Blog | Friday, December 8, 2017

'Mrs. Perkins' is why we have astronomical health care costs in America

Anybody with even the slightest passing interest in health care, has heard the mind-blowing statistics. As a nation, we spend almost $3.5 trillion on health care. To put that into perspective, that is more than the total gross domestic product (GDP) of every country in the world apart from China and Japan! Germany, next on the list, has an entire GDP of $3.4 trillion. At 18% of the economy, we spend almost double the Organisation for Economic Co-operation and Development GDP average percentage of other western nations. What's more, our health care spending continues to spiral out of control, and will only realistically increase with newer expensive treatments against the backdrop of an ageing population. If the brakes are not somehow applied, spending could reach over a third of entire GDP within 30 years—a figure that would quite simply destroy the American economy.

I'd like to introduce you to Mrs. Dorothy Perkins, a patient checking in at any U.S. hospital. She is 92-years old, has unfortunately been struggling in her assisted living facility, and has already been admitted three times in the last 6 months. She is reasonably with it, has no documented history of dementia, and has presented with some altered mental status and questionable left arm weakness. There's no family to talk to when she first presents, and she seems a little confused. Neurologically she doesn't appear to have any gross deficit, but it's difficult to fully examine her and ascertain her baseline.

She gets admitted via the Emergency Room, and within the first 36 hours of her admission has had a CT and MRI scan of her head, an echocardiogram, and is now waiting for a carotid duplex. She has been seen by the emergency physician, the hospitalist, the neurologist, the cardiologist (there was a brief wide complex tachycardia noted on telemetry), and also the nephrologist, because her admission creatinine was elevated above baseline.

Late on hospital day 2, her son arrives at the bedside and confirms that her mother is close to baseline. There's no time for an extensive conversation because the main Attending physician is so rushed, but by hospital day 3, there is enough time to ascertain that the son does not wish for any overly aggressive measures in his elderly mom, and is happy to treat conservatively. The attending also has time to explain that she unfortunately appears to be on the decline and in a pattern of recurrent admissions. The son already knew this, and was waiting to have this discussion.

Mrs. Perkins could be a patient anywhere in America. There are thousands, even hundreds of thousands of Mrs. Perkins, and that number is quickly going up as the population ages. Sadly, she is at a terminal stage of her life and on a rapid decline.

If you want a major reason why we are off the charts with health care spending, look no further than poor Mrs. Perkins. In no other country in the world would Mrs. Perkins be subject to such intense health care. I speak as someone who has experience of health care on four different continents with vastly different systems, and can say without a shadow of doubt that although there are many things to be admired about the top notch acute care we provide in the U.S., we are quite unique with how we manage end-of-life care. That's not to say that we shouldn't always respect the wishes of the patient and family, but in over a decade of clinical practice in so many U.S. hospitals, rarely does Mrs. Perkins—or any of her relatives—want so much done after everything is explained to them carefully and with empathy.

Let's also consider this: It's estimated that 50% of anybody's entire lifetime health care spending occurs in their senior years. Up to a third of Medicare's entire budget is spent on patients in the last year of life (with 30% of that in the last month). Surely if we look at the case of Mrs. Perkins, we can see an absolutely massive area of improvement within our health care system.

We should think about these 3 solutions:

1. Identification of the Mrs. Perkins

In my experience, it's easy to identify elderly patients who are chronically unwell, recurrently admitted to hospital and unfortunately probably in the last couple of years of their life. Most doctors also know which patients are likely to be readmitted very soon, just by looking at them on discharge (a well-kept secret I guess!). At both a hospital and primary care level, very serious discussions should be held with the patient and family as to their wishes for care. Do they want to be admitted to hospital? Do they want so many scans that will be unlikely to change anything? Do they want to see so many specialists? These should of course be held respectfully, and the communication by the physician needs to be exemplary and compassionate (usually the internist, but greater palliative care services are also a must). Keep in mind that the Mrs. Perkins of this country are different from those elderly people who may have been much healthier prior to becoming unwell, and often require a sudden “burst” of care when they become very sick. Those patients are much more difficult to predict and will usually understandably receive more aggressive care.

2. High-level focus

If we're talking uncontrolled costs, policymakers must understand where they need a fine knife instead of an axe. Approaching the problem in its entirety with a statement like “let's cut health care costs” is ludicrous! We should be highly focused, understand where the problem outlier areas are, and also apply Pareto's Principle (the 80-20 rule of 80% of effects come from 20% of causes). There also needs to be far higher public awareness of end-of life care, sensible and considerate, devoid of terms like “death panels,” so that people are not thinking about it only when the time arrives.

3. Engagement of the frontline

Doctors like myself, and likely thousands of other physicians at the frontline, can tell you almost immediately where costs can be improved. The problem with many administrators, executives and bureaucrat regulators is that they don't have the same perspective as we have. They look at only spreadsheets and numbers. Physicians (and even nurses) in the trenches can almost always accurately identify where the system spends unnecessary money.

When I hold the conversation, usually with the children of elderly patients at a terminal stage of life, and explain the options, I often tell them that: as doctors we can always be as aggressive as anyone wants us to be, buts it's not always the right thing to do, or what the patient would want—or even the family member would want for themselves. I really try to be as compassionate as possible and also emphasize the fact that it's a highly personal decision that we will all respect. The times when I've encountered requests to “do everything possible” are in the absolute minority.

Mrs. Perkins is a wonderful lady. She is from that great generation that did more for her country than many of the young today who take everything for granted can ever imagine. I've written previously about how our health care system needs to treat these heroes better. Mrs. Perkins remembers the Great Depression, worked tirelessly on the homefront during World War II (her two elder brothers stormed Normandy Beach), and she lived through some of the biggest social upheavals imaginable. She was born around the time when women started being allowed to vote for the first time, and remembers casting her first ever vote for Franklin Delano Roosevelt.

When you speak with her, she is a strong sturdy Irish-origin lady, who believes strongly in self-reliance and working hard. We've all met elderly patients like her. When you sit down with her, she wants nothing more than to spend her remaining time as comfortable and dignified as possible. She doesn't want to keep being admitted to hospital and definitely doesn't want to go through unnecessary scanners or be subject to any additional pain or discomfort. It's time common sense prevailed and we let her do so, and also shape our health care system to help her do so as well.