Lessons of a $618,616 death

[Cees Binkhorst]

REPLY TO: D66 at nic.surfnet.nl

17% van GDP voor Healthcare, waarvan 31% voor papierwerk (dus 5,1% van
GDP voor administratiekosten healthcare)
The documents revealed an economic system in which the sellers don't set
the prices and the buyers don't know what they are.

Groet / Cees

Lessons of a $618,616 death
http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/lessons-of-a-618616-dollar-death.aspx
Two years after her husband's death and almost 10 years after his cancer
diagnosis, a woman examines the wrenching emotional and financial costs
of keeping him alive.

By Amanda Bennett for BusinessWeek <http://www.businessweek.com/>
It was sometime after midnight on Dec. 8, 2007, when Dr. Eric Goren told
me my husband might not live till morning. The kidney cancer that had
metastasized almost six years earlier was growing in his lungs. He was
in intensive care at the Hospital of the University of Pennsylvania in
Philadelphia and had begun to spit blood.

<http://www.bing.com/search?FORM=MSMONY&q=health+care+reform+bill>
<http://www.bing.com/search?FORM=MSMONY&q=health+care+reform+bill>
Terence Bryan Foley, 67 years old, my husband of 20 years, father of our
two teenagers, a Chinese historian who earned a doctorate in his 60s, a
man who played more than 15 musical instruments and spoke six languages,
a San Francisco cable-car conductor and sports photographer, and an
expert on dairy cattle and swine nutrition, film noir and Dixieland
jazz, was confused. He knew his name, but not the year. He wanted a Coke.
Should Terence begin to hemorrhage, the doctor asked, what should he do?
This was our third end-of-life warning in seven years. We had fought off
the others, so perhaps we could dodge this one, too. Terence's
oncologist and I both believed that a new medicine he had just begun
taking, Pfizer's Sutent
<http://www.bing.com/search?q=pfizer+sutent&form=msmony>, would buy him
more life.
Keep him alive if you can, I said.
Terence died six days later, on Friday, Dec. 14.
What I couldn't know then was that the thinking behind my request --
along with hundreds of decisions we made over the years -- was a window
on the impossible calculus at the core of today's health care dilemma.
Terence and I were eager to beat his cancer. Backed by robust medical
insurance provided by a succession of my corporate employers, we were
able to wage a fierce battle. As we made our way through a series of
expensive last chances, like the one I asked for that night, we didn't
have to think about money, allocation of medical resources, the
struggles of roughly 46 million uninsured Americans
<http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/AsurvivalGuideForTheUninsured.aspx>,
or the impact on corporate bottom lines.

Terence's treatment was expensive. The bills for his seven years of
medical care totaled $618,616, almost two-thirds of which was for his
final 24 months. Still, no one can say for sure whether the treatments
helped extend his life.
Over the final four days before hospice -- two in intensive care, two in
a cancer ward -- our insurance was billed $43,711 for doctors,
medicines, monitors, X-rays and scans. Two years later, the only thing I
can see that the money bought for certain was confirmation he was dying.
Along with a colleague, Charles Babcock, I spent months poring over
almost 5,000 pages of documents collected from six hospitals, four
insurers, Medicare, three oncologists and a surgeon. Those papers tell
the story of a system filled with people doing their best. Stepping back
and looking at that large stack through a different lens, a string of
complex questions emerges.

31% for paperwork
Health care costs represent 17% of today's U.S. gross domestic product.
Medicare devotes about a quarter of its budget to care in the last year
of life, according to the policy journal Health Affairs. Yet as I fought
to buy my husband more time, it didn't matter to me that the hospital
charged more than 12 times what Medicare then reimbursed for a chest
scan. It also didn't matter that UnitedHealthcare reimbursed the
hospital for 80% of the $3,232 price of a scan, while a few months later
our new insurer, Empire BlueCross BlueShield, paid 24% for the same test.
And I didn't have time to be thankful that the insurers negotiated the
rates with the hospital so neither my employers nor I actually paid the
difference between the sticker and discounted prices.

Looking at that stack of documents, it is easy to see why 31% of the
money spent on health care went to paperwork and administration,
according to research published in 2003 in The New England Journal of
Medicine. That number has stayed the same or grown since then, says Dr.
Steffie Woolhandler, a professor at Harvard Medical School and a
co-author of the study. Often Terence's bills, with their blizzard of
codes, took days to decipher. What did "opd patins t" or "bal xfr ded"
mean? Was the dose charged the same as the dose prescribed?
The documents revealed an economic system in which the sellers don't set
the prices and the buyers don't know what they are. Prices bear little
relation to demand or how well goods and services work. "No other nation
would allow a health system to be run the way we do it. It's completely
insane," said Uwe E. Reinhardt, a political economy professor at
Princeton University who has advised Congress, the Department of
Veterans Affairs and other federal agencies on health care economics.
In reviewing Terence's records, we found Presbyterian Medical Center in
Philadelphia charged UnitedHealthcare $8,120 in 2006 for a 350-milligram
dose of the drug Avastin
<http://www.bing.com/search?q=Avastin&form=MSMONY>, which should have
been free as part of a clinical trial. When my Bloomberg colleague
inquired, the 80% insurance payment was refunded. A small mix-up, but
telling.

Some drugs Terence took probably did him no good. At least one helped
fewer than 10% of patients. Today, pharmaceutical companies and
government agencies are trying to sort out the economics of developing
drugs that will help only a small subset of patients. These drugs are
very expensive. Should every patient have the right to them?
Terence and I answered yes. Each drug potentially added life. Yet that,
too, led me to a question I still can't answer. When is it time to quit?
Congress dodged the question last year as it tried to craft a health
care bill. The mere hint of limiting the ability to choose care created
a whirlwind of accusations of "death panels."
One thing I know is that I don't envy the policymakers. As the health
care debate
<http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/senate-health-care-bill-11-goals.aspx>
heated up, I remembered the fat sheaf of insurance statements that had
piled up after Terence's death. Our children, Terry, 21, and Georgia,
15, assented to my idea of gathering every record to examine what they
would show about end-of-life care -- its science, emotions and costs.
Terence would have approved.
Taking it all into account, the data showed we had made a bargain that
hardly any economist looking solely at the numbers would say made sense.
Why did we do it? I was one big reason. Not me alone, of course. The
system has a strong bias toward action. My husband, too, was unusual,
said Keith Flaherty, his oncologist, in his passionate willingness to
endure discomfort for a chance to see his daughter grow from a child to
a young woman and his son graduate from high school.
After Terence died, Flaherty drew me a picture of a bell curve, showing
the range of survival times for people with kidney cancer. Terence was
way off in the tail on the right-hand side, an indication he had beaten
the odds. For many, an explosion of research and drug discoveries had
made it possible to daisy-chain treatments and extend lives for years --
enough time to keep our quest from having been total madness.
Terence used to tell a story, almost certainly apocryphal, about his
Uncle Bob. Climbing aboard a landing craft before the invasion of
Normandy, Bob's sergeant was said to have told the men that by the end
of the day, nine out of 10 of them would be dead. Said Bob: "Each one of
us looked around and felt so sorry for those other nine poor sonsabitches."
For me, it was about pushing the bell curve. Knowing there was something
to be done, we couldn't not do it. Believing beyond logic that we were
going to escape the fate of those other poor sonsabitches.
It is hard to put a price on that kind of hope.
--------------------------------------------------------------------

#2 kevnikov
<http://boards.msn.com/profile.aspx?ForumID=18&UserID=11570258&md=ic>
Monday, March 08, 2010 10:18:18 PM

This is an excellent story. You are very brave to share a very personal
and painful part of your life. You do an excellent job of sharing your
mindset through the decision making process... of revealing how much of
the costs and purchasing process that you didn't see. I understand your
struggle with whether you made the right choices


In truth, I think that you are too hard on yourself and your families
decisions. Insurance as a concept is that all of us who are healthy pay
some percentage of what we have to insure that if we are the unlucky one
who gets pancreatic cancer, the pooled money is enough to pay for it.

If, in your scenario...

Prices were not dependant on insurance company but were the same for the
insured and uninsured alike, your total costs would have gone down to
the 230k or so that you mentioned.

Then if:

Administrative records and billing were improved so that they made up
only 10% of the cost of care the total cost of that care would go down
to 190k or so.

Then if:

The experimental drugs that you were using were produced in an NIH
funded high throughput screening lab rather than at a drug company, a
huge additional chunk would be reduced.

Then if:

Diagnostic tests such as the MRIs were of similar costs to what you
might see in Japan


Your total costs would have been more in the neighborhood of 100k-120k.
Still a lot of money, but certainly manageable as pooled funds for one
of the unlucky people who gets a slow end like Cancer and probably less
than you have paid in your lifetime in insurance premiums.

With intellegent management of costs, the benefit of having insurance
should be that you never have to give up until you are ready to.

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