This journal entry was prompted by a discussion on the cost savings efforts being put forth for end of life care. There has been concern voiced by various groups about futile care and how valuable health care resources are used in our dying days. Bending the cost curve at the end of life is seen as a way of improving use of health care dollars and quite a lot of effort has been put into pushing an agenda of "advanced care planning".
I am certainly supportive of palliative care efforts and supporting patients and their families in the process of dying. However, it has crossed my mind that these discussions were not had before now to any significant degree. While there has been the occasional Supreme Court case every twenty years or so regarding physician assisted suicide, there has never, to my knowledge, been so many efforts to advance end of life planning.
Rising costs to the health care system of government funded services near the end of life are one reason for the new found angst over "bending the cost curve" but is it true that encouraging limiting interventions and treatments in final years of life will save our single payer system from it's own success?
I don't think it will.
The reality is that dying is quite inexpensive....people have been doing it for a very long time at zero dollars.
Here's why all the fuss over costs at the end of life will make little difference to the sustainability of single payer care:
Longevity is increasing at approximately 3 months per year. As we get better at prevention, people live longer lives.
If you don't die from dysentery, diarrhea, pneumonia or child hood diseases, you grow up.
If you grow up and don't die from infectious diseases or war or trauma, you live to older age.
If you live to older age, the likelihood of having heart disease and cancer rises.
If you survive your cancer, diabetes, heart valve problem or quadruple bypass you then go on to have a 1 in 2 chance of dementia for which nobody has any good treatment right now and likely won't for a very long time. It turns out that our brains are complicated.
So all the efforts we provide in terms of prevention, or being "proactive" as Dr Hoskins likes to say, end up pushing up longevity. All the diseases we manage to stave off are replaced by others.
And I'm not trying to be negative about this. I'm simply pointing out the reality that the better we get at providing all the prevention and quality care, the longer we live and the more things there are to provide and screen for.
There will be no true bending of the cost curve other than by distorting it over a much longer timeframe or by rationing using indices created by government. If you fall outside the standard line that gov't draws, you are out of luck. In the current health care arrangement of "single payer only medical care", you have no options should your needs not fit the standard or vote-determined priorities.
We've said all this before but it is worth repeating because bending the cost curve isn't going to happen in any significant way. We might appear to be reducing costs at the end of life but that won't make up for all the screening and interventions that will need to occur in the last DECADES of life due to advances in genomic understanding and epigenetics as well as other technological advances.
The only way out is a Hybrid system. The "prevention" and "proactive" stuff isn't going to save single payer.
Now, let's get on with forging the way forward with a Hybrid system.
What legislation needs to be eliminated, changed first?
How should the innovation beyond gov't single payer be supported?
Who should support it?
When should it be started ?
What do you think? What are your suggestions?