May 17, 2017

Patient Bills: The Other Cost

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In 1987, the advertising group Bozell, Jacobs, Kenyon & Eckhardt developed a slogan for the National Pork Board to promote pork sales. It was the simple and now-familiar phrase, “Pork: The Other White Meat.” The advertising gurus’ job was to draw attention to a quality product that was economical to buy. They wanted consumers to realize there was cost-efficient alternative to chicken.

Efficiency is defined as achieving the highest quality at the smallest cost. So the Holy Grail of those involved in hospital utilization is to provide the highest-quality care at the least cost to the hospital. But hospital cost is not the only cost, because just as pork is the Other White Meat, patient bills are the Other Cost.

Patients’ financial burdens are transparent to most of us who are involved in hospital utilization; we look through them and focus on the hospital’s costs. Recently, on rounds I encountered a concerned co-worker who told me that the hospital’s bill was $247,542.63 for a certain patient. However, it wasn’t only the hospital’s bill for this patient, it was also the patient’s bill for this hospitalization. As hospital employees, we are paid to focus on the financial well-being of our hospital.

But what about the patient’s financial well-being? And is that so different from the hospital’s well-being? Can saving the patient money save the hospital money? All these questions have seem to have the same answer in one form or another: quality care benefits both hospitals and patients. It seems simple so far: if hospitals provide quality care, then the costs involved will be equitable for both the hospital and patient alike.

But the quality metrics we are measured by have a limit. The limit occurs at the point that the patient’s life cannot be restored, when the patient is alive without having a life, when the clinical trajectory is leading to death. It’s also the point where suffering cannot result in a good outcome – where suffering becomes meaningless. It is precisely – as precise as clinical medicine can be – at this point that the nature of quality care changes from employing resources to restore a life to employing resources to prevent unnecessary suffering, and these are very different. It is the point, for example, when morphine replaces an ACE-inhibiter as quality congestive heart failure (CHF) care.

Beyond this limit, quality care is not care if it prolongs an irreversibly failing life. What is quality care is the care that relieves unnecessary suffering. Using state-of-the art care competently to keep a patient alive only to allow them to continue to suffer, without the hope of a restored life, is wasteful care: a waste of hospital resources and the patient’s money alike. While wasteful care in the hospital may be reimbursed, the patient’s wasteful care comes with a bill.

The leading cause of personal bankruptcies in the U.S. are medical bills. Recent reporting revealed that 62 percent of all personal bankruptcies are due to the financial burden of medical care, and 72 percent of these patients had some form of medical insurance at the onset of their illness. Is it possible that an entire life’s savings can be expended on care that only prolongs unnecessary suffering? Yes, it is.

This is all done with the best of intentions, but they are misguided intentions. They are the intentions that see death, and not unnecessary suffering, as the enemy. Good intentions are hard to reform because they are meant to achieve good. But who defines “good?”

The medical ethic of autonomy demands that we allow patients to make autonomous decisions about their care, but the decisions must be informed decisions. While the ethic of beneficence requires that we only treat to achieve good, it has to take into account whose “good” that is. Alternatively, non-maleficence requires we do no harm. What these “good intentions” fail to take into account is that allowing an inevitable natural death to occur is not unethical – but allowing unnecessary suffering to persist is. It is also waste of money.

Dying should never be a surprise when it comes to an end-stage disease. When dying becomes incorporated into the patient’s problem list, we violate their autonomy by not informing them and continuing to treat for an unattainable cure. Beneficence requires us to ask the patient what they want our care to achieve. If we assume they want more hospital treatment when they really want to be home with loved ones, we revert to a paternalism that was thought to have been ethically exterminated. Finally, we do harm when our treatment only prolongs suffering without a chance of attaining recovery. In other words, too much care is as unethical as too little care.

So, can we provide both efficient and ethical care when restoring a patient’s life is beyond the reach of medical treatment? Yes, because care that relieves unnecessary suffering serves the patient’s interests and prevents wasting the hospital’s money and patient’s money. There is a burgeoning literature that supports the notion that palliative care is both the most humane and efficient way to care for those whom Hippocrates referred to as “mastered by their disease.”

As healthcare providers, we are professionally obligated to work to ensure that all hospital care is efficiently provided. But we are also morally obligated to minimize the patient’s cost – the “Other Cost.” At all stages of their disease, including the beginning and at the end, it is incumbent on those who care for the sick to husband medical resources both efficiently and effectively.

There are times when efficient care restores a patient’s life, and there are times when efficient care allows the patient to die naturally. Those of us entrusted with the utilization of hospital and patient resources need to know and practice the difference. We must conscientiously and compassionately shepherd both the hospital cost and the patient cost: the “Other Cost.”

Perhaps we can write to Bozell, Jacobs, Kenyon & Eckhardt and ask for a catchy slogan – and perhaps they will write back: “Patient Bills: The Other Cost.”

Michael A. Salvatore, MD, FACP, CHCQM

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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