It sometimes feels like we middle-class and working Americans are doomed to work our lives away and die destitute.
We pay taxes all our working life and in the end it comes to nothing, and we can’t leave our children an pitiful inheritance, we can’t enjoy our senior years because the people at the top have found a new way to deplete our resources and savings even when we grow old and sick.
It used to be the biggest expense we had were mortgages but now we have medical costs that are equal if not greater than any mortgage most of us will ever carry.
Yet the billionaire class are screaming bloody murder at the prospect that they may have to pay more on their wealth.
Work, work, work and pay, pay, pay until our final breathe.
Something is grotesquely inhumane with our system.
1
Excellent analysis here. Succinct and on point: we can't know the timing of death; most of the cost of care isn't in the insurance system, it rest with the individual.
what is not covered is that most of what matter in staying well and healthy is also in the hands of the individual. we are the architects of our lives. yes, there are exceptions but that is but a small part of the population and no excuse for the majority to stay responsible for sensible fitness and eating.
As we discuss ways to reduce costs, cut perceived wasteful spending, trying to make bets on ‘how long it will take someone to actually die and quantifying the value of specific lives over others, we forget about the patient as a person.
Even new models of healthcare that are supposedly ‘patient centered’ are incentivized by cost cutting and increased profits.
Last night I watched the Ken Burns documentary about the Mayo Clinic. Everyone, especially lawmakers, insurers and health care providers ought to watch it.
The core values of patient first and actions for the greater good need to be brought back into the debate. Not only for healthcare in the USA but also public education, the quality of our environment and the preservation of our public lands.
Mayo isn’t perfect, which it readily and humbly admits, yet even with its missteps it has been able to preserve its vision through good times and bad, war and peace.
The greed in our healthcare system is obscene. The inhumanity in our inequity of affordable quality care from totally uninsured to those able to afford concierge care is undignified. The callousness of our elected government officials (ala Tom Price, Paul Ryan, Mitch Mcconnell etc.) is repugnant.
We can learn from the agnostic rural doctor who forged an enduring legacy of helping humanity with a sisterhood of Franciscan nuns.
5
My father was a hospice doctor at the end of his career. He told many stories of families that spare no expense on a parent who will certainly die within days. They’re not rational.
Many of these commentators seem to forget Hospice. My mother who had a living will had alsheimer's and I had health care POA. She lived in memory care assisted living and wasn't particularly happy with it but still had times of joy, playing with her cat who lived with us, and laughing with her grandsons. She had a great sense of humor. But she broke a hip at the age of 89. I decided that a hip replacement would be an advantage. After that she was never the same. She didn't know why her hip hurt, nor could remember not to get up and walk and rehab was awful. For the next 6 months she was mostly in a wheelchair. I took her for drives and to her doctor's appointments but she seemed sad.
Then she broke the other hip and her femur at the age of 90. The ambulance people told me that she had been joking with them on the way. I wish I had been there to share that. In the emergency room she mostly groaned in pain. The doctors there recommended no surgery this time and I agreed and told mom that we would get her into hospice. She was given strong pain medicine and went from the emergency room to a local inpatient hospice center. After a day or two she decided not to eat any more and was happy to find out they wouldn't make her eat. Soon after she slipped into unconsciousness and died several days later. The Agrace hospice was wonderful, both to us and to Mom. They talked with her and were so gentle whenever they rearranged her position on the pillows.
1
Instead of palliative care, why not choose crack cocaine care? Cost is cheaper, pain is less, and you'll have more fun. Party like you're dying. What have you got to lose?
Better yet, bring back opium dens. Although it might take forever to die in one, at least you're not enriching the medical-industrual complex.
But modern medicine isn't letting you go without attaching your estate.
6
My Medicare will be cancelled 1/1/2019 due to the fact that USPS took 24 days to deliver a bill dated 11/27 for my next quarter coverage. I have been told that since the check had to be received by 12/25, my coverage would be cancelled, I would pay a penalty, and would have to re-enroll, meaning no coverage until July. So one incompetent federal agency is undermined by another. What I did notice after receiving Medicare is that doctors who previously did not want to bother with treating me suddenly lined up like pigs to a trough, sucking all the swill they could manage.
4
I don’t believe that. In recent years I have seen a sign posted at the front desk of a gyn’s office, a PCP’s office, and an outpatient endoscopy center stating that new Medicare patients were NOT being accepted. No doctor or other provider is making money by treating Medicare (or Medicaid) patients. The reimbursement rates are crummy. There’s no “swill” to be had.
1
One of the biggest problems with Medicare is that our government does not consider the mouth, or any teeth within the mouth, as part of the human body. So even though I have to make high monthly payments for services that I never use for anything because I'm healthy, my teeth are rotting away, cause dental treatments are prohibitively expensive, and I simply cannot afford them.
Whose idea was it that teeth and gums are not part of our bodies? And why is this outrageous denial of reality allowed to persist?
12
What about your eyes and ears?Medicare does not include vision, hearing, or dental coverage. How many Medicare enrollees (by definition age 65 ) need eyeglasses and hearing aides?!
3
Go to Costco.
The best deal in the country for eye glasses and hearing aids.
At age 82, I would like to see a national consensus on self- assisted suicide rather than more angst over how long we should live. When you think of it life can be a real pain physically, emotionally, mentally. We need to consider that we should all be able to leave this veil of tears whenever we decide to. And make it a party, like Socrates, with loved ones hanging around drinking, smoking, eating and having a gay old time until the bell rings. There is no need for us to be laying prone for days, weeks, months, years. Let us take what is left that is good, and then go with no regrets.
20
The more I know, the more disgusted I am in a system that is absolutely failing everyone at every age.
11
Related, yet different from the main subject of this article is a major problem faced by many people who receive Medicare not due to age (retirement), but due to severe illness and disability. That problem is the gaping hole left by Part D (coverage for prescription drugs). Those of us who eventually get Medicare after reaching retirement age can get Medigap insurance to help cover the infamous doughnut hole and other shortfalls of part D that way. However, those who receive Medicare due to disability are simply not eligible for Medigap insurance of any kind. Amazing, right? I know of at least one case where the person who became disabled due to MS has to spend thousands of dollars out of pocket on the biologicals that, for now, avoid the need for a nursing home. That person will now basically have to go bankrupt to then, finally, also be eligible for Medicaid, which would cover those medications. I would really like to read and hear more on this underreported aspect of our care for the disabled. I can't help but wonder if forcing disabled Medicare recipients to choose between paying for food, rent or medicine isn't simply a convenient way to make sure that they just won't live that long. Basically, premature death by neglect.
14
Thanks for pointing out that Medicare doesn't have an "out of pocket maximum". Private insurance, like the plan that I have, does have a limit on out of pocket expenses. Of course, my premiums are over $800 per month, plus the relatively reasonable $1750 deductible. After that, the out of pocket maximum is about $7K.
For a Medicare patient, with thousands per month for Herceptin or chemo, the costs would be even higher.
And, a correction to this: "Over half of retirement-age adults will eventually need long-term care, which can cost as much as $90,000 per year at a nursing home."
My grandmother's nursing home cost that much in the early 1990's.
Mom's nursing home cost over $120K per year for a shared room, until she died in 2017.
7
First misconception most have is that medicare is free. Between the minimum $135/month for basic, there’s another few hundred for the add ons. Living & dying would be way better and easier without the constant drumbeat of medical care expense anxiety.
10
It is not only hard to predict when you are going to die, it is hard to predict when you will get sick. This is the problem with the Medicare add on insurance such as Medicare Advantage or Medigap Plans A through H. They are asking you ahead of time how sick you think you will get in the future and to pick out the best plan for yourself. How are you supposed to do this?
What a stupid system we live under!
16
I don't think you need the government's consent to end your own life. The 72,000 people who died last year from opioid overdoses last year didn't have government permission.
1
@Gideon. Are you including the patients who were abruptly taken off Opioids in your Survey?
I almost surely died when my blood pressure soared to 220/110 after being taken off pain meds I had been on 22 years in 6 WEEKS; when my Dr. lost her license. But no matter the costs, the So-called “Opioid Crisis” cost legit pain patients plenty. Disabled after 6 back operations, I do have Medicare subsidized by a “Medicare gap policy”. My sudden titration cost me over $5k out-of-pocket, a fee few disabled people had planned for and could ill afford.
And 17 months later my random symptoms leave an array of doctors baffled. I am still spending.....
Forget worrying about paying for palliative care; if you’re disabled in America you’re financially stressed.
(As an aside my pain doctor got her practice back so financially, she’s fine.)
2
Americans don’t like rationing, we always want more. Healthcare is no exception and it won’t change. The only reasonable thing to do is significantly increase the number of doctors that results in cash payments for all routine care. Insurance kicks in only for larger expenses. Really, double the number of doctors and see the costs plummet.
The argument of expensive tests, drugs and large student loans will sort itself out when you have enough doctors to just walk in anytime for a visit for mundane issues.
1
I read the obituaries everyday because I see my occupational therapy patients in there, eventually. The writer is correct that we can’t predict end of life. What I do see is patients who are not at terms with their mortality and see every specialist available, even getting second opinions, when the symptoms can be managed by the primary care physician. We may spend less if we educate patients that the medical system has limits, the WILL die, and they should spend their later years enjoying themselves and being comfortable instead of being swallowed by the healthcare system. That said, many of my patients clearly understand this but their late-middle aged kids don’t, so THEY feed mom and dad to be swallowed by the system. Tomorrow I’m seeing an 85 year old woman in her home, whose daughter told me they expect a full recovery—back to living independently—from her stage 3 cancer...
19
Deliberately depleting assets in order to qualify for Medicaid and thus be able to afford assisted living or a nursing home is fairly common. In many cases it is required in order to be accepted into these facilities.
15
"Ya'd better watch out; I am telling you why": It is really great when you are mentally ill or even slightly compromised and the courts strip you of your freedom and money, and lock you up in a 'rest home' to face a medically unaided painful death, that less than 2% ever have an autopsy to confirm what the rest homes call 'death caused by dementia'.
7
You've answered a question I've had for awhile, namely, how accurately can we predict the last year? We older people are always asked to predict our demise for purposes of financial planning, but it's obviously pretty much a complete guess when you're 65 or younger. Now I know that it continues to be a complete guess up until at least within a year of the end. I wouldn't be surprised that for many of us it will still be a guess within a few days. This is one good reason why we need Social Security and Medicare to be strengthened, not weakened. (You can still call it entitlement reform if you want).
18
'A widely held view is that much spending is wasted on “heroic” measures taken at the end of life.' This brings to mind a debate I had some years ago with an acquaintance who posed the very same question. And it came to mind again recently when a hospital here in NJ specialising in care for severely handicapped children had several deaths from a virus outbreak.
'If your problem is wasting money on people who aren't socially or economically useful, then surely we should not be wasting money on severely handicapped infants who could live not just a few more weeks or months but many costly years, and have just the same quality of life as these elderly'.
My acquaintance was horrified that I would propose letting children die. I didn't; my point was that he had no problem with throwing out the elderly like Kleenex, on a pretext equally applicable to the severely ill at other ages. An anencephalic Zika infant and an Alzheimer's grandpa can both enjoy the simple things. Surely their lives are of equal value to them.
I wonder if we cherish the child's life, but devalue the senior's, because the child represents a possible fate we escaped; while the senior is our Ghost of Christmas Future, so we fear him.
The Roman senator Cato prided himself on working his slaves to the limit, then, when they were old and broken, selling them off cheap to save the cost of caring for them. I'd hope we're more advanced; but a prominent right-wing think tank is named for him, so maybe not.
19
There is another important contributing factor...Doctor as "hero."
My brother in law's dad had what everyone thought was a bullet-proof set of advanced directives, filed with the local hospital, including some advance DNR's . He had a massive stroke, one that left him non-verbal and completely paralyzed, with minimal consciousness. The damage was readily apparent in the ER when he arrived.
The DNR was ignored, though it clearly applied, by the hospital medical staff. He was revived, and spent the next 5+ years in a hospital bed, with zero quality of life in minimal consciousness, fed by a tube. The expense wiped out their previously thriving family business as part of the pre-Medicaid asset mining. Millions spent, to support a breathing corpse against his wishes.
All because the doctor chose to ignore the clear directives on file, against the family direction as well.
43
The family, usually next of kin has the ability to choose withdrawal of care and transition to comfort with no ventilator and allowing natural death at any point if the patient cannot choose for themselves
As an ICU doctor, I don’t believe this story
16
It has been said (and I agree) that what makes life worth living is having: someone to love, something to do, and something to look forward to. I think each of us should be able to confront the inevitability of our own deaths and try to provide an advanced directive to save our families and loved ones the sometimes agonizing choices that come with the end of life. As we see from these comments, everybody has a different experience. While I think it is generally better for a family to be involved with end of life care, not everybody can handle the constant care needed. For-profit hospice companies often employ undertrained and uninvolved home care workers who are ill-equipped to deal with some of the emotional crises attendant on end of life situations. I have had to ask myself "under what conditions do I want to continue living?" and make provisions accordingly. Obviously cost can become an issue, but I hope that if we finally drag our country kicking and screaming into single payer health care it will include end of life care that allows sane choices, including physician assisted suicide when asked for, and extended treatments for cancer, heart attacks, etc. where a reasonable quality of life is expected as a result. Nobody wants to die. We can at least project the curcumstances under which we want to continue to live.
15
I am 70, so this is not an esoteric topic to me. If nothing else, could families start issuing DNR orders for elderly relatives who have Alzheimers or dementia. Dying from these conditions appears to be the most cruel death except for the absence of pain. If a patient is already diagnosed as terminal why bring them back from a stroke, heart attack, or kidney infection? Let them go when they are already halfway out the door. Families want to be comforted by the physical presence of their loved one, but if the loved one doesn't recognize anyone, there is little quality of life left.
27
@Kathleen YES! When my father-law was in his mid-nineties and deep in dementia, he was hospitalized by his care home for pneumonia. In the hospital he was frightened and disoriented. They filled him up with antibiotics and sent him back to the home after two weeks, where he then spent another five months sliding ever further away from any semblance of the man we had known before he finally died. It seemed criminal to me. The care home was obviously worried about lawsuits even though all of us in his small family wished dearly to just let him go. Unfortunately he had not made an advanced directive while he still had his mind in working order, but he would have been appalled by the end of his life and by his own death.
2
If we paid the average per capita that other nations paid for health care, then universal coverage would be within our reach. Instead, we are being taken for a ride.
We need a new political party.
28
One area of expense rarely mentioned is the cost of dental care. At the age of 75, I am facing a $20,000 bill for dental work to assure that my mouth and jaw are preserved as I age. I am blessed with a clear mind, and a loving family as well as relatives who have lived well into their eighties. I don't want to be felled by the poor state of my mouth, and will attend to it, just as I have endured a knee replacement. But that was covered. Dental care is not. It is a shame, because poor dental health is at the root of other medical issues.
68
This is a very smart observation . Dental is way out if control unaffordable for most .
14
We lack education on health. We all need to work towards better health during life to avoid costly poor-health outcomes at the end of life. It is the shift from "I can do whatever I want, it is MY life" to "what I do affects others, so I must be responsible."
7
My father had a stroke that left him paralyzed on one side and unable to swallow. My father when he was much younger had made my mother promise never to put him in a nursing home. He made an advanced directive when that became an option in the state where they lived, but the Catholic hospital would not put him in hospice care because, they said, he wasn't dying. Neither the hospital nor his doctor, who was connected to the hospital, suggested palliative care and I doubt it was available outside hospice. My father was unable to communicate with anyone to convey his wishes although I doubt it would have made a difference under the circumstances.
It took my father two weeks to die without the benefit of palliative care. It was sheer torture for all of us. The first thing I do now with any doctor who is treating me is to tell him this story and ascertain his views on dying.
17
I think the allowing people to decide when to finish their own lives could mitigate the problem. I think medical assisted suicide should be available to more people, and people should not be made to jump through the hoops to prove that they are dying. It is their body and they should be able to decide what they want to do. I think the Government should guarantee people the painless way out when people want it.
19
Costs may be pushed up by doctors... an Ithaca cardiologist convinced me a pacemaker in my 93 year old dad would enhance his quality of life. All it did was put him in a nursing home bed, non-ambulatory. Medicare paid for the operation, private pay for the nursing home.
7
Medicare spending in the last year of life is a complicated number to calculate— the 25% is based off a study done from 2000- 2014 and included a sample size of 5%. While its data worth acting on, understanding its validity in the context of what we see as physicians on the hospital would be prudent.
I would bet that number of 25% is low— the massive amount of resources that are spent on in-hospital clinical scenarios that are poorly prepared for and/or inadequately communicated among doctors and patients is insidious.
There is a culture in the US that prevents doctors from having frank discussions with families and patients when it involves someone who is elderly in dire health. No doubt its partly cultural combined with issues involving how we train our health care providers. But, it also involves fear of accusations of mistakes and incompetence with the ever looming lawsuit that inevitably looms, particularly within certain high tech specialties. Until our society better understands the limitations of human health, life, disease, and the capabilities of medicine I believe things will not improve. And it’s up to the medical community to provide that knowledge and understanding.
4
There is one major disconnect between this article and reality...our insurance policies do Not cover palliation and long term care in our homes; nursing homes should not be the primary option.
Well paid, home assistance (home health aides, home attendants, etc) supported by weekly-monthly professional visits, as needed, would greatly decrease the financial and emotional burdens of our present system.
30
Work in a hospital for a few decades. You will see waste fraud and abuse that employees are supposed to report. No one squeels when it’s the docs abusing the system. If patients and families had to pay a modest ten percent copay you would see massive change in end of life care. Heck even one percent. But when it’s free, look out as the vultures descend and feed. You should witness the extent of life saving measures we expend on patients in their final weeks of life, it’s immoral.
24
But who is deciding on those expensive end of life measures? It’s most often I think hospitals and doctors fattening their bills— not the families who want the suffering to end.
5
Lots of valid criticism about Medicare, highlighting significant shortcomings in coverage and very typical additional costs.
Just wondering how to reconcile these with frequent demands that the US switch to "medicare for all".
1
Maybe we should study how every other first world nation manages to provide free health care for all citizens — for decades.
10
Zeejee. Easy they wait decades to get care
4
But it’s absolutely not free. Google what others, say Germans, pay in taxes. Americans would be outraged (yet again). Then look into what those lucky Europeans get in the way of services. You’ll find far fewer choices than what Americans expect.
"Total health care spending for Americans 65 and older is about $15,000 per year, on average, nearly three times that of working-age Americans."
Which suggests that what Americans younger than 65 are spending on health insurance is far more than it ought to be, once one adds in all the deductibles, co-pays, medications, etc...
10
EVERYONE should read “Being Mortal” to better understand the complexities of dying in our American health care system. I have changed my health care directives based on my more-informed perspective on aging and end of life.
24
My father-in-law was hospitalized in his late 70s after a major heart attack. He ended up in the hospital for 4 months, and almost died 5 times from 5 different medical problems: the heart attack and quintuple bypass surgery, a mediastinal abscess, an obscure white cell dyscrasia, kidney failure, and cellulitis. He joked that the only hospital wards he had not spent time in were Pediatrics and OB/GYN. He survived and went on to live 14 years longer, exercising daily, watching the crows in the park across the street, remaining politically active and well-informed, and enjoying seeing his grandchildren grow up.
I shudder to think how much his medical care cost. But from our point of view, it was not wasted money. The quandary of "end of life care" is that you can never know for sure when the end of life will be.
21
The widespread use of hospice care in the home or in a facility would likely lower some end-of-life costs, but it's only available if death is likely within six months, not one year. Paradoxically, hospice care keeps some patients alive longer, even though the care is palliative and not curative.
I suggest the path my mother took if death is likely and imminent. When she learned she had pancreatic cancer, she was almost 83 and not strong due to a previous bout of another cancer. She opted for palliative care only, in her home, with my father, age 90 at the time, watching out for her.
As she said at the time, "I didn't expect to live this long. I'm grateful for the time I've had."
Likewise, my father had hospice care for about three or four months before he died, though he lived in assisted living at the time. We were very pleased with both firms we used and our parents got good care without wasting either money or time on unlikely cures.
114
I spend the last week of my mother’s life begging her physicians to connect us to hospice. None would. They didn’t think she was dying. The most I got was an attorney to draw up a living will. We used it less than 48 hours later.
26
@Barbara Similarly, our Aunt (age 86) with pancreatic cancer chose palliative care only for the same reasons. Her final year was one filled with grace, dignity, and comfort. Having watched others suffer through cancer treatments, she set an example of courage for us on a valid choice for end of life care that should be considered. She was able to remain active and in her own home to the very end, quietly passing in her sleep.
26
@CTCajun I am so sorry you encountered such ignorance. As you probably know, hospice can begin six months before expected death. My mother's oncologist recommended it.
9
Still, we need more conversations about end-of-life care so that families can make informed, realistic decisions. My dad had excellent advanced directives. When he was 90 living at home with in-home companion care and moderate dementia, he had a stroke. The reasonable thing to do based upon his situation and his instructions was to keep him comfortable at home. Yet, there were family members who were distressed that we were not doing more (take him to the hospital to "be sure that he had a stroke" or 'at least give him IV fluids'). Even with two trained as nurses in the family (me & a sister-in-law) and clear instructions from the patient, it was a struggle. We managed & he died at home in his own bed without ever going for tests.
I can only imagine how hard such a situation would be for a family with no medical background and/or no clear end-of-life instructions. Likely there would have been an ambulance, ER visit, hospital admission, Cat-scan etc. all to get him to the same end. The family would feel that they had done "all we could" for him, but really none of it could be life-saving at that point. In dad's case this would not have been terribly expensive, but in other cases it could be. Truly, there is a time to do something, but at other times simply being present is all that makes any sense.
247
@Anne-Marie Hislop I am an only child, my mother has a POLST form indicating comfort care, she consistently refuses any medication, and yet I am torn when she has had several TIAs...do I call for EMTs? Is not calling an act of elder abuse? Will doing nothing be seen as euthanasia? And, what is an elder to do if another well-intentioned person calls for an EMT? While living independently, mother had several falls on the sidewalk. The hospital to which she was brought was part of a system to which her doctor belonged. Her POLST was available on one visit, but the ER docs treated, tested and admitted anyway. This is in contrast to a different hospital near the assisted living home in which she lives: the ER does nothing, except take forever to discharge. Perhaps the difference is there are an unusually large number of assisted living homes in the vicinity this hospital, and the ER is more aware of the purpose of the POLST.
The new challenge we face is a disconnect between the staff of the assisted living and now board and care and my mother’s clear wishes: they call for EMTs as policy (liability risk management?). It’s a maddening merry-go-round: the home calls, the ER sees the POLST and discharges, repeat. The only way for an elder to avoid this situation is to live at home with confident relatives who are medically trained, as your father did. The best remedy I have found is to push for hospice admissions. The home turns to the hospice nurse for direction, thank goodness.
18
@Anne-Marie Hislop I think many of us with older relatives who have done their paperwork and made their wishes known are overconfident about our understanding of what nearing death and its crisis look like. A relative in their 90s died last year of acute respiratory issues caused by a combination of cancer and aspiration pneumonia. Where I had expected anyone near dying to be weak and fade gradually, instead they had repeating acute respiratory episodes and struggled physically during them. There was no fix available, but nothing in my concept of hospice prepared me for that kind of death. It took the palliative care people a while to find a good sedative combo that made them comfortable. We as families need more education in what may happen so we don't freak out during one of the varying events that are part of a death. I know from talking to other people that most of us expect a single cause death that follows a script. Nature is so much messier than that.
I would like to disagree with the article. I do not disagree with the facts, but with the conclusion. I have a dog who is 14 and was diagnosed with a cancer that I was told was treatable. The vets said that it was all about quality of life, but the treatment has made Darwin sicker and more uncomfortable with each passing day. There have been brief bouts of health and then he has another treatment. It this point I realize that I made a bad decision regarding his care. It has given me insight into my own end of life care. I do not ever wish to be in long-term care. If I get cancer, I will seek hospice not treatment. We do not know when we are going to die, but to encourage hope when there is none is the ultimate cruelty. I am much more afraid of living an impaired life than I am of dying. I just hope that I will be allowed that decision when the time comes. I am not saying do not treat someone who truly wants it, but inform them of all the negatives of the treatment. Do not lie to them as the veterinary oncologists lied to me.
265
@Dru Winters. End of life care decisions for a beloved pet can be just as wrenching as those for a relative or close friend--although I admit that this was not the main thrust of your comment.
29
@Dru Winters First, making an equivalency between a dog and a human being is offensive and I say this as someone who does love animals. Secondly, if you want to end YOUR life at any point is your choice. (I believe that barbiturates should be available OTC. ) But to extrapolate from that that a human being has no value because they are old or disabled is disgusting and is close to Nazism. Seniors are being pushed and pressured into allowing hospitals and nursing homes murder them mostly because of the profit motive on the "health care" provider's part.
8
@Dru Winters--Lumping all cancer diagnoses and treatment regimes into one category is not sensible. I got throat cancer at 59 and went through horrific treatment. But I emerged cured and was able to resume life. I have a number of friends who are enjoying life after breast cancer.
I am very sorry that your dog is suffering and that you are unhappy with the care you have chosen for him. I know how important pets' wellbeing is to us, their owners.
I hope you would do more research with your own care and get second opinions. Cancer is not one disease but many, and their are many treatments and many outcomes, which vary widely.
My sister's elderly golden had cancer in his foot, so they had that leg amputated. He had a great six months after, and they didn't regret giving them to him. So not every dog has a bad outcome either.
25
There is not enought discussionin the medical community with the elderly and their caregivers of the use of comfort care and hospice. I had to fight to have my mother, who was in her 90s, in a nursing home with dementia and a recurrence of colon cancer to have hospice instituted. Nursing homes are reluctant to do so because the Medicare rules shift the payment from the nursing home for medical care to the hospice organization.
I shepherded both my parents through their ends, with ther express wishes in mind. The hospital my father was in was wonderful about comfort care for him in his last week (he could not be discharged due to needing transfusions). When I finally got my mother into hospice, she was able to die the way she had wanted -surrounded by things and people she knew and loved.
Neither wanted extraordinary measures. But I’m a lawyer who deals with health care issues and I had to fight for both of them to get what they wanted. There needs to be more discussion of comfort care at the end of life.
88
My mother died four years ago, after a long, slow slide. Slowly slipped away in the night.
I sat next to her all night, realizing it was her last night. If she had wanted to save my sister and me money she could have stopped her treatments much earlier. Do we miss this money? NO!
The morning before she died, with my sister and me and our spouses there with her in the hospital, she asked for a breakfast with bacon. She wanted bacon. Bacon gave her pleasure, as did the company of us. The nurse was reluctant to order it for her, but we said "she wants bacon."
She had also asked for some red velvet cake with a special frosting that she liked, so my wife made one and she had a few bites of it the evening before she died.
What is the point? Until the very end she was still living life. Still had moments to enjoy, and pleasures to seek. It was worth any amount of money to her and to us.
She had bacon!
105
@Dan She had bacon and died happily. Good story, Dan.
3
Instead of focusing on end of life expenses, perhaps the author might have mentioned the biggest scam perpetrated on unwitting Medicare participants who do end up in the hospital. It's called Observation Status.
For people on Medicare, the distinction between inpatient and observation status is crucial in terms of coverage of care in a skilled nursing facility after the hospital stay.
If you are kept under "observation" -- same room, same care as inpatient, and can last several days -- you are not eligible for skilled nursing care upon discharge, unless you can pay out-of-pocket.
Probably saves hospitals and Medicare millions -- but costs the elderly a huge amount of money, worry and proper care. Until last year they didn't even have to tell you what "observation" really meant.
There's currently a class-action concerning this scam, and I hope it will eventually discourage the practice. But it was a huge surprise to me and my family.
19
@Jaye Observation care is stupid. It is an opportunity for hospitals to increase revenue and Medicare to shift finiancial responsibility to the patient & their family. Then if the patient is discharged from observation they are often still sick and then they are re-admitted (as a full admission) to the very same hospital. This benefits the hospital because the hospital is not penalized for the re-admission.
13
Eldercare is a time eater on the family. Despite her good health, mom was wisked away to a niece's house, but thats another story. That left my brother and I to care for dad who, for the most part, was healthy. I returned dad to his home one night. My brother arrived an hour later to find him unresponsive on the sofa. A call, an ambulence and the next day he was like a king holding court in his hospital bed. I was astounded. Discharged, he lived in an assisted living facility for about a month. An early AM call, he had died. My brother said dad's doctor told him, a day or two earlier, that dad had dementia. We were both floored. Unable to predict death. After dealing with dad, that comes as no surprise to me.
3
Dad had a long, pleasant retirement with a quick, surprising end. Mom's was long and unpleasant but she was blessedly unaware of much of it in the last years. Personally, I plan on opting out when I can no longer climb the hill to do my Tai Chi overlooking the valley. Can't really recommend that for everyone...
69
Be aware that relatives can initiate hospice care, at least an in-person evaluation; you do not have to go through a doctor or have his permission. It is common for providers (nursing home, lower-level primary care personnel such as a nurse practitioner) to resist hospice, claiming they're not ready, or that all necessary care can be provided in the current setting, etc. I got my mom started on hospice on this manner, smartest thing I've ever done. She stayed in the nursing home but hospice nurses were in charge, and they have special knowledge of meds, especially for pain control. All "curative" drugs were stopped; only pain meds were allowed. Mom immediately "woke up" from the heavy load of pharmaceuticals that had kept her half-asleep, weak and unable to communicate or walk. After about six pretty good weeks, nature took its course.
83
Yes on hospice — they might not have saved my life but certainly preserved sanity in my mother’s last months. After all meds except palliative were removed she had a huge rally and felt great. We worried that at 6 months she’d be thrown off but she had enough things going on that she could stay. She died 9 months after hospice care began and I never saw a bill.
11
@J. Harmon Smith
I will never forget finding out that my mother, in a NH w/hospice, was being given pain meds at the discretion of the meds LPN. When asked why the meds were so limited, I was told by this nurse "Oh, she's not that close to death". After telling the hospice MD who was around a few hours a week these exact words, the order was changed to a regular dosage pattern that wasn't at the discretion of the nurse.
She died 4 days later.
The ability of NH staff to assess and dispense drugs correctly for hospice care should never be assumed. The hospice nurses that came in periodically were terrific, but that kind of an order leaves them without direct recourse. They didn't take the time to review the chart to see how drugs were being dispensed and if that matched my mother's presenting condition, nor did they contact the MD, who also assumed things were going swimmingly.
I had to take charge, make enemies and let heads roll in order to help my mother die in peace.
Why? The system isn't to be trusted. Do not think that this is because the facility was deficient or the hospice team was untrained. Good care is nearly impossible to achieve in certain settings, and this is one of them.
4
@Cathy
It's very challenging when you deal with nursing home staff: some are highly competent and work cooperatively; others, well, they are less attentive to the resident, and perhaps less knowledgeable about state of the art best practices. I've found as well, that altho' my mother's dementia has progressed, they don't always talk to me about changing meds. And this is from a personal situation, but one that may be common - sometime changes in staffing sometimes leave me unsure to to speak to . . .
I will be 72 on Wednesday. Original Medicare and a supplemental insurance plan have paid my medical bills since Dec. 1, 2011. Until a few weeks ago, the biggest expense covered by Medicare and my Part B supplement was my "Welcome to Medicare" colonoscopy. (Some "welcome," huh? It was clean. Believe me, it was very clean.) In October and November I had cataract surgery, which is now my most expensive Medicare outlay in the past 7 years. In between those two events, Medicare has covered my semi-annual visits to a dermatologist for a history of basal cell skin cancer, and annual "wellness" counseling visits. During those 7 years I have paid a monthly Medicare premium (currently $135.50/mo), a monthly supplemental insurance premium ($214/mo for the coming year, up from <$100/mo at age 65)), as well as Medicare's annual co-pay (about $180 this year). I have roughly paid in, out of pocket, in the past 7 years at least $250/mo. or $3,000/yr at an absolute minimum. $21K+ for health care insurance, over and above my Medicare taxes paid in while I was working. Less (way less) than $10K was paid out by Medicare during those same 7 years. And I have no complaints about my insurance coverage.
Medicare Advantage? It is, in plain English, a rip-off, free money to Aetna, Cigna and the rest of the private insurance industry. At everyone's expense, not just us retirees paying in our premiums that no one ever finds worth mentioning when it comes to end of life health care.
108
Ahh! The rare chance to append to my posts.
As for death, I intend to take that step on my own terms, and it would be so much easier if the state, the nation and the nosy-bodies of organized religion would mind their own business. In truly civilized societies, suicide in the elderly is not decried as an abomination to god (whatever "god" is) but as a reasonable step in winding down one's existence.
No putting the barrel of a shotgun under the chin and pulling the trigger with your thumb, or a .38 in your ear to destroy the mid- and hind-brain. No hoping you've amassed a lethal quantity of sedatives, depressants, narcotics and washed it all down with a tumbler of cheap whiskey (no sense wasting money, even at this point; leave it to the ASPCA where it will do some good).
My father's last years were wasted away in dementia, while blood clot filters were stuck in his vena cava, his macular degeneration "treated" with injections into his eyeballs, his underwear exchanged for paper-and-plastic diapers. His father, by way of comparison, was lucky: a ruptured abdominal aneurysm (which Dad also had but which was "managed" with blood pressure meds) with death arriving in a couple of short days.
I would prefer to die peacefully, quietly, in a soft,warm bed and family and friends nearby and the taste of fine Scotch lingering on my tongue. But, I am prepared to go in other ways if I am denied that one final pleasure.
116
@Glen,
I am 71 and I must let you know that after reading your comments, I am somewhat strangely comforted that I have finally found someone, somewhere who actually echoes my feelings and my thoughts so precisely.
Here's to a meaningful exit ... after a meaningful life. Thank you.
67
@Glen I believe you speak for many seniors, about end of life decisions. If only the decision were ours.
64
If the USA government collected more taxes off the wealthiest people in the USA then you could have a universal health care system. It's criminal that the richest people in the USA are giving away much of their wealth to charities - like in the days of Oligarchies - the USA government should be taxing those billionaire people so they didn't have so much money that they could become oligarchies in the USA and privately decide whose worthy of their billions and who is not. That is not Democracy in action. Without taxation there is no Democracy and the rich need to pay more taxes so there is a universal healthcare system. USA citizens first.
5
"Although most who enter a nursing home don’t stay long, 5 percent of the population stays for more than four years."
True! And a sad thing for the five percent.
People don't stay in nursing homes for long because nursing homes are rife with germs. If you want to kill off your old aunt, put her in a nursing home. In a couple of weeks (or, at worst, a couple of months), she'll come down with c. difficile, and that'll be that.
Better to keep her at home if you want her to live.
Of course, if she's down to 80 pounds, doesn't know who you are, doesn't know her own name, and can't remember her own mother when shown a photograph of her, maybe it's time for a nursing home.
2
I made this deal with G-d about ten years ago where He/She promised to leave me here until I request otherwise and so far, it's working out just fine.
Unfortunately my request for a steep cut in my health insurance costs was denied.
3
If one reads the referenced study, you will see in the comparison they used, in addition to other jurisdictions, the province of Québec, to account for Canada presumably.
It should be understood that in general Québec government functions such as provided by the RAMQ (Ministry of Health) are overly bureaucratic; and arguably deliver the poorest service when compared to the other provinces. By way of example, the Ministry run hospital in the Western Québec city of Gatineau has been ranked as one of the worst in North America.
My point is that the cited study for this article cherry picked its data sources, and the claimed result in this article that US spending was not entirely out of line is suspect.
Oh, and one more thing, I would rather get my healthcare from Québec’s flawed system than anything I could get in the US because... single payer.
2
Death with Dignity legislation makes both moral and financial sense. We should all have the right to decide when our abilty to live a useful and meaningful life has come to an end. The right to choose both the method and time of our death. There should be no artificial religious constraints placed on that right. Dementia is incurable and severve depression is every bit as devastating to quality of life as terminal cancer is.
12
Agreed but the powerful forces of organized religion will never allow it.
Good grief, it's easy to predict who's going to die----ALL of us. It's also easy to predict who will live---those with less stress, more meaningful activity, and better diet and exercise habits. Tall order for a country as rapacious, ill-regulated, and discompassionate toward the elderly as is the US.
4
Every time I read an article like this it just reaffirms my decision to forgo expensive medical treatments at the end of my life. I have discussed this with my children more than once and will continue to do so even though it is uncomfortable for them to consider my death. I live in a time where our country refuses to initiate health care coverage for every citizen from pre-natal care to end of life palliative treatments so I have calmly accepted the fact that when I am ready, I will die my way. I’m not depressed or suicidal, just profoundly prosaic and unwilling to leave behind a mountain of debt for my children to shoulder.
33
This was a much-needed summary of the reasons why no one should go into retirement assuming that their healthcare needs will no longer be a problem. Thanks to the disastrous rise in healthcare costs in recent years, and to the reality that Medicare doesn't cover everything, even one minor spell of illness can easily be the cause that triggers the loss of one's home and independence and, potentially, one's life.
It bears repeating that the cost of premiums for Medicare (Parts A, B, D), added to the cost of an essential Part B Supplement, is far higher than most people contributed to their employer-sponsored insurance. Buying a Long Term Care policy is an expensive option, but also one that renders one's total monthly healthcare costs exorbitant.
Younger people who assume that this "entitlement program" will reduce their monthly spending needs at retirement are mistaken.
12
And Long Term Care policies only cover you for about 3-4 years.
1
That’s why I declined to purchase one.
Navigating Medicare is a challenging but not impossible task for the retiree. I recommend consultation with an independent insurance agent when the time comes to enter the Medicare market. Healthy retirees may do very well with Medicare Advantage (Part C) in early retirement years. The additional cost of a Medicare supplement may not be warranted. Medicare Advantage does expose you to $6700 in additional out-of-pocket costs should you become seriously ill. It is a chance that may be worth taking, as it does save the cost of the Medicare supplement premium. Take the time to review the offerings every year during the enrollment period. Plans change, and changes in Rx formularies can be especially costly and not easy to discover. Change plans as you need to. You can even choose to switch to a Medicare supplement plan as you become older. There are many options. It pays to be an informed consumer.
6
@Wanda If you switch from Medicare Advantage to traditional Medicare you may be subjected to medical underwriting at that time. Also, if you do become really ill with Medicare Advantage, your network of doctors is limited.
2
I have found Medicare supplement insurance well worth the premium..the one from AARP is a rare gem of a way to get Medicare F...and I dont work for aarp nor ge t a commission for my input
Re the Manhattan vs Rochester example - is it clear that the difference is due to waste in Manhattan? What is the explicit evidence for wasteful spending? Perhaps health care is better and/or more available to more people in Manahattan than it is in Rochester.
4
I will have lower costs at end of life because I will refuse treatment and die as quickly as possible. I have no interest in prolonging my life if I am bedridden. I wish there was a way to help those of us who feel this way and not thwart us. Let younger people use the money I will save the system....
34
@Shelley Diamond Me too!
2
@Shelley Diamond Better to put that in writing now and make sure that decision is known to everyone involved in your care currently. You may not have that voice later when it might be needed to direct your wishes.
4
Thought-provoking - to be sure.... But here's something that some would deem UN-scientific, but I'm less certain - and I'm pretty comfortable with things like statistics & western medicine.
My in-laws were in a good "retirement community" when they reached old age. But the staff alerted us to the likely "imminent" passing of one of them - more tactfully than that suggests.... The context was "After a while, you get so you know ..."
OK, I admit that that was far from "double blind," but maybe that's the point. The "numbers" may be poor predictors, but it's a little like our amazing "vision" vis a vis a camera's - PEOPLE see things that rely on "pattern recognition" that we haven't yet been able to program.
Call it a kind of "tribute" to the man in question, my father-in-law - when it was suggested that they let him be hospitalized, he summoned up the last of his strength and said NO clearly and firmly. I doubt that he based that on economics - rather, it was a sense - still shared by many of us ... and far from contra-indicated by this article - that "end of life" care benefits the care-givers - i.e., doctors and hospitals - far more than it does the elderly, "ill" or not.
21
@edtownes. And sometimes it’s the family caregivers who insist on ‘everything’ possible. Be sure to put it in writing if you don’t want that—in systems where more is the default position, you will often get ‘more’ whether it’s better or not.
4
@GeriMD
86 year old here who just spent 3 days last week in a hospital she struggled mightily not to enter.
I'm fortunate in that I have a living will and a hospital who honors that. Telling one's children how one feels about major illnesses or end of life can be disrupted by one child not willing to let go.
More elderly try to stay out of hospitals than want to go, so those of us who eventually cave in and go have very strong opinions about what they will accept in care and what they themselves feel is of no use.
3
@edtownes Doesn't sound very statistical or medical science to me.
"not supported by evidence" often means not FDA-approved. That's not the same thing. Evidence may accumulate for years before formal approval. Most cancer chemotherapy is "off-label", a synonym for this article's "not supported by evidence". It is supported by evidence, but doesn't have an official seal of approval (getting that from the FDA is enormously expensive, and unnecessary if doctors read studies in medical journals).
5
Any patient (regardless of age) with a chronic progressive disease should seek a palliative care clinician. Palliative care focuses on symptom management- chronic progressive disease usually carries a burden of symptoms- shortness of breath, pain, fatigue, anxiety ....and planning for future care- what are they willing to do, not willing to do. Often palliative care is thought of as hospice or end of life care- it can be- but it's effectiveness lies in earlier conversations regarding advance health directives and making people feel the best they can with their disease. Palliative care can be delivered alongside traditional care, such as chemotherapy, surgery, interventions, hospitalization. Usually there is a PC service in hospitals, as well as out patient programs. The majority of people who have had PC involvement earlier in disease/aging process choose not to have non- beneficial, expensive treatments/interventions that may prove to only prolong the dying.
17
Let me dumb it down and recap it for you Austin.
While Medicare is inferior to just about any other peer countries' health plan, because you can technically still go bankrupt on it, it is light yrs. better than our de facto criminal health care for the rest of the populace.
It is not rocket science, just about every other peer country has figured it out, universal, quality, affordable health care for all of its' citizens.
We can do the same if we have the will power.
149
@Paul Yes, a healthier country will be a happier country, (just from knowing their health care is covered and relieving the constant stress) which will be a more productive country. It is so obvious, unless you are currently a Republican. They do not connect the dot's or simply don't care. The only people in the world who reject climate change. They are nuts!
Let's win in 2020 and at least shore up and fix the flawed but fixable system in place before we jump right into universal health care. People need some time to get used to change.
8
@Hal Paris, of course when you're dying you have less time to get used to change, and you might even be grateful for things having changed very quickly.
1
@Hal Paris-Yes a sweep by those in favor of what the rest of our peer countries have.
However, a veto proof majority in the senate is needed and that is unlikely.
The dems #1 priority in 2020 is to push this issue and warn any republican that is not for it, it will be used against them just like what happened in the House in 2018.
There must be republican support and the dems should let any republican running that if they are in favor of it, they will most likely be re elected.
2
"Everybody wants to go to heaven, but nobody wants to die."
- Albert King
OK, I know that's not totally on topic, but it's such a great line.
34
@Miss Anne Thrope
And, Miss Anne, those who fight the hardest and spend the most to keep from dying are...wait for it...yep, Christians!! This bit of shocking news from an old ER and end-of-career hospice nurse. Me.
Go figure.
1
Ironic isn’t it. You’d think they would be happy to go to their reward in heaven. Or maybe they have their doubts..,,
When doctors are paid by the "procedure" or RVU, there is little incentive for them not to operate regardless of outcome, age or condition of the patient. Medicine is driven in the US by profit, not by "what's the right thing to do?"
17
@Anita Yes, but medicare has better controls on this than private plans for working people.
4
@Anita
That's simply not true. As a Hospitalist I see this all the time. Specialists I consult (at request of family) frequently say treatment is futile and recommend Palliative Care, but family resists. They "want everything done." Even at times when they know that's NOT what their loved one would want if they could tell us. Everyone needs an advanced directive.
11
Let's look at the data more carefully. For a hospitalized patient with a known terminal condition (hemodynamically unstable sepsis with an elevating lactic acid for instance) I am convinced that predictive analytics are very accurate. Hospitals make a fortune in the ICU. It is a profit center. It should be fortified with state-of-the-art technology, no doubt. But for patients who are about to expire we need to all be realistic but in our personal lives and as we craft reasonable healthcare policy. Dr. Jha's comment that spending more money up and until death is too broad and insufficiently specific. The hospitalized, terminally ill patient is not a case for advanced heroics in some cases. There are exceptions but there is a dying process and we should accept terminal states for patients who present with specific clinical circumstances. Death is not a defeat in some cases, it is an inevitable outcome after a long course of therapies and interventions. The human body eventually terminally fails.
31
This thinnest space in today's medical world is the shrinking gap between ''testing too much'' and ''protecting the doctor's patients and practice from ruinous tort lawyers looking to buy their first Maybach with cash.''
13
The waste is real, but exaggerated. It might be 10% over-use of expensive treatments with little benefit. We don't call that "futile treatment" anymore, we call it non-beneficial treatment (or where the benefit does not equal the harms caused).
But there is another 10% of waste in just overhead and executive salaries and hospital administration.
Out of almost $4 trillion dollars/year, together that's close to $750 billion in waste!
To be blunt: if we set very minimally acceptable limits to what is paid for, similar to what is offered in Norway or Denmark or the Netherlands or France (all of which have a longer life expectancy than the US) and had single payer, we could afford very generous benefits for every person in the US.
As to predicting death, I heard an expert on that topic say doctors were over 90% accurate when it got to "3 days or less." In other words, not very helpful at all. That is NOT where the saving will come from.
18
@priceofcivilization you are exaggerating the adminstrative savings of single payer. The real savings comes from paying providers less and you don't really need single payer to get that (and I say that as someone who supports guaranteed coverage). The real waste is our "have it all" mentality towards health care. As long as any attempt to restrain costs or utilization can be demagogued as "rationing" there won't be any savings.
3
ConsDemo. Not disagreeing with you but how do you convince people who have plans that allow them to have it all or almost all
to give that up. Remember if you like your doctor you can keep your doctor. It just doesn’t work that way. Anybody with good care will be forced to accept less
1
This articles ignores the fundamental question:
Should a “wealthy” democracy provide essential disease care to all its members - regardless of ability to pay?
If yes, then the questions are:
1) What are essential disease care services (and products)?
2) How to pay for them?
3) How to regulate the costs/charges?
4) How to provide efficient and effective care?
A critical tool to use in answering these questions is what has worked best so far in our nation and around the world.
Stephen Rinsler, MD
23
The big question that is highly deserving of a long, hard look by investigative journalists is whose advantage we're talking about in "Medicare Advantage" plans. Doesn't appear to be the patients. I wonder how careful the Center for Medicare and Medicaid Services (CMS) monitors these plans.
22
@Pete in Downtown - Agreed - here's an article from the NYT on that topic:
It's bad enough that the "health insurance" leeches lurk in the money stream, sucking out profits and adding 30% "overhead" costs to manage claims - "Management" that primarily consists of delaying and nitpicking legit payments while they overpay their execs. Medicare Advantage is an even more blatant way to transfer wealth to The Bigs - Insurance, Pharma, Hospital, yada, yada.
14
I’d like to know about issue of procedures done on aged and infirm patients which pay hospitals and doctors well.
4
There is some good information in this article. But I wonder if the study that shows the US pays less for elders' health care at the end of life controlled for access and ability to pay for that care given the gaps in coverage under Medicare mentioned earlier in the piece.
We all get entered into the Death Lottery. Will we die instantly from a massive heart attack, or have a series of debilitating strokes? Will we linger in the hell of dementia for a decade, or die sweetly in our sleep? As unpleasant as it might be to know the answer in advance, it would certainly make it a lot easier to plan a graceful exit.
28
It would be handy to see the share of doctors still accepting Medicare now and how that trendhas changed evey 5 years....
1
@L'osservatore
The percentage of physicians accepting traditional Medicare, sir, is extremely high. Locally, where I reside, a few years back, physicians at the local hospitals, and the hospitals stopped accepting Blue Cross/Blue Shield but gratefully accepted payment from Medicare.
A not-unrelated anecdote. Fifteen or so years ago, my personal physician moved away from this area because so many of his patients were on Medicare. He ended up in southern Colorado. A couple of years after he moved there (and long before I was on Medicare), I had the opportunity to drop into the clinic where he practiced, just to say "Hi." He asked my wife and me to wait while he finished seeing his last morning patients, then took us to lunch at a nearby restaurant. He told us he had completely reversed his position on Medicare recipients and now welcomed them, and, on top of that, rued having left north Texas for that very reason.
9
@L'osservatore There are a significant number of doctors in Manhattan who do not accept Medicare, including the practice group of which I am a patient. I don't have any statistics, but I have heard similar observations by friends.
3
@Joel
Yet another reason to no live in NYC.
Great place to visit, no argument about that, but live? Not a chance, for this commenter anyway.
The incredibly high cost of housing on Manhattan wouldn't have anything to do with the docs refusing to see us old veterans now, would it?
2
Tried to get to the Science article cited by Austin Frakt as he observes, "The study used all the data available from Medicare records to make predictions: For each beneficiary, it assigned a probability of death within a year. Of those with the very highest probability of dying — the top 1 percent — fewer than half actually died." However, the Science article is behind a paywall. Very frustrating for the advocates among us, since we would like to understand the data used to predict. Wondering if they looked at the capacity to perform activities of daily living, the term used to "measure" the degree to which someone can still ambulate or wheel themselves about, groom themselves, manage their own toileting needs, feed themselves. Or were they still focused on just the traditional medical measures? Wish Mr.Frakt had been informative about the methodology as he draws attention to the headline.
3
Well I was able to tunnel under the paywall and carefully read the study methodology, including the data and variable definition section. The data are from CMMS claims from 2007 and 2008. Their variables were numerous, but none included the ones that you mention.
4
Nice, you didn't blame patients for unneeded, overpriced care, many do. When care is "free" or insured, care and costs skyrocket, patients should pay some.
But drs. are far worse, they can charge ridiculous amounts for anything, why not > $1000 to look at a few x-rays of a broken finger? My surgeon looked at those x-rays, charged nothing, but somewhere a radiologist got a hold of them and dx a fx, a 5 year old could see it's broken (It was unneeded, unwanted, felt like fraud, know it's not illegal, disputed it anyway to no avail.)
There are dozens of such bills in any hospital visit. Insurance may reduce some but if they really did that, they couldn't justify their costs.
4
@Oreamnos
Don't blame the radiologist, but blame the hospital administration. These days doctors have to write their notes following guidelines which are intended to maximize the amount that can be claimed from insurers. The insurance companies collaborate by defining the content of a report which gives maximum payment to the hospital. In turn, the hospital rebukes the luckless radiologist who writes an honest description.
21
Not only is it difficult to predict when someone is going to die, it is very difficult for providers to differentiate between "we can do something" and "we can do something that will help and not create more problems of another kind".
Implanting pacemakers in very old, very ill people is an example. Surviving one acute problem so that you can die slowly of another problem or problems that strip you of your dignity and sense of agency is very likely. But if you don't ask, you will not be told that this is a distinct possibility.
I don't know anyone that thinks that death sounds wonderful. And I have yet to personally meet a cardiologist that doesn't want to save the life of a frail person. They won't be visiting that patient in their NH to see the end result......
16
Often senior citizens do have a crystal ball to the future. If you look back at the declining quality of some people's lives during the last year or two, you can often tell what the future, short of a miracle, holds. When a person’s quality of live has steadily declined, the person can decide or has previously indicated that it is time for comfort medical care. Then there is often such relief once the person is freed from the burden of aggressive medical care that has virtually no chance of long term benefit. That person can then get on with living the rest of her life. We-society-are improving our tolerance for decision making in the face of terminal illnesses.
People and families also have to be prepared to make decisions about dying from medical conditions that are not typically thought of as inherently terminal illnesses. For instance a person can have massive GI tract bleeding or have a septic bloodstream infection. These examples are not terminal, like the way we think of terminal cancer, but are still very deadly. However, often doctors can achieve improvement regarding bleeding or sepsis within half an hour in the emergency room. But a person may have established that her declining quality of life has reached a point where it is more natural to pass away then to be kept alive by doctors. Then the bleeding or septic infection can be seen as a window of opportunity to die and the person or responsible relative should be able to decide for comfort care.
21
We left the US for Mexico, and healthcare was part of that decision. A few pros and cons:
No Obamacare, which means pre-existing conditions are an issue in the private market. (That means I have a US$10,000 deductible on anything involving my left knee.) This premium will certainly increase every year until it's unaffordable.
Our worldwide (minus the US) private insurance policy is about $4,000/year for two over-60 adults with $1000 deductible.
We also pay $700/year to access the government health system called IMSS, which is nationwide and has zero deductibles or copays. Service can involve long waits (like in Canada) but care is good to excellent Pre-existing conditions were only excluded for the first year.
Going to visit a doctor for minor issues can cost nothing (many pharmacies have one) to around $65 for a specialist (gastroenterologist, surgeon, etc.). So it's easy to just pay out of pocket.
Just good for thought.
22
@Dave
"No Obamacare, which means pre-existing conditions are an issue in the private market."
Well, Dave, when that Texas court case makes its way up to Justices Clarence Thomas, Alito, Kavanaugh, and friends, we won't have Obamacare either, and preexisting conditions will make it impossible for many of us to get insurance.
Who, after all, but the very young, and not all of them either, doesn't have a preexisting condition?
Blood clot? It's been there a while. A tumor, even a benign one? Probably it's been budding at least a year. A degenerated disk in your back? Ditto.
All conditions fixable. That is, if one's insurance will cover them.
1
My personal solution is an advanced directive prohibiting extraordinary measures in most circumstances and, in my enlightened state, WA, the freedom to decide when to stop expensive treatment that may technically be life-prolonging but is not a life--in my view--worth living.
It's about time that we began discussing these issues in public, and for parents to take steps to preclude the kids from exercising the "Keep Mom alive no matter the cost/quality of life tradeoff" guilt-driven option.
51
@Malby Once you have an advanced directive it's easy to feel "covered." Except that doctors often don't abide by them. In the rush of an emergency surgery, say, the doctors don't/can't take time to read your chart. I know from experience (twice, with my 99 year old mother) that patients rights are often lost in the doctor's instinct to save a life. Additionally, if a patient dies during surgery or close after, that's a mark on that surgeon's "numbers," that is, his healthcare outcomes. He/she has strong incentive to ignore your advanced directive. What it takes to make an advanced directive work is a firm-minded spouse or loved one close at hand to carry that weight, and to make sure your last wishes are fulfilled.
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@Malby
Mu mother's MOLST (detailed directive) got "lost" in the back of the chart when she was moved from the ER to the med/surg floor. How was I to know where it went after the ER staff received it? If she had coded the previous night, they would have done anything and everything. So much for having an advance directive.
Do not think it is "one and done". As in the previous reply, your proxy should be there and intensely involved in your care, willing to make a stand. And if you go to short term rehab, it isn't valid. The NH's own policies apply. That is hidden in the fine print.
The only thing worse than no plan is thinking that your plan is foolproof.
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@Cathy
You are right that producing the right papers at the right time is tricky and often doesn't happen. Maybe we should have them tattooed on our backs.
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The problem is people don't want to die--but after a certain age, spending all that money keeping them alive is truly wasteful. After, say age 85, do we really need to spend those huge sums giving someone a new kidney? Or, if we know the person is going to die, why not go to palliative care instead of those $30,000 drugs that maybe give them 2 more weeks. People need to make these decisions about what they want at an early age and stick to them. Of course families also cause problems with this "Keep him alive last any cost" mentality.
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@BCP, at 78 I ask but what if it gives him not two more weeks but 2 or more years?
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A good but seemingly incomplete article. Where is the discussion of hospice and palliative care near end of life? These resources are a win-win aspect of elder healt. Costs for Medicare/Medicaid are lower for hospice patients than other medical care and the patient is treated in their own setting.
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There is a fantastic healthcare plan available to nearly all Americans. All it takes is 20+ years of military service. No, it’s not the VA. The V.A. is for military service people who don’t make it to retirement. For military retirees,the plan is known as TriCare, and it also covers spouses of retirees. Cost? About $100/month each for retiree and spouse. No copays, n deductibles, no caps, no pre-existing condition limitations. You see any doctor you want. No referrals required.
Medicare pays 80%; TriCare pays the remaining 20%. Contact your local recruiter.
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@JSK *BUT* Tricare does not cover long term nursing home care either.
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A better description of this article would be "misconceptions about end-of-life care." The kicker quote tells all: "Spending more money on people who are suffering from an illness is appropriate, even if they die."
Really? Spend more on a fourth chemotherapy regimen on an 85-year-old with metastatic disease? Send the advanced Alzheimer's patient who catches pneumonia to the hospital for treatment?
Statisticians may not know who among at-risk people are in the last year of life. But in my experience, doctors, patients (especially those with the wisdom to have developed a health care directive), and family members generally have a pretty good idea.
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@Merrill. Yes, really. When the metastatic patient who is receiving her 4th chemo regimen is my mom, who at 81 still has all her marbles and lives on her own and wants to keep living to see her grandson get older each year. And I want that too. So sorry if you think this is wasteful expense but she isn’t your mom and it isn’t your life. And she was diagnosed as metastatic 8 years ago, so continuing onto new chemo regimens could be expected after this much time.
Medicine is not a one size fits all situation. Please have some empathy and awareness of others before you decide who should live and who should not receive medical care. Thank you.
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@Merrill
I agree completely. My aunt, ninety years old, would have been far better off had she died of pneumonia three summers ago, when she still somewhat knew her name, and when prodded could remember her dead brother and sister, and could smile at a photo of her mother.
The emaciated creature now lying in bed is a reminder that modern medicine isn't always benign.
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@B. - Sorry to hear about your aunt's state.
Pneumonia was once called "the old man's friend" because of the swiftness with which it dispatched the afflicted and hence ended their suffering.
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I am a retired physician who writes a daily commentary on health policy (PNHP, Quote of the Day), believing that everyone should have affordable access to beneficial health care services when needed (i.e., I support Single Payer Medicare for All). I am also an octogenarian undergoing an evaluation for a medical problem that may well have a guarded prognosis. Believe me, I am very tuned in to this article on late-life care written by one of my favorite health policy analysts, Austin Frakt.
Should an old man like me have a workup for a condition for which there may be no beneficial intervention (though that is uncertain because of the lack of a definitive diagnosis at this point)? Can society afford to fund such care? Well, there is extensive literature that indicates that we can, in fact, afford to fund essentially all truly beneficial health care services for everyone as long as those services are priced reasonably. The line we should not cross is when diagnostic and therapeutic health care interventions become futile, but then that is precisely why we have palliative/hospice care.
The goals of health care should be to prevent premature death when possible, and to maintain quality of life as best we can while we are here. Studies have confirmed that such care would be affordable for society with a well designed, improved version of Medicare that covered everyone - a system that's efficient, effective and equitable - a system that places the patient first.
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@Don McCanne
Nice essay. I feel the humanitarian impulse coming through with a fine sense of responsibility in your comment.
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@Don McCanne The problem comes when physicians do not distinguish between beneficial health services and just doing something. The family is in no position to judge. I have spoken with 2 nurses who just got the family to accept the inevitable and move to hospice when the doctor came in with a new treatment to try. The nurses both felt like strangling the doctor. This is what I have experienced with my dog and it scares me for the end of my life.
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@Dru Winters, Thank you. Might you share the link or email for subscribing to your daily comment? Thank you.
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The latest in the ongoing series, "Yes the US healthcare system has its challenges but what we have is the best of any possible alternatives" that function to assure that the most expensive system in the world remains such and that the bales of excess money flow to where it always has. In other words, patients, count your blessings and we'll be content to count the cash.
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Right now, we continue to be in the grip of medieval, theologically saturated thinking about the life-death continuum. Let's see what happens to the statistics when we become enlightened, when there is broader acceptance of the right to die, and we have legal choices of when, how, and where.
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Society is at cross purposes in these considerations because the timing of discovered cures plays such an important role. The attitudes of the aging regarding their lives comes into play too. You need to go a lot deeper to properly discuss costs.
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America has very weird ideas about dying and death. The Christians look forward to being in heaven, but want to drag out life till the very last, at great cost to the health care system as a whole and at risk of living past their ability to function. There is an end age (82 wish) at which I intend to stop all medications that prolong life without an overriding contribution to quality. I am much more fearful of dementia or incapacitation than of dying of a heart attack or stoke, or even cancer. Hopefully, I can access death with dignity options for terminal diseases - but not with dementia, which keeps you alive at great cost and suffering for your kids. Want to avoid that and die younger! Am 68 now, so this is no longer strictly theoretical. And PS - if you have an option to keep dental insurance, do it. Biggest surprise has been how many more dental issues my husband and I have had since I retired that are now at $30K in last 5 years and keep happening.
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@DB Your concerns are similar to mine (also age 68). I have dental insurance, and it helps contain costs, but it's not employer-subsidized. Fortunately, medical insurance is excellent. I'm at high risk of stroke, but due to a mild version of a condition that the long-lived George H.W. Bush had. My father died with a dementia that had begun early. I've seen, repeatedly, that altering one's living arrangements to adapt to age-related disability is difficult. A neighbor drove off on an errand one day and ended up running out of gas, two hours away. By the way, I would not generalize about Christians. Some insist on maximum possible medical care, but if you look closely, I think that's often among portions of our population who were long discriminated against, and may still be, and who are wary of what seems second-class medical care. I'm a member of a relatively conservative United Methodist congregation with lots of older members. Many age and die, as gracefully as possible, given that the insults and illnesses of old age conspire otherwise. I've been repeatedly impressed.
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@DB I don't think you can set a date like this. My aunt is 97. She lives in a retirement community basically independent. She is becoming more frail, but her mind is still sharp. We go up to see her 3 or 4 times a year, take her out to eat, the movies, etc. My kids grew up with her and love to see her, she feels likewise. She has been treated for some mild infections, but has has no major surgeries, although she did have a knee replaced a long time ago (+15). I see no benefit to you or your family if you don't treat something easily taken care of simply because you have reached an age you deem 'old enough'.
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@DB - "America has very weird ideas about dying and death." We do, DB. Here's a wiser view:
"What caterpillar calls death, the rest of the world calls butterfly."
-Richard Bach
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If you can access managed medicare you should. That is really the only way to get some kind of a cap on your out-of-pocket expenses.
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@Frank. May want to reconsider this choice. I’m an RN Discharge planner at a large west coast hospital. We call these plans Medicare Disadvantage Plans because good luck finding good follow up, a specialist, to see you after discharge. One Humana Medicare patient I helped had to wait 6 months to see a cardiologist- and this patient was discharging after cardiac arrest!! My Mom only got 3 home health visits after being hospitalized for a stroke. Medicare with a supplemental and Part D is worth every penny should you need care after a serious health crisis. Advantage plans are corporate welfare.
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Most post retirement health care expenditures are for bad lifestyle choices. A lifetime of Fast food, excessive drinking and lack of exercise makes for a miserable existence. Look around at the future generation of retirees. Obese, sedentary and diabetic in middle age.
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@Mark Stone There are a few other influences in play: Environment, access to care, socioeconomic stats, education, genetics, to name a few. This is not quite as simple as you suggest.
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@Mark Stone The "bad lifestyle choices" meme seems to come in very handy whenever people are casting about for rationales for denying services to people who are ill. To me, it seems to lead right to the conservative version of the death panels they love to claim would result from providing affordable health insurance to all Americans.
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@MLChadwick
I don't disagree with you, except I believe the statement might be better phrased "the meme seems to come in very handy when people are casting about for denying medical services to people who are *poor*"
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Excellent article. Thank you. The problem is identified: death is not predictable 100% prospectively, but spending is proven 100% retrospectively due to death. My husband, a physician, and I discussed this for years at breakfast. How much medicine, how many procedures and operations are ethical for patients who are 70,80,90 or 100? My aunt received a pacemaker at 94ish. Really? She is now over 100! But, she is in a nursing home, with little memory and may outlive her memory. Was it ethical to implant a pace maker? Articles in this paper have told the poignancy of families who must face the decision to turn off the pacemaker in a loved one with Alzheimer's disease. Do no harm.
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Who do you want making your end-of-life choices? An emergency room doctor who's never known you? A grieving child? No! Decide for yourself. Learn about the options, declare your choices. A living will may not always be honored, but documenting your choices gives you a fighting chance.
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@Kathryn While I agree in theory, I found it difficult to make my own decisions about an unforeseen condition that might occur under unknown circumstances sometime in the indefinite future. Medical progress is being made by such leaps and bounds that even the definition of "extraordinary care" is likely to change substantially during the next 10-20 years. Even after watching many episodes of Grey's Anatomy, I do not consider myself especial well informed about standard medical treatments today.
I only hope that my children know me well enough to make reasonable health care decisions for me, in consultation with my doctors, should I become unable to make them for myself.
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The root cause of excessive cost is where, not who. Hospitals are very expensive for everyone, not just elderly. Why are people spending times in hospitals? 73 days out of final 2 years seems excessive. If regional differences exist for same age group, they are first target.
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@Michael Blazin
The article states 73% more days, not 73 days. For example, 17.5 days vs 10 days would be 73% more.
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@JK
make that 17.3 vs 10, please.
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Missing data alerts: First, the statement that "Total health care spending for Americans 65 and older is about $15,000 per year, on average" is less than half true if you look at the referenced publication. That is average over a retirement and as the referenced publication notes, it starts at less than $4,000 a year at age 75 and goes up rapidly from there. There are many more studies that put the average health care costs for a majority of retirees at about 5-7 thousand per year. Second, one hears the repeated number of 250,000 - 280,000 dollars that a retiree needs for medical care. The big scary number. Yes, that is the total, but break it down over a 22+ year period they use and look closely at the components of the annual expenditure. You get a number of about 10 - 12 k per year and they included Medicare B, Medicare D, Medigap or other insurance and an average out of pocket of $1000. Now look at what you paid when you were working. Considering the average cost for the employee premium portion of employer provided health insurance is now about 6,000 per year and out of pocket is another 1,000, do the math. Compared to when you were working, you have just an additional 3,000 a year for health care as a retiree and a majority of retirees, even less than that. Don't let the big number scare you but look at it logically. Yes, you will have more health requirements when you are retired, and you need to plan for it, but it is not insurmountable.
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