Katy Butler has a must-read piece in the June 20th edition of the Sunday New York Times Magazine, about the prolonged and miserable death of her father:
In short, [Butler's parents] were seemingly among the lucky ones for whom the American medical system, despite its fragmentation, inequity and waste, works quite well. Medicare and supplemental insurance paid for their specialists and their trusted Middletown internist, the lean, bespectacled Robert Fales, who, like them, was skeptical of medical overdoing. "I bonded with your parents, and you don't bond with everybody," he once told me. "It's easier to understand someone if they just tell it like it is from their heart and their soul."
They were also stoics and religious agnostics. They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society's "Final Exit" in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives - for cardiologists, hospitals and especially the manufacturers of advanced medical devices - skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.
Butler's parents were part of the "oldest old" age group, the fastest growing group thanks to advanced medical procedures and technologies that save and preserve the lives of the oldest among us, but whose lives are often far from pleasant - "nearly a third of Americans over 85 have dementia," writes Butler. Butler's own father suffered and survived at stroke - thanks to medical technology - at 79. Later, after increasing deterioration of his health, he required surgery to fix a hernia, but his cardiologist wouldn't okay the procedure before implanting a pacemaker.
The pacemaker allowed Butler's father to live for years through increasingly severe medical problems that caused him great pain while simultaneously taking his mental capacity. By the end of his life, Butler's father was in great pain and completely change in personality, having little or no cognitive ability.
...there is no doubt that economics helped shape the wider context in which doctors made decisions. Had we been at the Mayo Clinic - where doctors are salaried, medical records are electronically organized and care is coordinated by a single doctor - things might have turned out differently. But Middletown is part of the fee-for-service medical economy. Doctors peddle their wares on a piecework basis; communication among them is haphazard; thinking is often short term; nobody makes money when medical interventions are declined; and nobody is in charge except the marketplace....
It was a case study in what primary-care doctors have long bemoaned: that Medicare rewards doctors far better for doing procedures than for assessing whether they should be done at all. The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them - specialists, hospitals, drug companies and the medical-device manufacturers - spend money lobbying Congress and the public to keep it that way....
And so my father's electronically managed heart - now requiring frequent monitoring, paid by Medicare - became part of the $24 billion worldwide cardiac-device industry and an indirect subsidizer of the fiscal health of American hospitals. The profit margins that manufacturers earn on cardiac devices is close to 30 percent. Cardiac procedures and diagnostics generate about 20 percent of hospital revenues and 30 percent of profits.
"I couldn't help feeling that something precious," writes Bulter, "our old faith in a doctor's calling, perhaps, or in a healing that is more than a financial transaction or a reflexive fixing of broken parts - had been lost."
Of course, it's this end-of-life, extremely profitable care that not only degrades our quality of life in death, it's also one of the factors responsible for our rapidly rising health care costs. It's the free market creeping into our very lives, distorting the very meaning of existence with its amoral obeisance to business' bottom line and no accountability to the humanity of consumers.
Frankly, as long as our system of fee-for-service survives, our health care costs will increase as our quality of life at end-of-life will decrease. |
