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Lessons of a $618,616 Death
theodp writes "Two years after her husband's death, Amanda Bennett examines the costs and complex questions of keeping one man alive. The bills for his seven-year battle with cancer totaled $618,616, almost two-thirds of which was for his final 24 months. No one can say for sure if the treatments helped extend his life, and she's left with a question she still can't answer: When is it time to quit?"
It is only time to quit when the patient ceases to be happy. As long as they are still in good spirits and enjoying their life, keep trying...
try to estimate cost vs. life expectancy in a function and derive the local maximum.
After all, when it comes to health we should never forget what a life is worth... in terms of hard currency.
In f.e. Sweden, the cost for this case, over 7 years, would've been a staggering whole lot less in the shape of the extra taxes we pay here for our free healthcare (yes, I do consider it free after all). Over here, everyone helps to pay for everyone, and people get the care they need without being subjected to "pay lots, or get out". Over there, people die, or go broke in the process of staying alive.
In your case it's 300 €, but keep in mind that the amount you pay for insurance is directly linked to your income, not to how much you've been sick last year. You could argue it's unfair that you have to subsidize a bunch of students and old people for a while, but it sure beats any other system I've seen. I agree it's not fun to pay the insane amount of insurance and taxes here in Europe, and yes, a huge part of it is going to be wasted on government pork and mismanagement. We need to address that. I'd speculate we could cut those insurance premiums in half if we abolished all the profiteering, corruption and misappropriation. But all in all, it's the price we pay for a pretty decent attempt at social equality.
Having private health insurance and then not letting people make use of it seems to be the worst of both worlds...
Why is it when we have health care discussions, the media tends to quote widows and widowers? They are not experts in health care and they are not unbiased. Sure, her story is interesting and compelling, but does it tell us anything useful about medicine in the US?
True, it's horrendously expensive. But that money pays for research, and that research will allow people to stay alive or even get cured a lot cheaper later.
People aren't going to pay half a million for battling cancer forever. At some point it'll be understood and become curable with a few of the right pills and injections. But for that to happen, somebody needs to try the less understood or experimental treatments and see if it works out.
Incidentally, I believe that paying for the "vaccine for nearly a quarter million children in developing countries" is on the long term a rather pointless thing. Doing it that way we'll just be shipping vaccines over there forever. Instead, money should be invested on infrastructure in those countries that need it, so that they can manufacture their own vaccines. Also, actually allowing those countries to manufacture them by eliminating the need to obey the patents would do a whole lot more of good.
In Australia, the last time I looked, around 90% of the lifetime medical expenses is spent on the last year of life. This has been true for decades.
You think you are doing good stuff, but all too many suffer and die. As a GP, my role is to keep folk alive. If I was a complete rationalist, I would work out some way of stopping useless treatments, but unfortunately that is usually only obvious in retrospect.
I counsel folk on the pros & cons of cancer treatments.
Sometimes it is obvious you are flogging a dead horse, and really they should pull out and enjoy their last days in comparative health, without the misery of chemotherapy et al, with the horrible side effects, and before you recover, the cancer catches up to you & you die in continued misery. I kept one of my mates out of lung cancer chemotherapy (in this case there really was no chance), and he enjoyed his last few good months without being stuffed by chemo. His family still thank me years later.
Then there are the less obvious cases, where the therapy may help, but usually just adds to life's burden of misery, worst just before they die.
Then there are the successes. They are wonderful, but not that common.
Sure, some guys making chemo drugs make a lot of dollars, but what drives most medicos is that we care, and we are not very good at pulling back when things are hopeless, because sometimes we succeed.
Unfortunately that is bullshit fed to you by expensive PR.
An example demonstrating it very clearly is the cervical cancer vaccine developed with Australian taxpayers money, certified to US standards by the Australian taxpayer (similar to Australian standards so not a lot more) and licenced to US manufacturers for a very low fee. Guess what - it costs more than twice as much as anywhere else in the USA with the "R&D" excuse without a single dollar spent on research and development by those jacking up the price..
Most US commercial medical "R&D" is finding loopholes in patents or slight refinements in research paid for by taxpayers somewhere, often US taxpayers. There are exceptions but the markup seems to be an order of magnitude more. It's really just a way to lie about profit instead of being up front about it. Since there is very little competition in that market there is a lot of room to gouge money about of people instead of just making a comfortable living.
Very simple - make medicare reimbursement legally dependent on eliminating the disgusting practice of overbilling uninsured patients. Legally mandate the same price for a procedure for everybody. The problem is right now they bill a theoretical price of $3000 for an X-ray, as somebody else just posted in this thread, but an insured patient gets $2200 of that price "waived by agreement" on their insurance statement, the hospital gets a $700 reimbursement from the insurance company, and ends up with a $100 bill to pay out of pocket.
A medicare or medicaid patient will be billed whatever the legally reimburseable and billable amount for the procedure under those programs.
The amazing part is only the uninsured patient, who is likely either young or poor or simply unlucky, is the only yutz who ever gets billed $3000. That is a made-up number. NOBODY else pays $3000. I promise you. My mother was hospitalized for a long period of time and I used to get these bills all the time for $2k-$5k procedures done while she was there. Reimbursement was generally between 20% and 40% of the theoretical billed amount. Even when a procedure was not reimbursed at all by the insurance company, they often would waive 60-70% of that theoretical cost "by agreement with insurance company" so I'd end up owing 500-600 bucks instead of thousands.
This practice should be made illegal. It's really despicable and punitive to the uninsured. If the hospital knew that medicare would immediate cease all reimbursements if they discovered this practice occurring, they'd suddenly find a way to bill a true, common price for the same procedure, not a hypothetical maximum which represents the most they think they could ever extort from any insurance provider or individual payer.
The problem is that the best interests of the doctor are not aligned with the best interests of the patient. Instead, we've got a situation where the best interests of the doctor are to "play it safe, spend as much as necessary, preserve life at ALL costs (because that won't get me sued)". The tail is wagging the dog, in the form of a very small percentage of patients who will someday sue their doctors.
However, the solution is not tort reform--in the sense of limiting verdicts--because the problem is not the size of verdicts. The problem is the things that doctors do in over-the-top efforts to avoid really frivolous lawsuits. (Believe it or not, many doctors are devastated when they lose a patient, and to then be sued by the patient's family just makes it worse. So, to defend their own self-image, they of course do *everything* they can to avoid being sued. Which is very expensive.) I think something more akin to the "good samaritan" laws, where the nature of a doctor's obligations are spelled out, would be a better choice.
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I'm assuming by "brain leaking out", you mean that they performed a decompressive craniectomy. With such treatment, even someone with a severe head injury has some chance of survival without serious damage. What the doctor did in this case might not be at all unreasonable, depending in large part on a lot of subtle considerations like whether the patient had good pupil response on admission, the age of the patient (which in this case leads to a much better prognosis than with an older person), etc.
In one (admittedly small) study of severe head injury cases (all of which, AFAIK, would likely have been described in much the way you described this case), fully half of the people who underwent such surgery survived, and a third survived with no or minor disability.
In other words, the outcome is not always clear from outward appearance or even from the severity of impact. The doctor might well have legitimately thought the girl had a reasonable chance of recovery. Nine days is not really unreasonable. Brain swelling can easily continue for a couple of weeks, and I actually had a teacher once who was in a coma for many months (or was it years, I forget). I'd have to know a lot more than you've given me before I would agree that the case was hopeless.
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I work in a publicly funded tertiary hospital in Australia. I'm not medical (I used to be a medical scientist) so I don't have the hands-on, day-to-day experiences of the clinical side of the hospital, but I do get to have glimpses of a 'big picture' view of it.
The head of radiology recently told me that the Uni was willing to "donate" a big expensive machine. Poisoned chalice, he said. They get all the kudos (and access to it for research), the hospital gets the bills. And no funding. Things like:
- floor space (and these are big mofos, some machines require vibration-proof rooms, or shielded rooms etc)
- installation (cranes and shit)
- power, both getting massive amounts of power to it and paying for massive amounts of power.
- operators
- maintenance (that's a biggy it seems)
None of these costs fit under "misc. expenses" I'm afraid.
Plus there's things like the PACS system to store all this data. Radiology has an IT storage system a little bigger than the rest of the hospital.
Buying the machine is small potatoes.
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