De Facto Death Panels In Canada: The Medical Staff Decides You're Too Old And Expensive To Keep Alive
Really smart piece at Forbes.com by Dr. Paul Hsieh about the de facto Canadian death panels -- a number of instances of hospital workers shifting a person's written wish to be resuscitated to DNR:
If Canadian doctors still want to make the patient a DNR despite the family's opposition, they can appeal to a judge or an "administrative tribunal" of "experts and wise community members." For DeGuerre or Rasouli, that would have been the Ontario Consent and Capacity Board, which would have had the final authority to overrule the family's wishes.As Goldenberger notes:
In Canada, with our single-payer health care system, Rasouli's situation has a very public bottom line: Should taxpayers foot the bill for his family's indefinite goodbye?... When taxpayers provide only a finite number of acute care beds in public hospitals, a patient whose life has all but ended, but whose family insists on keeping her on life support, is occupying precious space that might otherwise house a patient whose best years are still ahead.
Hsieh continues:
With respect to potentially expensive end-of-life care, most people will still have to rely on some form of insurance. Yes, insurance is a form of "somebody else" paying for your care. But in a free market (which we don't currently have), this is done through voluntary risk sharing. Willing participants pay predictable small premiums into a common pool, and receive payments under mutually agreed-to terms if they become seriously ill.The problem of paying for expensive treatments of possibly limited value can be handled by a version of Russell Korobkin's innovative concept of "relative value" insurance. As explained by Frakt and Chandra in the New York Times:
Health plans could define themselves at least in part by the value of technologies they cover, an idea proposed by Professor Russell Korobkin of the UCLA School of Law. For example, a bronze plan could cover hospitalizations and visits to doctors for emergencies and accidents; genetic diseases; and prescription drugs that keep people out of hospitals. A silver plan could cover what bronze plans do but also include treatments a large majority of physicians find useful. A gold plan could be more inclusive still, adding coverage, for instance, for every cancer therapy shown to improve patient outcomes (no matter the cost) as long as it was delivered at a leading cancer center. Finally, a platinum plan could cover experimental and unproven cancer therapies, including, for example, that proton beam.This way, nothing would be concealed or withheld from consumers. Someone who wanted proton-beam cancer treatment coverage could have it by selecting a platinum policy and paying its higher premiums. Someone who did not want to pay higher premiums for lower-value care, in turn, could choose a bronze or silver plan. This gives a different, but more useful, meaning to the terms "gold," "silver" and "bronze" than they have in the new insurance exchanges today.
The higher tiers of insurance would cost more -- but recipients would be guaranteed to receive those more marginally beneficial treatments. Other patients might prefer to pay lower premiums and forego unwanted aggressive measures at the end of life -- but instead be able to use that money now for more important personal priorities, such as buying a house or sending their kids to college.
A free-market version of Korobkin's plan would thus allow people to join risk pools with other like-minded individuals sharing similar priorities. This gives patients maximum control over their health dollars (and thus their medical care), even in the end-of-life scenarios.
Not a surprise at all, and only hotly denied by people eager to seize power and/or feel good about themselves by managing the lives of others - some of whom think that's possible.
The only possibility for any "free" system to work is if someone rations it, because demand is not held in check by price.
But there will always be those who have never paid anything, or who think their matchless self-worth entitles them to a happy ending, no matter the cost.
I've asked this question here before: how much of a nation's resources should you be able to command to summon your own comfort?
Radwaste at October 2, 2014 2:31 AM
The assumption that Hsieh is that a person chooses one tier (metal, whatever) and pays into it for life. That's not how people are. My priorities now are completely different than they were 15 years ago and I am sure how they will be 15 years from now.
It's a question of time -- how long do I pay in, before the benefits kick in.
If I want a bronze plan now, and in 15 years want a platinum plan, is it fair to those who've paid into the platinum plan for decades? Is it OK to be covered right away? After three years? ten?
Nice theory (clear, clean, fair) -- but I don't see how it could work in practice.
flbeachmom at October 2, 2014 6:35 AM
I feel it's very unfair that I've paid dutifully for my health care for 27 years and now the quality has gone markedly down and the price has gone up a great deal because I'm being made to subsidize so many people who chose not to have care and then got sick.
I realized I could get seriously ill (because I'm not a drooling moron and I see that this can happen to humans), so I found an HMO and got in in my 20s. (Sorry to repeat for those of you who've been around here for a while.) I had reasonable rates -- affordable rates -- for the highest standard of care there...until the "Affordable" Care Act came in.
Amy Alkon at October 2, 2014 6:47 AM
Here's the thing: most of us here will eventually require aging-related expensive medical care. It won't necessarily be end-of-life care per se, but it will be at a point in our lives where our expected future lifespan is limited. This makes it a poor fit for an insurance model, which relies on the probability of the insured event being low.
So to address flbeachmom's question, the old-age care part of health insurance will necessarily have to work as a savings plan. You'll have to pay into it for most of your life, and to make it work, most plans will have to include this component separately from other covered events.
As a young person, you can buy a bronze plan that covers AD&D and other uncommon events that might hit you when you are young, but that plan will also necessarily include the savings part. Because if you don't start paying in when you're young, there won't be enough there when you get old. As much as I hate the general idea, I can see it being made mandatory -- it appears to be the only way to prevent the free-rider problem.
Cousin Dave at October 2, 2014 7:34 AM
how much of a nation's resources should you be able to command to summon your own comfort?
Supposedly this is a question answered by public officials with all their debate and rule-making.
doombuggy at October 2, 2014 9:09 AM
I don't think the motivation is an insistence on a happy ending, with happiness defined by luxury state of the art care.
It is common that a lot of the extra time afforded by that care is time spent suffering with pain or from being mentally or physically removed from loved ones.
I think the impetus is bald fear of death. A mixture of fear of the unknown and fear of being irretrievably alone. People have a tenacious hold on the attempt to avoid that.
Michelle at October 2, 2014 9:48 AM
"flbeachmom" raises a good question about life priorities changing over time, and how to accommodate that.
My best guess is that if there was sufficient market demand, insurers might include options for upgrading/downgrading one's "tier", with pricing/rebates to match.
Or they might offer a rider to a lower tier, where you could pay a little bit extra now each month in order to have the option for a future upgrade later at a set predictable price. Some people might want that locked-in option, and others might not.
I'm sure those with more knowledge about insurance markets can come up with other ways in which this kind of (legitimate) consumer demand could be met.
Paul Hsieh, MD at October 2, 2014 10:49 AM
Thank you for reading our comments, Dr. Hsieh.
I also think Cousin Dave's suggestion, of aging care as a savings plan, is an option. That's similar to the rider idea. I'm not a fan of making it mandatory, but I don't see how it can be fair otherwise, given that we are (thankfully) averse to leaving sick old folks out on the street to die. And so someone somehow has to pay for that care.
But yeah, the idea that end-of-life care being different from urgent unexpected medical issues is something to be considered.
flbeachmom at October 2, 2014 2:32 PM
"Supposedly this is a question answered by public officials with all their debate and rule-making."
I bet the public does NOT think about this. They have been encouranged to believe that Big Brother will take care of them, and not even the Speaker at the time wanted to know how.
Radwaste at October 2, 2014 5:18 PM
For those who assume that all the really expensive stuff is "end-of-life" OR who equate that with being old, please remember that while that may be a good general rule, there are a significant number of people hit with serious illnesses in their 20's and 30's (i.e. their prime). So, any insurance model must include such events.
Shannon at October 2, 2014 7:38 PM
I wonder if it would be profitable for a life insurance company to include a benefit in a life insurance policy that would pay up to half of the face value of the policy to cover the cost of medical care that could save the insured person's life.
For example:
Insured person has $1 million life insurance.
He gets sick with brain cancer that's always fatal. Cost of a new, experimental treatment with unknown chance for success is $500,000. Medical insurance won't cover it. The life insurance company pays up to $500,000 for the treatment. If it works, the insurance company hangs on to the other $500,000 a little longer (or maybe a lot longer). If it doesn't work and the insured person dies, his beneficiaries get the remaining $500,000.
A different insured person in the same situation might choose not to try any unusual or experimental treatments and leave the whole $1 million to his beneficiaries. Either way it seems like it would be all the same to the insurance company, with some chance of maybe coming out ahead by $500,000.
Ken R at October 2, 2014 8:48 PM
Seems like it would create an incentive for more people to buy more life insurance.
Also seems like it would create an incentive for life insurance companies to gather knowledge and information on the most promising experimental and alternative treatments so they can give good advise to customers with life threatening conditions, increasing the customer's chance of surviving longer and decreasing the insurance company's chance of having to pay out the full death benefit.
Also seems like it could create a market for more research on cures and alternative therapies for life threatening diseases.
Ken R at October 2, 2014 8:59 PM
I think Goldenberger (now there's a guy who should open an eponymous fast food chain!) missed a key point when he wrote:
"When taxpayers provide only a finite number of acute care beds"
The taxpayers did no such thing. Bureaucrats and politicians made that decision.
Gog_Magog_Carpet_Reclaimers at October 3, 2014 3:58 AM
Shannon,
There are two very different forms of disease here. There are age/life style diseases that affect large segments of the population. As others have pointed out these diseases are poor fits for the insurance model. If it costs $100/mo to treat a disease and 75% of the risk pool have said disease then there is no value in paying a third party for treatment. After all the third party will take a cut just for moving the money around. Hence the recommendation for splitting these out as a savings plan instead of an insurance plan.
But rare disease works great with the insurance model. It may cost $1M to treat a rare disease. But since it is rare, 1M people in a risk pool only have to pay $1 and it is taken care of.
Insurance is good for expensive but rare situations. So, while my auto insurance covers accidents it doesn't cover oil changes. Health 'insurance' needs to move in the same direction.
Ben at October 3, 2014 10:17 AM
Do make the distinction:
This is socialized medicine, not "insurance", because there is NO person will NOT make a claim.
In "insurance", there are always payers who do NOT get something from the system.
Radwaste at October 4, 2014 9:23 PM
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