death’s earnings

Advanced Directives are in the news.

Medicare spends nearly 40 percent of its budget on the final month of life.

Figures are thrown about and studies are rare, but it’s not life-preserving technology that explains the ‘end of life’ share of billings, although dying in an ICU might.

What else is going on? Seventy percent of Medicare’s budget is spent on 10 percent of its patients. Why is dying in Miami four times more costly than Minnesota?

A doctor met with a 90 year old, a “100 pound guy who glowed yellow. He looked skeletal. His skin was paper thin, like cellophane wrapped around a chicken breast”. The doctor recommended hospice for the old man and went home.

When he returned the next shift:

I stared at the chart for a while. I was a little tired and foggy brained. But I couldn’t believe it. The poor guy was zonked out in his bed, exhausted from all the tests and procedures that had been administered that day.

In the interval, an astounding amount of medicine had been practiced. Consults had gone out to GI, oncology, and nephrology (creatinine 1.9). The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.

That’s fee-for-service in a nutshell.