The Sad Truth About Health Care

There's an old rule that roughly applies in so many situations - the "80-20 rule". It means that 20% of a population accounts for 80% of a certain result. For example, as a church treasurer I know that 20% of contributing families account for 80% of the total contributions in many churches. Or, as I look out my window this morning, I consider that 20% of the times it snows account for 80% of the total annual snowfall in Rochester. Well, the same concept likely applies to health care - 20% of us probably account for at least 80% of total health care costs.

My ten years of work on an ambulance have given me a new outlook on health care. Prior to this work, I thought that people got sick randomly and that health care costs were distributed rather widely across the entire population. Now I know that this is not true; health care costs are concentrated in a few sub-groups of our population. If we are to get these costs under control, the areas of concentration are the primary places to look for savings. Yet these areas don't seem to be discussed at all in the "great health care debate" now taking place in Washington. This lack of candor represents a failure of our governmental process.

So, where are the costs concentrated? As you might guess, we spend a lot for health care of aged people with serious chronic health problems - heart disease, respiratory disease, circulation problems, and cancer. More than 25% of total health care costs are incurred for people who are in their last year of life, and much of this is spent in the last month of life. I've met many of these people - people whose quality of life is questionable at best due to pain, invasive medical treatment, and altered mental status due to the drugs they have been administered. I have serious doubts about the value of costly medical interventions for many of these patients, and some countries have established protocols that limit such interventions. Republicans have characterized these protocols as "death panels", and perhaps they are correct. However, in my view such panels are necessary and humane. Significant cost savings would be a by-product of letting these people die with dignity.

A second area of health care cost concentration relates to people with chronic diseases; diabetes and coronary/respiratory issues are likely the major ones, although other conditions like lupus and Crohn's Disease are also common. These are diseases that require constant attention and patient compliance with treatment regimens. In my experience, patient non-compliance is often an issue that results in frequent hospitalizations and increasingly costly interventions. At some point, non-compliance should result in the categorization of the patient as not interested in being stabilized, and costly interventions should be curtailed. It seems strange, but I've often felt that non-compliance is aimed at getting attention...but should society pay a high price to deal with conditions that patients knowingly create?

Health care costs are also concentrated for older persons with very severe mental illnesses. A large number of citizens are now permanently hospitalized for severe dementia or Alsheimers - conditions where many of them do not know where they are or who their relatives or caretakers are. When these people are afflicted with life-threatening medical conditions, is it right to employ costly procedures to continue a life they often cannot comprehend? I think not. Their families should have the authority to let them pass on with dignity and without pain, and at some point should be held accountable for costs that a "panel" feels go beyond reasonability given the overall condition of the patient.

Lastly, chronic drug use causes a host of severe health problems. These persons often cycle in and out of hospitals regularly, each time incurring very large bills that they cannot pay. One might wonder if there should be a limit on the cost any person can put onto society due to voluntary behavior. This is a very difficult issue, but also one that is much larger than most people would ever guess.

The issues discussed above are relatively new. During the past 50 years, medical science has developed the ability to keep many people alive who in previous times would have expired from natural causes. I'd be the first to agree that in many cases these life-saving procedures have added years of productive life to many, and particularly to those with cancer or heart disease. I am thankful that we live in an age when terrible diseases can be cured or arrested. However, it may be that technology has now forced us to come to grips with the reality of resource allocations to health care.

When the total cost of prolonging certain lives becomes great, one must consider the benefits of employing these resources elsewhere. For a fraction of the avoidable costs I've identified above, for example, every child could receive a college education or technical training, or the infrastructure of Haiti could be rebuilt. What other great needs might be met? Or, for you, does maximizing physical life for every person outweigh all other considerations? Something to think about...