Advanced care and palliative care can reduce healthcare costs for people with serious chronic illness. It’s hard to dispute that this is a good thing. But some dispute it anyway, using graphic language to frighten people into believing that something wonderful will be taken away from them in a heartless attempt to cut costs.
Yes, these are scare tactics, but they are more than that. They reflect a deep cultural anxiety that the mistakes that led to the downfall of managed care will be resurrected by health care reformers. “Death panel” rhetoric may give voice to justifiable fears that access to services wanted by patients and their physicians will be denied by agents of payers and of providers who are increasingly assuming financial risk.
These fears must be confronted head-on. Advanced care and palliative care take no test, procedure or intervention off the table. They take nothing away. In fact they provide new services and a new kind of support to seriously ill people and their loved ones. They preserve dignity, maximize personal choice, and promote responsibility on individual and societal levels. Interestingly, this happens to result in cost savings.
Let’s break this process down. The Oxford Dictionary defines dignity as the “state of being worthy of honor or respect.” Ironically, although “state of being” may evoke images of spirituality and healing, this particular state of being is rarely seen in the battle zone of ICU or ED. But it’s the starting point for innovative programs to help vulnerable people come to terms with their illness and all their options for care. These programs promote maximal choice based not on clinical urgency, but on personal values and goals elicited with care over time. These programs also actively foster clinician and patient responsibility to make timely decisions together, so hard choices don’t fall on the shoulders of loved ones after it’s too late to know what the patient would have wanted.
How do dignity, choice and responsibility lead to cost savings? Given the real choice that these programs provide, most seriously ill people eventually decide to stop being patients, especially in the hospital. Instead they choose to remain independent and safe, right where they live, with support provided by these programs. This breaks the pernicious cycle of “revolving door” hospitalizations that now commonly occur as death approaches. When these unwanted hospital stays are avoided, Medicare saves a lot of money. Here’s the key point. These savings don’t require a managed care gatekeeper to deny services. They emerge naturally from basic principles of human decency.
These new services will turn current clinical and business models upside down. We will no longer make seriously ill people to come us for treatment. Instead we will bring, not just “health care,” but real caring to them. We will stop promoting their dependence on us for vain attempts to cure the incurable. Instead we will support the marvelous human capacity to adapt to even the most trying of circumstances. We will transform the natural human desire for independence from what we now see as the liability of non-adherence into the strength of self-management.
As we redesign healthcare delivery, we should stop flying under the radar. We should state very clearly what we’re doing. We are promoting dignity, providing free choice in all aspects of care, and encouraging responsibility in advance planning and self-care. We are bringing real benefits to those who are grappling with the demands of advanced illness, but we are also bringing them to a health care system straining to cope with wrenching change and a society trying to wake up to what matters most for our sickest and most vulnerable citizens.
Here’s the new bottom line: We are doing the right thing and making it pay. We are changing the game so that everyone can win. Let’s stand up and speak the truth. Only healing can result.
Brad Stuart MD