We don’t get to choose much about our death. We seldom hear of people living a vigorous life until their one-hundredth birthday, when they slip away quietly in their sleep after a delightful celebration with generations of loved ones.
It’s often a lot uglier, with tubes and fluids dominating the scene. Lown Institute Senior Vice President, Shannon Brownlee addressed this topic in her Washington Monthly article, Death With Indignity.
In her article, Brownlee describes her father’s last weeks. He had been clear about his desire to stay away from hospitals. He ended up back in one anyway. Her father’s story is touching, but not at all unusual.
Further, she discusses two important books that bring this issue into sharp focus. The first, The Conversation: A Revolutionary Plan for End-of-Life Care by Angelo Volandes. It details the author’s novel approach to patient education about end-of-life choices.
The second book is Curing Medicare: One Doctor’s View of How Our Health Care System Is Failing the Elderly and How to Fix It by Andy Lazris. It delves into how “Medicare policy, federal subsidies for hospitals, and taxpayer dollars for medical training all have helped create a technology-rich, hospital-centric system.” As Brownlee explains, we end up with a system that is driven by high-tech interventions.
Lazris believes we have an alternative: a system that helps seniors maintain autonomy and dignity. Changes need to be made. But I don’t know that the current system can be repaired by a few policy changes. When a system is built on paying for treatments, new regulations are no more than engagement in the sunk cost fallacy.
A total transformation is necessary.
Last week I discussed a medical model based on membership in a medical practice. For a monthly fee, a patient is seen by his physician as often as necessary. Outpatient care and some other services, such as basic radiology and labwork, are included in the membership fee. The physicians are usually available to their patients by phone or email 24 hours a day.
Often, health coaches and fitness classes are a part of the membership.
Memberships are capped to allow the personalized attention patients need. So one physician may only have 500 to 1000 patients in their care. Typical practices need around 3,000 to stay afloat. It’s a bit hard to track because a physician may never know if a patient leaves his or her care.
Membership practices are not options for Medicare patients. In fact, Medicare patients can’t even pay out of pocket to join them.
But this model is the basis for my vision of “The New Medicare.” Currently somewhere above $450 per person is spent on Medicare Part B each month. Most of that is funded by tax dollars. Only 23 percent comes from Part B premiums.
What if that $450 was paid to a membership practice? Physicians would see their Medicare patient as often as needed. They would manage their diseases and build a genuine relationship with them.
Further, each patient would have a health coach who is a specialist in senior health. This coach would help patients make and maintain lifestyle changes to keep them healthy and independent as long as possible. This person would touch base with each patient to be sure they are able to care for themselves and that their basic needs are met. They would also counsel patients who need to make the big decisions about screening tests and medical interventions. Finally, they would work with patients to help them understand their own preferences for end-of-life care.
With this physician-coach-patient team, each patient would receive highly individualized care. They would have the best available information from a physician with time to devote to them. They would receive unbiased counsel from a highly qualified coach in both health and illness.
What would result? Expect a lower usage of emergency rooms. There would be more judicious use of screening for diseases later in life. I would expect fewer of the heroic efforts that serve to prolong dying rather than enrich living. Finally, we can look for patients engaged in these arrangements to live longer lives of higher quality.
Hurdles must be overcome to install such an overhaul of the system. First, there are not enough primary care physicians to implement this model on a large scale. It would take several decades to increase their ranks enough to care for all Medicare patients. Second, training for these physicians and coaches must include more focus on the risks and benefits of end-of-life interventions. They must be skilled in presenting this information to patients without inserting their own biases.
But, there is nothing stopping a trial of the model. I would love to see Medicare offer this an optional program for a select number of providers and patients. Pilot programs in a dozen cities for five years would provide a good dataset of patients. We could see the benefits and struggles presented by the model. It would allow us understand the outcomes in health and healthcare costs.
As Brownlee says, “Dying is hard. The epidemic of futile, indifferent, often harmful medical intervention that has infected American health care makes it even harder.” I’m willing to bet that a transformation in how we approach health in our later years can make it easier.
Amy Rogers MD is not a practicing physician and nothing written here should be taken as medical advice from either Amy or AssetBuilder. Medical decisions should be made with care in consultation with your health care provider.