Op-Ed: Cut Health Care Spending On The Elderly
REBECCA ROBERTS, host:
Now, to the TALK OF THE NATION: Opinion Page.
To be clear, Richard Dooling is not talking about pulling the plug on granny. That accusation was tossed around last week in the health care debate. But Richard Dooling argues that we do spend too much money on surgery after surgery for grandma, with so much evidence of wasteful and even harmful treatment, he writes, shouldn't we instantly cut some of the money spent on exorbitant, intensive care medicine for dying elderly people and redirect it to pediatricians and obstetricians offering preventive care for children and mothers instead.
Do you agree? Is the money spent on dying or elderly patients worth the cost or should have be redirected? Give us a call at 800-989-8255. Our email address is firstname.lastname@example.org and you can join the conversation on our Web site, go to npr.org and click on TALK OF THE NATION.
Joining us now from member station KIOF in Omaha, Nebraska, is Richard Dooling. His op-ed "Health Care's Generation Gap" appeared in today's New York Times.
Welcome to our program, Richard Dooling.
Mr. RICHARD DOOLING (Author, "Health Care's Generation Gap"): Thanks for having me, Rebecca.
ROBERTS: You think I'm thinking about this generation gap when you were actually working with elderly patients. Tell us what you saw.
Mr. DOOLING: Well, I was a respiratory therapist working in intensive care units. And it was back in the mid-1980s, and as I point out in a piece, that was when we are spending about eight percent of our gross domestic product on health care. And even then, we had the impression that so much of the excessive, aggressive medical treatment that took place at the end of life was not only unnecessary but it was cruel.
ROBERTS: And give me an example what might that look like.
Mr. DOOLING: Well, before we have ventilators, an elderly person, let's say they're 90, they have pneumonia. If you read Sherwin Newland's "How We Die," it was a great description of this, used to take about three days because your lungs were filled up with fluid, you would slowly go to sleep. In the last two days, you would be unconscious, and then you would die.
Nowadays, you get pneumonia, you're 90 years old, and the question becomes, should we put you on a ventilator?
Now, I'm not saying nobody should go on a ventilator, but I'm saying when you do go on the ventilator and you don't get off, then it takes you three, four, five months to die. The whole time you're being stuck with needles, you're being turned, you're acquiring bedsores. You can't talk because you're intubated. The intubation tube goes in between your vocal chords into your trachea. And, of course, you feel like you're chocking the whole time, so you want to pull that tube out. So what do they do? They tie your hands down to make sure that you can't pull that tube out.
So, if you're going to that situation without having some end-of-life counseling, which everyone is hysterically referring to now as a death panel, you go in there with no information, it's basically too late. You're in no condition to express your wishes, which may be, please, just get these machines out of here and let me go to sleep.
ROBERTS: Which means that those decisions are last to your family members who are either emotional or ill-equipped, or just want to try to fix whatever they possibly can?
Mr. DOOLING: And your doctors who have every incentive to treat, treat, treat, to protect themselves from, A, litigation; B, because they're getting paid by the procedure, not for counseling you about what your options are at the end of life. Under Medicare right now, I get paid to put a pacemaker in you, but I don't get paid to counsel you about end-of-life care.
That's all that the president's plan was proposing, as I read it, is to be able to tell people what their options are. And, oh my gosh, just the suggestion that we should withhold this insanely expensive, cruel treatment at the end of life, is enough to make people, you know - the accusations start flying and as my - as the other op-ed columnist today, Ross Douthat. Douthat observes - I mean here we have the Republicans suddenly championing entitlement for the elderly; it's too ironic for words.
ROBERTS: Well, I want to get back to what you were saying about the profit incentives for doctors that, yes, they are being paid to prescribe more procedures that is a slightly different issue than the needs of the patient not necessarily being observed or written down in time.
Mr. DOOLING: Yes. People seem to have this intuitive notion that the more you spend, the better health care you get. That's simply not true. The best article I can recommend to your listeners on that is Atul Gawande's article in The New Yorker, "The Cost Conundrum." It was published on June 1st.
Very simple idea, he looked at two cities in Texas. One, where they spend $15,000 per Medicare recipient, and another where they spend $7,500 per Medicare recipient. And guess who came out with the better care, the better outcomes. The people who were costing half as much because they received less diagnostic tests, less medication, less hospital admissions, specialist visits, procedures. These aren't always in everywhere a good thing, especially for an elderly sick person. And we have to be able to talk about this in order to place some restraints on spending at the end of life, because right now there aren't any.
ROBERTS: Let's hear from email. This is Bev(ph) in Syracuse, New York. She writes: at this stage of my life, I'm 57, surgery for grandma means surgery for my mother. Can this point actually be debatable? She's a person and should have the same rights as any other person. Actually, last week, she did need surgery. Due to a stroke, she lost the use of part of her legs. Her toes started turning blue and gangrene fit in. Surgery was the only option that I would consider, though the surgeon did say that she could opt out. I cannot fathom death by gangrene. She had her leg amputated and is recovering well. Now, she will have a chance to eventually live in the same facility as my father and to experience the joys that occur in life even at 90.
Mr. DOOLING: Well, I say God bless your mother. I mean, that's great. Maybe - when I wrote this piece for the op-ed page, I saw it as an argument for - against over treatment and excess in the health care system, and it's come out as pitting the elderly against children. So let's put it in the affirmative, would your caller object to this? Let's take care of mothers and infants first, and then let's see what's left over for everybody over 50. I'm over 50. If I get sick, I would rather have money spent on children before it's spent on me. Is that objectionable? That's my question, I guess.
ROBERTS: Well, let's ask our audience, 800-989-8255 is the number. Our email address is email@example.com. Let's hear from Peg(ph) in Tucson. Peg, welcome to TALK OF THE NATION.
PEG (Caller): Hi. Thank you so much. Great topic. Basically, I just called to say that I think so many times, there is this unnecessary surgery as people get older. My stepmother, point in case, when she was 90, which is six years ago, she was told she had to have open heart surgery and if she didn't, she wasn't going to last six months. And she watched my father die because of surgery that really wasn't needed and said, no, I will take the time I have left and live my life the way -and here she is, six month - six years later and still doing fine.
ROBERTS: Thank you so much for your call, Peg. Again, this might get to the question of changing the structure, the pay structure for hospitals and doctors, which is a much bigger turnaround than a sort of philosophical thought about end of life.
DOOLING: Mm-hmm. There's a great image in Dr. Gawande's article about - where he compares health care to building a house. Now, suppose you're going to build a house and you have the carpenters and the electricians and so on and you say, okay, you get paid $200 for every cabinet you put in, and you get paid $200 for every outlet you put in, go to it, you know. Are you going to be surprised that you get a house with 400 outlets and 65 cabinets, whether you need them or not? That…
ROBERTS: Well, of course, the fallacy of that argument is that if you have too few cabinets, it's not going to risk your health or potentially your life. I mean, the stakes are much higher with a medical decision.
Mr. DOOLING: Right. But it's the way people are being compensated for performing procedures. That's his point. If you say, you get paid for every pacemaker you put in, you're going to subconsciously have an incentive to put in as many pacemakers as possible, whether or not it's the best thing for the patient. Do you see my point?
Mr. DOOLING: Okay.
ROBERTS: Let's hear from Bob(ph) in Norfolk, Virginia. Bob, welcome to the TALK OF THE NATION.
BOB (Caller): Thank you so much. This is such a great and important topic. I really think it just drives home the point that people really should have advanced medical directives in place. I mean, when - God forbid, if I'm 96 and I have pneumonia, you know, I don't want to be on a ventilator. You know, I really don't. And people should be counseled about this sort of things. And I would hope that the writer there is also, you know, trying to promote that part of the argument, as well. Because, you know, whether or not money gets spent on infants, mothers, elderly, whatever, people need to be educated as to, you know, what life can bring and how it can and/or should end, you know, regardless of your views on religion or anything else. Who wants to be 110 and sick but alive?
ROBERTS: Do you have a living will?
BOB: I do have a living will, absolutely.
ROBERTS: Thanks - thank you so much for your call. Do you have a living will, by the way, Richard Dooling?
Mr. DOOLING: Yes, I do. And I think that your caller makes an excellent point. I think that most of the waste and the over treatment and the excess in the system - the Medicare system, especially, would vanish if you allow the information to flow, which was the aim of that provision, the end of life counseling.
If people could see a videotape of what it is like to spend the last two, three months of your life receiving mechanical ventilation, kidney dialysis, being turned, what do bedsores look like and so on, you would have a lot more discretion. You would have a lot more people saying to themselves, gee, I didn't know that life ended like this. It's a mess. It's never pretty. But, at least, if people have the information, they can make their own decisions, so never mind having the government or anybody else make the decision. Just give people the information so that they see what it's like before they're there. That's all I'm arguing.
And I think that most people would elect to either have durable power of attorney, where someone else makes the decision because you can't, or to have an advance directive of what they call living will, where you specify what heroic measures you do not want at the end of life.
ROBERTS: My guest is Richard Dooling. You can read his op-ed, "Health Care's Generation Gap," in today's New York Times. You're listening to TALK OF THE NATION from NPR News.
Let's take a call from Summit(ph) in West Bloomfield, Michigan. Welcome to the program.
SUMMIT (Caller): Hi. I'm a resident at a hospital here. And it's been my experience that a lot of times you don't know ahead of time how patients are going to turn out. In the rush of emergent sort of things, you might go ahead and put people on ventilators and things like that. And it's not until maybe a week later that you're - and you are not able to get the person off the ventilator that you realize that this is going to take quite a bit more time or money and they might never ever get off.
So I just want to, like, for the people who are keeping patients alive on life support, I think things are, like for months at a time, that seems to be a bit more obvious. But even then, I've been surprised at people getting off the ventilator, in fact. So…
ROBERTS: And so what do you think about the argument in general in this op-ed, do you agree or disagree?
SUMMIT: I actually generally agree. There definitely should be a flow of information, definitely should - people should think of these ahead of time when they're healthy and of sound mind, and let all of their family know their wishes, too, so that there won't be any arguments when the time come.
ROBERTS: Thanks for your call. Well, of course, but not knowing the outcome of the decision to go in a ventilator is why people keep making these decisions, right? That they think this next procedure might actually help.
Mr. DOOLING: Sure, and shouldn't we try it if there's any chance whatsoever? And another point going to your caller there, right now, when you go in the hospital, there are federal regulations that require the people to ask you, do you have an advance directive? And that's so that when the doctor is rushing around in the middle of an emergency, the advance directive is on the front of the chart. That's the way it's supposed to be.
But, you know, having worked in the ICU, we all know it doesn't always work like that. There's an emergency and people automatically go into CPR and Code Blue, which is a pretty violent event, not like the ones we see on TV.
(Soundbite of laughter)
So I think, you know, again, just information. If people had it, they would be sure they had an advance directive, they would be sure their family knew about it, they would be sure that it's on the front of their chart.
ROBERTS: You say in your op-ed piece that when you were working in the '80s and the nation was spending eight percent of GDP on health care, you assumed it couldn't last. You say, somebody would surely expose the ruse for what it was, an enormous transfer of wealth based on the pretense that getting old and dying is a medical emergency requiring high-tech intensive care intervention and armies of specialists which could cost 10,000 more per day - $10,000 or more per day.
Where do you think that idea that getting old and dying is a medical emergency that requires intervention, particularly expensive intervention, came from? And do you see any prospect for that changing?
Mr. DOOLING: I don't as long as all the incentives in place right now pay doctors by the procedure instead of by the outcome. As long as that remains in place, you're going to have every incentive to treat and no incentive not to treat. One of my jobs in a former life was as a lawyer. I'm also a law professor right now. And the arguments used to be that if you…
ROBERTS: That if you don't treat a patient - we have run out of time. Richard Dooling joined us from member station KIOS in Omaha, Nebraska. He's a novelist and screenwriter. His op-ed, "Health Care's Generation Gap" appeared in today's New York Times. Thank you so much for joining us. Soundbite of music)
This is TALK OF THE NATION from NPR News. I'm Rebecca Roberts in Washington.
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