Health Care Reform Debate from a Cardiologist's Perspective
Life is full of hard choices. Nowhere is this clearer than in world of medical care.
Now in particular, we are all faced with hard choices. President Obama has proposed a major overhaul of our health care system. Just this past Friday, Congress announced plans for a new health care plan.
To pay for the bill, Democrats are proposing a combination of cuts in government health care programs and a tax increase on the wealthy of more than $500 billion over 10 years.
How health care will be delivered for generations to come could be affected.
Are medical costs out of control? Is the way medical care delivered broken?
I don’t have any definitive answers to these questions but I do have a number of observations/opinions.
First observation/opinion: Yes, medical costs are out of control. Premiums for health insurance are up over 100% over the past 10 years in some parts of the country.
First question: Why is there so little debate on the thorny issues of medical care, the types of issues that is the major expense in health care delivery.
Congress plans to reduce spending, how do they propose to do this? They plan on limiting drug costs, but what are they doing about the difficult decisions?
Let me tell you a real life story, a tragic story that illustrates what every doctor who deals with hospital patients knows are one of the chief causes of why health costs are out of control. It is a story that rarely gets discussed in the media. Or if it does it happens with so much fervor, so much side taking that the real issues get lost and the issue is pushed away under the table.
A few months ago, I was involved in the care of a patient who had been admitted to the ICU for a ruptured bowel. The patient was an elderly woman 83 years old, with a major infection due to this ruptured bowel. Prior to having this unfortunate event happen this woman was living independently with some assistance.
Not wanting to be in the hospital the woman had delayed by 24 hours coming to the hospital. Now the infection that had developed was severe. She had been overcome with what is called septicemia. It is a condition where the infection has spread throughout the body, through the blood. By itself a ruptured bowel, with overwhelming infection is life threatening. But due to the infection; she developed a significant drop in blood pressure. The patient normally had hypertension and her blood pressure typically ran 150/80 (she was on medications for this). After her admission to the ER and with the infection coursing through her body, her blood pressure was 70/30. She was in shock, due to the severe infection.
Three antibiotics had been started, and she was started on powerful medications designed to raise the blood pressure as well as large amounts of fluid needed to keep her alive. By the third day, her kidneys began to fail. She became more and more confused. She didn’t respond to verbal stimulation or by touching her. By the afternoon of the second day, her breathing had accelerated and her overall respiratory status was beginning to be severely diminished.
She went into a fast cardiac rhythm, and I was asked to consult for her cardiac status. When I walked into the room, at first glance I could see that the woman was in a perilous condition. Her heart rate was over 140 beats a minute (normal is 60-90). She was breathing very rapidly. Her oxygen saturation (a measure of her ability to maintain a safe level of oxygen carrying ability) was dramatically low. I started some medications that over the course of a few hours were able to lower her heart rate to about 110 (acceptable but not ideal).
I saw her again 2 hours later. Even though her heart rate was better, her respiratory status and kidney function was not improved. It was clear that a decision would need to be made about putting her on a ventilator (a machine that would keep her alive, artificially). She would also need kidney dialysis, taking off her blood, to reduce the congestive heart failure that was developing.
So here was an elderly woman, over 80 years old with an overwhelming infection, kidney failure, respiratory failure, congestive heart failure, septic shock, questionable mental status, and a rapid heart rate. In addition she had hypertension, diabetes, and severe obesity.
Due to the multitude of medical problems, the likelihood of her recovering and living meaningful life was extremely low- perhaps one in 100, probably less than a 5% chance of living.
Placing her on a ventilator and performing dialysis would likely keep her alive- for a while. Yet, her chances were grim. She had already been in the hospital 36 hours and was still in critical condition.
The question was: what should be done?
A went out to talk to the family regarding her condition. The room was full of very concerned people. Her husband, three daughters, a son, and seven grandchildren of various ages were worriedly waiting outside. I spent about 20 minutes explaining what I thought was a very thorny decision that had to be made. Should she be put on a ventilator, kept alive artificially? Should we proceed with dialysis? Without these two treatments she would surely pass away.
Now, no discussion of the medical costs ever came up. What would be the cost to the medical system- Medicare, and Blue Cross if she was put on artificial machines and kept alive? No one can predict how long she might live: a day, a week, or even six weeks. She might even live for years (I’ve been involved with a similar patient who lived 6 years after just such an event). Since her mental function had not improved she could overcome the infection, never regain normal function, yet live many years on a ventilator. She might need permanent dialysis ($25-$50,000/ year). The total cost could of her care could run $100,000 to perhaps over 1 million dollars. The ICU costs alone could be $50,000-100,000.
Now of course, no price tag can be put on a human life. And I am not making any suggestions as to what should be the proper course of action here.
What I am suggesting is that the current health care bill has stated that a dramatic reduction in the cost of medical care has to be implemented.
One of the chief reasons that medical costs are so out of control is that such difficult issues like the one above have not been addressed. We haven’t come to a consensus as a society as to what is a proper course of action.
Here is another observation: last year, over 20 million CT scans were ordered perhaps unnecessarily, due to physicians fear of being sued. Patients are being exposed to excessive radiation and the costs are staggering. (http://www.cumc.columbia.edu/news/press_releases/ct_scan.html)
Overall, 94% of physicians, 66% of nurses, and 84% of hospital administrators agreed that unnecessary or excessive care is provided because of the fear of malpractice.
The costs are surely in the hundreds of billions of dollars. Yet, where is the discussion on this topic? Have you heard any discussion about serious malpractice reform?
As a cardiologist we have had dramatic reductions in our income over the last 3 years, (over a 20% reduction in the tests we perform) with plans to reduce this by another 30% as well plans to markedly reduce hospital consultative fees (66%). Yet, this alone won’t cure the rising health care costs.
What happened to the woman with septic shock? The family decided that they wanted to place her on a ventilator. She had kidney dialysis and was placed on a breathing machine. She stayed in the ICU 10 more days with only partial improvement.
She never regained consciousness. The family eventually decided that they should stop the medications holding up her blood pressure and take her off the ventilator. She passed away 20 minutes later.
As I said in the beginning, I don’t have any answers when it comes to difficult choices such as this. Understand, however, no real control of health care costs can occur without facing these prickly questions?
Where is the discussion?
Another opinion: We need to take some time to discuss what needs discussing.
Dr. Kirk Laman