I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with healthcare in America today.
Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid bruit. After a duplex sonogram and a CT angio, a high-grade unilateral internal carotid stenosis was identified, and carotid endarterectomy surgery was recommended. My friend called me to see if I could recommend a surgeon in the city where she and her father both live.
Continue reading The Good, the Bad and the Ugly
I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”
OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.
Continue reading Over and Out
Everybody recognizes that the United States spends considerably more on healthcare than other “western” countries do. It doesn’t matter if you look at per capita expenditure or percentage of GDP spent on health services, we rank at the top by a large margin. Of course, how much we spend is only part of the story. If, for example, we enjoyed better care and, as a consequence, better health, then one might conclude that all that “extra” money is worth it. The story line would be: we live in an affluent society, and we choose to spend a large portion of our wealth on healthcare to enjoy the added benefits of better health. Most observers have concluded, however, that we don’t enjoy better health than our western European friends, and so conclude that health care fails to deliver value – we are spending more than others, and not getting any measurable benefit. This is one of several arguments (I hope to address others in upcoming posts) for the need to lower health care expenditures in the US.
I agree that we spend more on healthcare than we need to, but it is important to consider that population health measures like life expectancy at birth, or rates of chronic disability, are poor measures of the value of our healthcare expenditures. Why? Continue reading U.S. Healthcare Costs & Benefits