In the News

The multi-million dollar conversation

(To view the story on the Boston Business Journal website, click here. )

By JULIE ROSEN
Boston Business Journal

While the national health care reform debate focuses primarily on coverage and cost, an important but lesser known provision would allow Medicare to reimburse doctors for end-of-life conversations with patients, including discussions about living wills, choosing a proxy and information about medications to treat chronic pain. Unfortunately, the Senate recently eliminated this section from its proposed legislation, but it remains in the House version. This issue, which has been characterized unfairly by critics as mandating “death panels” that would lead to euthanasia, is not about coercing patients to forgo the care they want but rather about improving communication between doctors and patients. It is about engaging in the tough, but meaningful, conversations about the big questions: How much medical intervention is too much? When should comfort replace cure? How does the patient define quality of life? And what is a “good” death?

Simply talking to patients about what kind of care they want at the end of life, what one researcher called “the multimillion-dollar conversation,” can yield significant cost savings. And most importantly, those conversations can also yield a much better quality of life in the final days, with the focus on palliation, not invasion. Dartmouth College researchers say that Medicare could have saved $50 billion from 2001-2005 if patients’ end-of-life care was more on par with that delivered at the Mayo Clinic, where doctors and nurses work collaboratively with patients and families to really understand their values and preferences. In Massachusetts alone, the savings would have been $2.3 billion. However, even when the “talk” occurs, not every doctor is listening. A 2002 study by Brown University researchers found that a third of the patients who expressed a preference for their care to focus on comfort believed they received aggressive treatment instead. And that disregard has huge cost implications. Patients who received the comfort care they wanted had average one-year health costs of $52,098 compared with $92,442 for patients whose life-extending care was contrary to their wishes.

Palliative care involves improving the quality of life for seriously ill patients — not just dying patients — through addressing pain, nausea and other symptoms, as well as helping with the emotional toll of illness. Palliative care can — and often does — go hand-in-hand with curative treatments.

Regardless of what type of bill Congress ultimately passes, the health care system needs to do everything it can to encourage the use of the most low-tech tool in doctors’ black bags: superb listening skills. This will not only save the system billions of dollars a year, but it will go a long way toward creating a more compassionate, patient-centered system.

Julie Rosen is the executive director of the Kenneth B. Schwartz Center, a national organization that focuses on promoting a compassionate health care system.