats on their website (2nd quote below) are even more astonishing, though I haven't tried to corroborate them yet. Clearly not just end of life care. And look at his results so far, a 56% cost reduction without reducing results (1st quote below)!
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One of the physicians he profiles, Jeff Brenner, is a family practitioner working in Camden, N.J. In 2007, Brenner started treating chronically sick people who accounted for a significant percentage of the health care costs in Camden.

Brenner was operating under a hypothesis: He figured that the people who had the highest costs in the health care system were also getting the worst care. By helping them, he could also lower the health care costs — not just for them but for the entire city of Camden.

After three years, Brenner and his team appear to be having a major impact. Gawande writes that his patients *"averaged 62 hospital and E.R. visits per month before joining the program and 37 visits afterwards — a 40 percent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after — a 56 percent reduction."
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The Camden Coalition of Healthcare Providers (CCHP) works with healthcare providers, hospitals, and physician practices to improve the care and coordination of healthcare for Camden residents while decreasing costs.

Utilizing information collected from a large patient data set, CCHP learned that in Camden, 80% of healthcare costs were spent on 13% of the patients, and 90% of the costs were spent on 20% of the patients. The total cost for hospital and emergency department (ED) care in Camden over five years was $650 million, mostly public funds.

We believed that if we could affect this small percentage of “superusers” with better, more coordinated care, we could increase the quality of care and decrease the cost to the system.

For the past eight years, CCHP has done just that. By developing programs and working in conjunction with those on the front lines of healthcare delivery, we have reduced the amount of ED and inpatient stays for our patients.
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Old 03-23-2012, 07:57 PM   #119
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It was indeed Camden NJ, that segment caught my eye too. The stats on their website (2nd quote below) are even more astonishing, though I haven't tried to corroborate them yet. Clearly not just end of life care. And look at his results so far, a 56% cost reduction without reducing results (1st quote below)!
This is why some folks are more optimistic that the cost control initiatives we're attempting may be more powerful than widely credited. Coordinating care doesn't sound like much but has proved incredibly effective at the micro-level. Whether these things can be scaled to have a meaningful impact at the national level is anyone's guess. But it certainly seems like we should be pushing hard in this direction and incentivizing providers to adopt best practices from places like Camden.
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Old 03-23-2012, 09:37 PM   #120
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I'm sure a lot of hospitals wouldn't be crazy to see revenues drop by 50% a month.
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