Newsweek's Evan Thomas on 'The Case for Killing Granny'

A prudent gerontologist may opt to remove the September 21 edition of Newsweek from his waiting room. today has a cheeky frontpage headline in "The Case for Killing Granny," with a subheader promising an explanation as to "Why curbing excessive end-of-life care is good for America."

For good measure the magazine also promises readers to explain "Why We Should Insure Illegals" and how "Health Reform Could Combat Crime" in related articles linked on the front page. More illegal immigration, fewer criminals and old people. What a deal!

The "Killing Granny" link takes readers to a September 21 print edition article by Evan Thomas which is more measured in tone than the sensational headline suggests, but one that nonetheless laments how Medicare, presently structured, has a built-in bias towards heavy per-patient spending with too little government bureaucrat oversight (emphasis mine):

...By training and inclination, doctors want to do all they can to cure ailments. And since Medicare pays by procedure, test, and hospital stay—though less and less each year as the cost squeeze tightens—there is an incentive to do more and more. To make a good living, doctors must see more patients, and order more tests.

All this treatment does not necessarily buy better care. In fact, the Dartmouth studies have found worse outcomes in many states and cities where there is more health care. Why? Because just going into the hospital has risks—of infection, or error, or other unforeseen complications. Some studies estimate that Americans are overtreated by roughly 30 percent. "It's not about rationing care—that's always the bogeyman people use to block reform," says Dr. Elliott Fisher, a professor at Dartmouth Medical School. "The real problem is unnecessary and unwanted care."

Paying doctors per-procedure is not cheap, and Thomas makes clear that significant federal overhaul of health care would require reining in the cost of Medicare, a must-do in order to ensure the financial solvency of covering millions of younger, healthier Americans (emphasis mine):

But how do you decide which treatments to cut out? How do you choose between the necessary and the unnecessary? There has been talk among experts and lawmakers of giving more power to a panel of government experts to decide—Britain has one, called the National Institute for Health and Clinical Excellence (known by the somewhat ironic acronym NICE). But no one wants the horror stories of denied care and long waits that are said to plague state-run national health-care systems. (The criticism is unfair: patients wait longer to see primary-care physicians in the United States than in Britain.) After the summer of angry town halls, no politician is going to get anywhere near something that could be called a "death panel."

There's no question that reining in the lawyers would help cut costs. Fearing medical-malpractice suits, doctors engage in defensive medicine, ordering procedures that may not be strictly necessary—but why take the risk? According to various studies, defensive medicine adds perhaps 2 percent to the overall bill—a not-insignificant number when more than $2 trillion is at stake.

Thomas then concluded that "economic reality may force us to adopt a national health-care system like Britain's or Canada's" in the future but "before that day arrives, there are steps we can take to reduce costs without totally turning the system inside out," including end-of-life counseling (emphasis mine):

Although demagogued as a "death panel," a program in Wisconsin to get patients to talk to their doctors about how they want to deal with death was actually a resounding success. A study by the Archives of Internal Medicine shows that such conversations between doctors and patients can decrease costs by about 35 percent—while improving the quality of life at the end. Patients should be encouraged to draft living wills to make their end-of-life desires known. Unfortunately, such paper can be useless if there is a family member at the bedside demanding heroic measures. "A lot of the time guilt is playing a role," says Dr. David Torchiana, a surgeon and CEO of the Massachusetts General Physicians Organization. Doctors can feel guilty, too—about overtreating patients. Torchiana recalls his unease over operating to treat a severe heart infection in a woman with two forms of metastatic cancer who was already comatose. The family insisted.

Studies show that about 70 percent of people want to die at home—but that about half die in hospitals. There has been an important increase in hospice or palliative care—keeping patients with incurable diseases as comfortable as possible while they live out the remainder of their lives. Hospice services are generally intended for the terminally ill in the last six months of life, but as a practical matter, many people receive hospice care for only a few weeks.

Our medical system does everything it can to encourage hope. And American health care has been near miraculous—the envy of the world—in its capacity to develop new lifesaving and life-enhancing treatments. But death can be delayed only so long, and sometimes the wait is grim and degrading. The hospice ideal recognized that for many people, quiet and dignity—and loving care and good painkillers—are really what's called for.

In other words, American health care is "miraculous," but miracles don't come cheap and can't be afforded for everyone, especially when medicine is socialized.

Thomas's article makes abundantly clear that socializing American medicine to a greater degree will come at the cost of doctors and patients being the sole persons determining the course of medical care. Bringing third-party pressure to bear to keep costs down will be "good for America," even if it means granny has to give up earlier on life than she was ready to.

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