Cost and Transparency in End of Life Care

One possible approach to the growing cost of end of life care is to make a person’s estate responsible for half of the cost of care during the last three months of a person’s life. This would leave medical decisions in the hands of the family and doctors but would reconnect financial considerations with decisions being made by the family. This reconnection of cost and decision-making is crucial to the sustainability of Medicare—not to mention the entire U.S. healthcare system.

Financial disconnection and lack of transparency are significant issues for our healthcare system. The people making the decisions about care are often disconnected from the financial impact of those decisions. Because of the lack of transparency, they often have no idea how much the care actually costs. The decisions on how much care to provide at the end of life–when to try to resuscitate, or when to let nature take its course—are rightly in the hands of the person, their family and care providers. Yet currently, the family typically has no idea how much money is being spent to extend the life of their loved one; as importantly, the family does not bear any of the financial cost of extending life.

The cost can be extreme. Machines can replace most of the basic functions of the body, allowing a person to be kept alive for years in a hospital bed. However keeping death at bay can be extremely expensive–it can cost a hundred thousand dollars each time an individual is brought back from the brink when encountering a cardiac event and hundreds of thousands of dollars a year to keep a body alive after its own organs can no longer do so. By some estimates, Medicare now spends an average of $70 billion annually on costs related to the last six months of life.

While the concept may make us uncomfortable, cost needs to be a factor in medical decisions. Government is a finite institution, with finite resources. It is nice to think that we should spend any amount necessary to keep a person alive, but the reality is that the government must weigh the cost of healthcare against the cost of national defense, education and road building. Our country does not have an infinite amount of money to spend extending the lives in the waning few months of life for those who have no chance for any quality of life.

When to take heroic measures to try and save a life and when to let nature take its course are very personal decisions. These decisions do not belong in the hands of the government. Seniors, their families and their care givers are those who should be making the decisions. However the financial reality remains: it costs money to extend life, and at some point we aren’t extending life; we are simply delaying death.

Currently family members involved in decision-making do not bear any of the related costs. Care providers involved in the decision-making actually benefit financially. Making a person’s estate responsible for half of the cost of care for the last three months of life restores an element of cost consciousness that has been lost—one where families would start weighing the impact that heroic measures may have on their inheritance. This would also create pressure for transparency–families will want to know ahead of time how much it will cost to “buy” those last two weeks of life.

At some level it will seem cruel to make families take into account the financial impact of extending life, however these are the hard decisions that must be made. Right now Medicare spends hundreds of thousands of dollars to extend a person’s life by a few months to give the family time to say its goodbyes. Upon death, the family inherits all of the person’s remaining estate, while the government pays all of the healthcare bills. As callous as this may sound, it doesn’t make sense for the taxpayers of the United States to be responsible for bearing all of the cost of giving a family a chance to say its goodbyes. The family, via the individual’s estate, needs to be partially responsible.

When talking about healthcare reform we often avoid the hard truths and the hard decisions. But like it or not there is a finite amount of money our country can afford to spend on Medicare. Making the estate responsible for half of the cost of care during the last three months of life re-couples financial impact to the decision-making and creates an incentive for transparency. The decision still rests where it belongs, with the family, although the financial cost of extending the life would, once again, be a factor of consideration in the decision-making process.

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