A health economist on the cost of care

It’s tricky to talk about the rising cost of public health care, which includes the price of dying

A quarter of health-care spending goes to taking care of people in their last year of life. It’s a significant statistic when you consider that, on average, Canadians live more than 80 years; a bit more than one per cent of one’s lifetime eats up 25 per cent of one’s health-care expenses.

But it’s not all that surprising when you think about it. After all, the last year of life by definition includes some sort of fatal medical condition, whether it be cancer, infectious disease, or serious injury. Unless death comes very suddenly – think catastrophic accident or massive heart attack – doctors will spend a lot of resources trying to keep you alive, and rightly so. Indeed, you might find it encouraging that the other three quarters of health-care spending is so successful.

As a society, we spend a lot of money with the intent of keeping people alive, and failing to do so. The bean counters suggest that we could spend our scarce health-care resources more efficiently. The resources we spend on one person are not available for another. Is it really worth it to spend so much on heroic measures to save, say, a terminally ill or very elderly patient when those resources might allow us to actually save more lives or prevent disease in the first place?

Dr. Konrad Fassbender says that isn’t a callous question. As a professor of palliative care medicine with expertise in health-care economics at the University of Alberta, he says it’s time to open up a discussion about how we choose to spend our health-care resources. Saving lives and improving the quality of them are valid objectives, after all. So at what point does an unlikely cure become an impossible cure?

Health-care spending is not simply about keeping people alive, but about maintaining as much as possible a high quality of life.

Dr. Fassbender says that there’s no single clear threshold. “The best way to think of this is in terms of percentages,” he says. “When doctors provide treatment options for patients, there’s a probability of cure. We are all familiar with cases where patients survived having been given little chance of survival.” And of course, there are no guarantees for those given a high chance of survival, either; sometimes people just die, despite good odds. That doesn’t mean that money spent trying to save them was wasted. Health-care costs in the last year of life, Dr. Fassbender says, do two things. First, they attempt to cure or prolong life. Second, when no cure is possible, they go to maintaining comfort and care.

The question of when curative treatment becomes futile (and who should decide) is controversial, and probably always will be. Consider the case of Hassan Rasouli, a 60-year-old Toronto man whose brain surgery was followed by an infection that left him tragically in, what doctors described as, a permanent vegetative state. Accordingly, they proposed to discontinue life support, but his family objected, and the case is now before the courts. Both sides hope that the decision in this case will clarify the standards for resolving similar situations in the future.

While the point-of-no-return may be difficult to identify for certain, there are inevitably cases in which it is clear that we’ve passed it. Heroic or sustained efforts are often no picnic for the patient, either, which is why some people choose to execute advanced directives to avoid the discomfort and intrusiveness of desperate measures. Yet few people get around to preparing such documents before they need them.

In any event, health-care spending is not simply about keeping people alive, but about maintaining as much of a high quality of life as possible. And, as Dr. Fassbender points out, “The transition from extending life to preserving the quality of life is gradual.”

There are great personal costs to dying, too. Dr. Fassbender says that when you look at total health-care costs, which include patients’ and caregivers’ time off earning, medicines, supplies and aids to daily living, that 30 per cent of the burden of health care is shouldered by private citizens. “One of the less understood costs is associated with care giving. A large portion of caregivers are in the workforce,” Dr. Fassbender says. His research shows that the value of the caregiver’s time in the last six months is equivalent to what the health-care system provides – “They’re equal partners in the care of that patient,” he says. Another stark statistic: he found that 50 per cent of people who die of cancer do so in poverty.

Dr. Fassbender urges people to consider the cost of health-care in a broader framework, one that takes that 50 per cent into account. At no time does a doctor advocate to a patient to save money for the system, nor should he. But surely, Dr. Fassbender says, we could imagine a forum for a healthy and open discussion about health-care costs, not at an individual level, and not limited by time or pressure in hospital setting.

Critics would argue discussions like this put a price tag on care – is this ethical?

“There’s abhorrence to associating a dollar value with care and so there isn’t a lot of push to know what those costs are,” Dr. Fassbender says. But not knowing those costs has a big impact. “We don’t have the accountability, the checks, the balances, to understand if we’re receiving value for our money,” Dr. Fassbender says. The inefficiencies in the current system come with consequences that impact care into the future.

Dr. Fassbender would like to see decisions about health care happen in an informed way through thoughtful public discourse that could lead to better solutions and innovation. For example, he says, there might be ways to deliver life-prolonging but not curative care at a fraction of the cost in settings apart from expensive intensive care units in hospitals. Beefing up hospice care and intermediary care settings is an up-front investment that could save the system money in the long run. “We can’t manage it without talking about cost,” Fassbender says.

Dr. Fassbender acknowledges that harder decisions would theor-etically have to be made in times of famine or disaster, when food and basic necessities are scarce. He recalls the story of elderly Inuit who would go off on an ice floe to die, so that the next generation would have enough to survive. But we do not face such a choice. “Although resources are scarce,” he says, “we can afford to look after our dying.”

How that palliative care looks in the future is up for discussion.

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