The Crushing Cost of Care

The July 7-8 Wall Street Journal Review contains a feature article with this title, authored by Janet Adamy and Tom McGinty. Here are some excerpts:

On Valentine’s Day 2009, Scott Crawford, 41 years old, received the break that he thought would save his life. A surgeon at Johns Hopkins Hospital in Baltimore removed his ailing heart and put in a healthy one. The transplant was a success.
But complications put the former tire-warehouse worker in intensive care for almost a year. Surgeons removed his gall bladder, his left leg and part of a lung. And Mr. Crawford soon became one of the most expensive Americans on Medicare.
As his condition turned grave, one of his doctors questioned whether to keep treating him. Nurses reported feeling “moral distress” over his unrelenting pain. Still, medical opinion was split, and Mr. Crawford’s family, with the backing of his transplant surgeon, pushed forward.
A few days before Christmas 2009, Mr. Crawford died, leaving behind a young son.
According to a Wall Street Journal analysis of Medicare data, the government spent $2.1 million on his inpatient and outpatient care in 2009. That was the fifth costliest of all Medicare beneficiaries that year and the highest among those who died by that year’s end. Medicare covered Mr. Crawford’s costs through federal disability insurance.
A primary goal of the 2010 health-care overhaul that the Supreme Court upheld last week is to slow the growth of costs. Even so, the law does little to address a simple fact: A sliver of the sickest patients account for the majority of US health-care spending. In 2009, the top 10% of Medicare beneficiaries who received hospital care accounted for 64% of the program’s hospital spending. . .As for Medicare’s long term cost trajectory, it is relentlessly upward. The program’s net expenditures totaled $488 billion last year, according to the Congressional Budget Office, or 13.5% of all federal expenditures. In March, the CBO projected that Medicare expenditures would grow an average of 5.7% per year through 2022 and equal 16.2% of all federal outlays.

“We’re always going to have patients in the Medicare program that need a disproportionate number of resources,” said Jonathan Blum deputy administrator and director for Medicare. As for Mr. Crawford, “A lot of the costs were driven by complications that could have been avoided,” he said, citing an early infection as an example.

Johns Hopkins estimates Mr. Crawford’s claims for 2009 totaled $2.7 million, and that $766, 919 remained unpaid. The total is higher than the number logged by Medicare, because the agency didn’t cover all Mr. Crawford’s costs.

My comment:

Go to WSJ.com/Review for more information about this case and Medicare’s most costly patients.

The American people are terrified of death and do very little to prepare themselves for the end of life. Thus, we tend to demand more and more life extending care at very high cost but with little to show for it. The rush to provide high cost care is risky for the patient. Each surgical intervention comes with risks. And the US health care system carries more risk for patient safety than is true elsewhere in the developed world. The fact that ‘death panels’ became an easy way to panic American voters says a great deal about our national unwillingness to confront this issue. But we can do ourselves collectively a favor by recognizing that more health care is not necessarily better. I find no fault with the surgeon who performed the transplant in this case. Mr. Crawford was young and had every expectation of a long life if the transplant succeeded. However, once an infection with a multi-drug resistant bacteria was identified, from which recovery is rarely if ever seen, the entire clinical effort should have changed. The actual transplant cost was $376,336. I question the value of much of the remainder of the expense. I am willing to back that up by choosing to personally forgo inappropriate care. And I am asking on behalf of the public that patient safety become a matter for mandatory public health surveillance and oversight.

What are you willing to do?

Dr. Joe Jarvis