Monday, November 19, 2012

Don’t Let Death be a Monkey Wrench

Levitt and Dubner highlighted a really interesting aspect of medical treatment, the fact that prescribing anything, whether it has been proven to be effective or not, acts as a powerful incentive. In their discussion of ontology treatment, L & D made it clear that the successes of chemotherapy are marginal at best – in one large study, only 63% of cancer patients survived, but chemotherapy contributed less than 2% of this success (I’m curious as to what factors were found to account for the much more impressive 61%). Despite this weak evidence in the efficacy of cancer treatment, such practices consumer a huge portion of the health-bill. Why? L & D respond that incentives such as high salaries of oncologists, and the average gain in two-months to live motivate doctors to prescribe these expensive treatments. However, they also point out a third reason, which I find to be the most compelling. They write that doctors find it difficult to tell patients that there’s nothing they can do – that modern medicine has no answer for them and they must face death without any tools with which to fight. I highlight this reason not only to defend the morality of doctors, but because I believe it reveals an important factor coming from the demand side of the health market. If cancer treatment is as ineffective as L & D suggest, even if doctor’s prescribe it, why would anyone do it? Consumers, (in this case patients), are not stupid; when they are diagnosed with a disease, they have the capability of looking up survival rates, treatment success, etc. Thus, it seems like cancer victims should opt-out of chemotherapy treatments much more frequently. While 30 % already do this, 70% do not. Their reason for suffering through the painful side-effects associated with such treatments must be hope – while chemo will probably fail in lengthening their life span, they understandably cling to the small hope that they will be the anomaly, and doctors are willing to oblige.
            This trend to delaying the reality of death is also illustrated in ER visits in last weeks of life. A study conducted by UCSF and Harvard colleagues found that over 50% of older adults who had died had visited the ER during their last month of life (this number rises to 75 % when extending the time constraint to 6 months). Furthermore, more than 75% of these people were admitted, and 68 % died there. These statistics highlight that people frequently use hospitals for comfort, which is a wildly ineffective allocation of resources. ER’s exist to diagnose and treat, whereas hospices are much more suitable to the type of care these elderly patients seek. These ill-advises visits may help explain why a quarter or more of Medicaid spending occurs in the last six months of life. In sum, similar to the chemotherapy battle, we as a society are guilty at throwing money at unfixable conditions in an effort to avoid accepting death – this fear acts a monkey wrench in the machine, preventing it from making optimal allocation decisions. This trend is extremely difficult (for those of you who disagree, I would say you probably haven’t faced this type of decision), but still clearly merits change from both the demand (the patient-side), and the hospital side, who are all too willing to appease fears and admit incurable patients.

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