Rational healthcare, not rationing

The Affordable Care Act remains in Republican cross hairs and very much in the news. In recent days, several patients have asked me what the law will mean for them. Many of the people I care for are incurably ill and need expensive medical care to stay alive. They’ve heard politicians say “Obamacare” will take away their choices, rob them of hope for living longer and cast their fate to “death panels” of faceless bureaucrats. Fortunately, none of this is true.

As a palliative care physician, I was relieved by the Supreme Court’s ruling and hope Congress allows the law to stand. This is not a partisan reaction. Diseases know no politics. I’m relieved because this law may well unravel patterns of payment and practice that promote irrational care and make dying much harder than it has to be.

Today, most doctors are salaried employees and healthcare is a complex industry. Yet we still pay physicians for the quantity of procedures they perform rather than the quality of care and results they provide. Our system is specialist-centered rather than patient-centered. And anyone who has watched a loved one die badly will tell you that sometimes specialists do too much.


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Our current structure for financing and delivering medical treatment developed in the decades after World War II, when doctors’ offices were the engines of the healthcare system. Doctors were paid for services: an office visit, house call, setting a broken bone, performing an appendectomy or tonsillectomy. The busier doctors were, because of demand or reputation, the more money they made.

The state of end-of-life care in America is marked by too many treatments and too little attention to alleviating pain, clear communication between doctors and patients (or their families), and coordination among multiple specialists or treatment centers. In the quest to save lives, our healthcare system has become exclusively a disease-treatment system.

Medical miracles abound: antibiotics, sophisticated surgery, organ transplantation, artificial kidneys, mechanical ventilators, implantable defibrillators and pumps to assist failing hearts. But medical science has yet to make one person immortal — although from the way the healthcare is paid for and delivered, you would think we had.

In the prevailing fee-for-service financing system, insurers, including Medicare and Medicaid, routinely reimburse hospitals and doctors for treatments regardless of whether they have been proved to be effective. All of this makes money for doctors, hospitals and pharmaceutical and medical device companies. But it makes no sense for dying people, only adding to their and their families’ miseries.

The Affordable Care Act advances a new approach, called accountable care, that aligns financial incentives with high-quality treatment. This key feature of the law transforms healthcare by making local health systems — made up of doctors, hospitals, clinics, laboratories and imaging facilities — responsible for the outcomes of care and the costs for the population of people they predominantly serve.

Accountable care has real potential for moving our system toward safer, more effective, and less wasteful treatments. Person-centered services, such as individualized care planning, thorough communication and coordination of care, ongoing monitoring, meticulous medication management and early response to problems, make economic sense. In fee-for-service medicine, such things are reimbursed poorly and consequently are often not available.

Reforming healthcare to make it rational is not the same thing as rationing. The best care gives people every chance of living longer and well and, when the time eventually comes, allows them to die peacefully.

Thankfully, biology is kind. Hunger and thirst wane with serious illness. Failure of our liver or kidneys sedates us with metabolic byproducts. Heart failure or pneumonia cause our oxygen levels and blood pressure to diminish and consciousness to fade. Nature, in her wisdom –— or, if you prefer, God in his — has given us gentle ways of leaving this life, if healthcare politics, payments and practices will allow.

Ira Byock is director of palliative care at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and the author of “The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.”