I was talking about the long-term effects my father’s chemotherapy and radiation were taking on him; to be sure, the treatments had probably given him as yet uncounted years of life, but they have come at a price. My girlfriend, who had cared for both of her parents during their struggles with cancer, agreed: The burdens and costs of treatments were greater than patients often understood.
And, she told me, she and her husband had developed an entirely different sort of treatment plan. When their time came, she said, they were going to broach their health insurance plans with a deal: They would forego $100,000 in treatments for a one-time payout of $50,000. And, check in hand, they would ride off into the sunset on their ultrafast street production motorcycles, wind in their faces, sun at their backs. “Dream on,” I told her.
But after watching a pre-release version of “Money and Medicine,” a new documentary by Roger Weisberg, my girlfriend’s preferences seem almost worth thinking about. The program, which will premiere Tuesday, September 25, at 8 p.m. ET, on PBS stations nationwide, talks honestly about the incentive of profit in health care while juxtaposing the actual financial costs of various treatments and procedures with the profound and troubling human costs of undergoing those treatments. (Watch a trailer here: http://www.youtube.com/watch?v=a9oEtRwoVxs) It follows several patients being cared for by the vastly different systems available to them at the University of California-Los Angeles Medical System and at Intermountain Health Care, based in Utah.
There are heart-wrenching scenes in the UCLA ICU, where we watch a young African American man, convinced his comatose mother will one day recover, as he struggles to understand the hospital having decided that it would be “futile” to try resuscitation if (and when) her heart stopped. The hospital was continuing all other support, keeping her in a limbo of unresponsive survival.
“I call it a medical execution,” he says, as he explains that the hospital will offer his mother comfort measures only. The mother, who has been in the ICU for 10 months, has run up millions of dollars in costs to Medicare; there is no indication that she could ever recover. The son, devoted and loving, spends hours with her, showing her old photos and talking to her.
Another poignant scene, again an African American family, shows the desperate family gathered around the patient’s bedside; the husband/father is tethered to life support. Although an ICU physician has explained in clinical terms that the patient is never likely to return to any semblance of fulfilling life, the family is determined at first that he undergo any and all possible procedures. His wife sobs, “Life is so unfair.” This family eventually acquiesces in the clinical team’s plan to deal with any symptoms but to accept stopping treatment and allowing the dying that is in store.
The film underscores these personal tragedies with the larger social issues of how much we are willing to pay for endless medical tests and treatments–and how much those tests will cost us in the future, as the price of medical care becomes something our society will no longer be able to afford. The program uses several common conditions and treatment options–Cesarean-section rates, and breast cancer and prostate cancer screenings–to bring home its points: We have tremendously powerful prevention and detection procedures available to us. But each is very costly to administer, each exacts a psychological toll on patients and families, and each is imprecise in targeting exactly who can benefit from it. As one of the many experts interviewed for the program explains, “One person’s story does not tell you the whole story.” At a population level, certain tests have tremendously high rates of false positives. But at an individual level, patients are often willing to play that lottery.
All of this makes for an interesting contrast to our work in improving care transitions. Some medical situations run up tremendous bills with modest justifications, bringing into question the professionalism of those ordering the tests and treatments. In contrast, until now, care transitions improvement efforts have been largely rooted in improving patient experiences and reducing patient suffering, with no real chance of improving the bottom line. The new penalties on hospitals with high readmission rates and the payments to community-based organizations in the Community-Based Care Transitions program and to physicians in the proposed Medicare physician payment rule may allow good practices to show modest gains.
The money at stake in the diagnoses and treatments in Money and Medicine are huge – often more than $100,000 for an uncomplicated patient. The care transitions work, however, relies on far less expensive interventions–indeed, many of the interventions involve virtually no-cost changes in patient and provider communication, in medication management, and in patient activation. These changes are not the stuff of drama at the fringes of technological innovation and medical research magic, but they are innovative and important. In our experience, the most sustaining impetus for improving care transitions has been professionals’ realization that patients suffer when transitions go badly–and that patients do better when transitions go well. Doctors, nurses, and everyone else prefer to work in systems that work for patients.
Improving care transitions may prove to be a cornerstone for what we need to do to improve care generally. As communities around the country are discovering, it truly takes a village to improve transitions. It takes a community-wide (and deep) commitment to improving care, to working together, to coordinating services, and to focusing on patient experience. Improving care transitions provides a base for achieving broader “MediCaring” reforms for care of older Americans: recognizing the special needs of the period of frailty that most people have in the last years of life; developing and implementing care plans that go with these patients across time, setting, and provider; and developing a local coalition that integrates, monitors, and assesses that process. To learn more about our ideas in this arena, check out our recent blog on the Altarum Health Policy Forum at http://altarum.org/forum/post/call-action-boomers-we-grow-old
In the meantime, we hope you’ll watch “Medicine and Money” on Tuesday, September 25, and that you’ll respond here for a discussion of the issues and ideas in the program.
key words: overtreatment, health disparities, Money and Medicine, PBS, health care spending, cost curve