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Can ethics and economics of healthcare share common ground?
Palliative care is one example of overlap
Hospital ethics committees sometimes find they are drawn into local cases that reflect national debates over healthcare costs and policies. These debates might surface when there are conflicts between family and hospital providers over continuing life-sustaining treatment, including nutritional support and ventilator care. But adding healthcare costs to the mix can make the situation more complicated.
The high expense of most life-sustaining treatment also contributes to healthcare inequities and disparities, experts say.
"We have vast healthcare disparity domestically as well as globally," says Norman Daniels, PhD, Mary B. Saltonstall professor of population ethics and professor of ethics and population health at the Harvard School of Public Health in Boston.
"The main barrier has been in financing services," Daniels adds. "So if people do not have insurance coverage, then some kinds of services in hospitals that are not emergency-based are not available to them."
For instance, one type of life-sustaining treatment that typically is not available to some patients, including undocumented workers, is dialysis for end stage renal disease (ESRD). However, some hospitals will provide this care to all patients, regardless of their ability to pay.
The consequences of providing a treatment irrespective of cost can be wrenching from an ethical perspective when that cost no longer becomes sustainable, an expert notes.
"Hospitals have difficult questions about what to do when an undocumented alien comes in and is on dialysis or needs to be on dialysis," says Haavi Morreim, JD, PhD, a professor in the Department of Internal Medicine, College of Medicine, University of Tennessee Health Science Center in Memphis.
This situation happened at Grady Memorial Hospital in Atlanta, when the hospital announced it was forced to shut down its dialysis clinic that offered treatment to all patients who were ineligible for treatment through any other payer. It mainly served undocumented workers. After court challenges and national publicity, the hospital agreed to continue to provide treatment for existing dialysis patients through Sept. 1, 2011, according to Advocates for Responsible Care of Atlanta.
Most U.S. citizens have access to clinic-based dialysis treatment through Medicare's End Stage Renal Disease (ESRD) Program, implemented in 1973 as a way to pay for treatment for people with chronic kidney failure.
"It's one thing for Medicare to cover dialysis, but it's another for no one but the hospital to cover dialysis expenses because the person is undocumented," Morreim says.
Unfortunately, there have been some unintended consequences of the Medicare ESRD program. One is that it costs Medicare more than $20 billion a year because dialysis treatment is expensive and more people are using the program than initially anticipated. Secondly, its outcomes are poor when compared with other countries, according to DialysisEthics of Timnath, CO. The U.S. death rate is higher than many other countries.
"What originally was supposed to be a program to save the lives of relatively young and active people tends to be used quite unthinkingly, no matter how many complications or comorbidities a person has," Morreim says. "A person could be dying of end-stage cancer, and they could be put on dialysis."
The Medicare payment has reinforced a one-size fits all type of dialysis treatment, whereas some patients would have better health outcomes from at-home dialysis, which is being used in other high-resource nations, according to DialysisEthics.
Healthcare providers and researchers usually are aware of medical costs even when cost savings is not a priority in patient care. It might not be enough in a costly healthcare environment to think only about outcomes and quality of care, experts say.
For this reason, palliative care researchers at Mount Sinai School of Medicine in New York City, have conducted studies about the cost of palliative care medicine, says Diane E. Meier, MD, director of the Center to Advance Palliative Care (CAPC) at Mount Sinai School of Medicine in New York City. "We studied the costs because from a pragmatic standpoint in this kind of fiscal environment in healthcare, there was no way we could make the argument that palliative care should be a core component of every hospital and nursing home and every doctor's and nurse's training unless we could make a business case for it," Meier says.
Hospital ethics committees need to focus on whether a palliative care program is promoting ethically good care, and not on the program's cost savings, says Robert M. Arnold, MD, Leo H. Kreep chair in patient care and chief of the Section of Palliative Care and Medical Ethics at the University of Pittsburgh (PA). "The fact that palliative care programs can save money may be a reason why it's easier for them to get funded in this tough economic time, but from an ethics point of view, this shouldn't fall into the equation," Arnold adds.
R. Sean Morrison, MD, director of the National Palliative Care Research Center and a Hermann Merkin professor of palliative care, a professor of geriatrics and medicine, and vice-chair for research, all at Mount Sinai School of Medicine, says, "Palliative care teams take on care of patients with serious or life-threatening illness in their families, and our approach is to improve their quality of life while they live with a serious illness." Morrison and Meier were authors of a recent study on palliative care and cost savings.1
"We address distressing symptoms such as pain and communicate about difficult topics while matching treatment to goals," Morrison says.
However, in the current economic environment, it is also important to find out if palliative care treatment costs hospitals and the healthcare system more than standard treatment, or if there is a cost savings, he adds.
"We looked at those patients who received palliative care and compared those to patients who received usual care, and the findings were fairly dramatic," Morrison says. "The cost was less for patients treated by palliative care teams."
The study found that Medicaid patients facing serious or life-threatening illnesses who received palliative care had $6,900 less in hospital costs during a given admission than a similar group of patients who received usual care.1
The Medicaid study builds on Morrison's previous research, including a 2008 study that showed that patients seen by palliative care teams had a net savings of $1,696 in direct costs per admission.2
The 2008 study looked at eight hospitals across the United States. The patients' healthcare costs were paid by all different payers, Meier says. "For this latest study we concentrated on New York state because the state has a terrible Medicaid crisis due to reduced income tax revenues, increasing numbers of people in poverty, increasing Medicaid needs, and the continually rising costs of healthcare," he explains.
"We hoped to contribute to that dialogue involving finding the least restrictive, least harmful alternative ways of improving quality while avoiding unnecessary spending," she says. "Part of the reason Medicaid patients end up in the hospital is because there is no safety net for them."
These patients often lack family members who can stay home from work to care for them, and they cannot afford private pay assistance. "Their problems are a direct result of poverty and social inequity, and it's related to poverty, not the fault of the healthcare system," Meier says. "This is why I was not optimistic that we would show the same kind of cost savings impact with a Medicaid population."
Yet, that's precisely what happened. The cost savings were remarkable, she says. The reduced costs of patients seen by palliative care teams included $4,098 less in hospital costs per admission for patients discharged alive and $7,563 less for patients who died in the hospital. Investigators estimated the reductions in Medicaid hospital spending could range from $84 million to $252 million annually if every hospital with 150 or more beds had a palliative care team.2
"The question people ask is 'Why?'" Morrison says. "The answer is that the patients that palliative care teams take care of are the sickest patients in hospitals."
They consist of 5% of the general population, and they utilize 50% of healthcare costs, he adds. "These patients are very complex, so palliative care teams focus on those with special needs," he says. "They sit down with patients and families and talk about what their values and goals are and what they hope to accomplish."
For that reason, palliative care patients are less likely to die in intensive care units (ICUs), spend less time in ICUs, and are more likely to receive hospice referrals.
Once members of the palliative care team understand what their patient wants, they can match treatment to the patient's goals. It's a patient-centered model that improves efficiency and reduces unwanted and non-beneficial treatments, all of which helps streamline costs, Morrison explains. "One of the things palliative care teams do is sit down with patients and help them go through the benefits and burdens of particular treatments, depending on their goals," he adds.