Yesterday the New York Times asked me to participate in a "Room for Debate" forum on Medicare reform. Here’s the topic: "The Obama administration will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive. What’s the one thing Medicare should stop paying for? Please be specific."
Below, my contribution to “Room for Debate.”
Note: The Times headlined my piece “Don’t Let Oncologists Make All of the Decisions” which might suggest that I’m “blaming oncologists.” My original headline was the one I use below. My argument is that the burden is on the hospital: it’s up to the hospital to ensure that patients know that palliative care exists, and that a palliative care consult doesn’t mean that they are dying or that they should give up treatment. Palliative care consults are appropriate for any seriously ill patient who wants to know more about his odds and the risks and benefits of various procedures.
Finally, the hospital should not let another physician “block” a palliative care consult. (At some hospitals patients can see the palliative care specialist only if the patient’s oncologist or surgeon agrees to let a palliative care team talk to “his” patient.) Patients have a right to a consult. Oncologists and other physicians should view palliative care specialists as collaborators, not adversaries.
Cancer Care: Give Patients the Information They Need to Make Informed Decisions
Many cancer patients spend their last days undergoing treatments that both oncologists and hospitals know will give them a few extra weeks, at best a couple of months. The medical evidence is clear. Yet 20 percent of patients with solid tumors receive chemotherapy during their final two weeks of life.
Hospitals should ensure that patients have access to palliative care specialists who are trained to talk about odds, risks, benefits and a patient's desires.
Oncologists just aren’t trained to break the brutal fact that the “chances of cure [are] always near zero for patients with metastatic solid tumors,” as two candid oncologists observe in the most recent issue of the NEJM. As a result, they say, “most cancer patients have “unrealistically optimistic expectations regarding their prognosis and response to therapy.” In their essay, Virginia Commonwealth University’s Thomas Smith and Bruce Hillner also report on one recent study which shows that lung cancer patients expected to live more than two years, even though the average length of survival is about eight months.
Without knowledge, patients cannot make informed choices about continuing chemo. Hospitals have a role to play here: they should ensure that patients have access to palliative care specialists who are trained to talk about odds, risks and benefits, and, most important, draw a patient out to express her desires.
Too many hospitals let oncologists decide whether a palliative care team can see someone he views as “my patient.” Why? Not long ago, a Manhattan palliative care specialist told me that hospitals are afraid of their “rainmakers” (physicians who bring in well-insured lucrative cases). So the oncologist is allowed to block the consult, while ordering more chemo. Over half the profits in oncology flow from drug sales.
Meanwhile, the cost of cancer care spirals from over $104 billion in 2006 to a projected $173 billion in 2020. U.S sales of anticancer drugs are now second only to heart disease medications and most new molecules are priced at $5,000 per month or more.
Still, isn’t it worth the price—and the suffering—to buy a few weeks or maybe, months of precious life? Ultimately, the patient herself should answer that question, based on her hopes, fears and beliefs. To do so, she needs the facts.
Why take away her hope? Because most cancer patients want to die in a hospice, or at home, with hospice care. If they don’t make plans, they are likely to spend their last days in a hospital or an I.C.U. Interestingly, recent research suggests that patients may well live longer if they leave the hospital and receive hospice care.
In the original piece that I sent to the Times, I added:
Pain kills. Depression hastens death. Empty beds cost hospitals money. Full ICU’s bring in revenues. Under the Affordable Care Act, Medicare will strive to eliminate perverse financial incentives while rewarding hospitals that give each patient the care that she needs and wants—“no more and no less.”
(I suggested that the Times cut the final paragraph so that the piece would fit the allotted space, but it explains what Medicare is trying to do: realign financial incentives so that patients receive better, more affordable care.)