Academic journal article Generations

The Problem Isn't Payment: Medicare and the Reform of End-of-Life Care

Academic journal article Generations

The Problem Isn't Payment: Medicare and the Reform of End-of-Life Care

Article excerpt

The forces that have produced our current disaffection with the process of dying are much more fundamental and less tractable.

Of the roughly 2.4 million Americans who die each year, approximately 75 percent are insured by Medicare at the time of their death. Death in America is now something that happens primarily to older people, and Medicare is the primary source of health insurance for almost all Americans over the age of 65.

Medicare spends more than $50 billion annually on beneficiaries who are in their last year of life, determined retrospectively (Lubitz and Riley, 1993). That phenomenon, in turn, is consistent with a pattern in which Medicare, like most health insurers, spends the great majority of its funds on the relatively small minority of beneficiaries who have disproportionately high expenses.

The management of terminal illnesses and the dying process is the source of considerable dissatisfaction among growing numbers of Americans, as this issue of Generations so well reflects. Dying people are routinely subjected to unwanted and ineffective high-technology interventions; the inertia of the healthcare system appears to run roughshod over the preferences of patients, their families, and their caregivers, both volunteer and professional; the most intimate and difficult of personal experiences are bureaucratized and dehumanized. The growing recognition of these problems, in conjunction with widespread perceptions and misconceptions about how Medicare works, has focused increasing attention on the idea of changing Medicare policies in order to remedy some of the worst problems now confronted in the dying process. In order to permit the delivery system to treat dying patients more humanely and more compassionately, the syllogism runs, changes must be made in the way Medicare operates (Last Acts, 1998).

The problem with this syllogism is that it is wrong. Medicare is not the problem, nor is it central to the solution. Implementation of"optimal" programs or systems for care of dying patients may require relatively minor tweaks in the ways in which Medicare operates, but those are secondary problems in the design and management of such systems. The forces that have produced our current disaffection with the process of dying are much more fundamental and less tractable than issues of Medicare policy and are therefore much harder to change. In that sense, it is too bad that Medicare is so tangential a part of the problem; if it were a larger part, the problem would be easier to fix. But so long as those concerned with improving the process of dying in the United States remain preoccupied with Medicare financing and reimbursement, attention will be diverted from the more basic, and more difficult, issues.

WHAT MEDICARE DOESAND DOESN'T DO

Medicare is so large and pervasive a part of our healthcare system that it may seem only natural for health professionals and policy analysts to ascribe near-magical powers to it, but in fact there are two fundamental reasons that the influence of Medicare on phenomena like the care of dying patients tends to be exaggerated. First, the increasing hegemony of economic modes of thinking, not only in policy analysis but other aspects of public discourse, has led to widespread confusion about the effects of economic incentives on behavior. Most of economic reality takes place on the margins: It is true that, if the price of hogs rises relative to that of cattle, farmers will breed relatively more pigs and fewer cows, but cattle ranching will not cease to exist altogether, nor will even the most aggressive and entrepreneurial farmers seek to eum their cows into pigs. If economic incentives were the only determinant of human behavior, then we would have neither pediatricians nor geriatricians.

In addition, the relative naivete of most health professionals regarding financial matters often produces confusion about the difference between an economic incentive, like those embodied, intentionally or not, in practices Medicare permits or encourages, and a requirement or prohibition made by an authoritative body, Medicare rules and regulations being a prime example. …

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