Medicare already does very well in administrative costs -- far less than private insurance companies. In my capacity as ICU nurse, I've seen far too much money spent on futile care in the last two weeks of someone's life. I don't have any real statistics, just anecdotes -- and one Wall Street Journal article that has stayed with me since I read it first.
For some reason, my phone won't let me copy and paste a link the the article, which appeared in the WSJ in 2012 and was entitled "The Crushing Cost of Health Care." The article described a young man named Scott Crawford and his $2.1 million hospital bill for the year of 2009. Prior to 2009, Medicare paid for an implanted defibrillator (over $75,000) and a left ventricular assist device (nearly $276,000). In 2009, Scott received not one but two heart transplants and a plethora of other treatments and surgeries to treat complications. Mr. Crawford died just before Christmas in 2009.
According the the article, 10% of patients account for around 64% of hospital costs in any given year, and although most of those patients are seniors, young patients on Medicaid account for significant costs as well.
I have long said that if we're going to control health care costs in America, the place to start is with those costs who BEST benefit would be to extend the dying process of someone for a few short weeks or, in Mr. Crawford's case, months. Physicians are responsible for much of these costs. It is difficult to lose patients, and some physicians develop tunnel visions. Reading between the lines, it seems that Dr. Shah, who was Crawford's surgeon, developed such tunnel vision. Each separate health crisis, by itself, may have been survivable. But when you looked at the whole picture, as suggested by Dr. Pronovost, Scott's prospects of survival seemed bleak.
The conversation is a difficult one -- I've participated in many of them, both in my role as a daughter and daughter-in-law and in my role as an ICU nurse. Different physicians handle the conversation in different ways, but it is the rare physician who just lays it out for the family. "Your father/son/brother isn't likely to get better, and we have nothing to offer him that fix his problems. It is time now to consider making his death as comfortable as possible. How would you like to achieve that?" Instead, the doctor may offer some wishy washy "might do" solutions. "We can do another surgery to fix this problem, but it won't fix that one, and his recovery time would be significantly longer," and families seize upon the idea that another surgery might "fix him" even after the physician has just ***** footed around the fact that it really won't. So t hey opt for another surgery. And another. Until the patient just wears out.
If physicians didn't OFFER the extra surgeries that aren't really going to improve Dad's chances of long term survival and independent living, families would be far more content to focus on making Dad comfortable in his last days. Or if Medicare stopped COVERING these extra surgeries and families were told that the surgery was available, unliklely to result in Dad returning to his former quality of life and that since Medicare didn't cover it they would have to pay for it themselves, people might make better decisions.
When my father was dying, the doctors didn't offer us the hope that dialysis would fix his renal failure and a CABG alleviate some of his cardiac symptoms. He just told us that given the damage from Dad's stroke, he would never be able to see, participate in conversation or use his right side again. Ever. And after that had a moment to sink in, he suggested we think about getting the family together and making Dad comfortable. My mother and my sister were able to take that suggestion without ever second guessing themselves, and without ever wondering whether they should have opted for another surgery to "fix" something. That was not only kinder to my family, but it saved Medicare the money it COULD have spent on additional procedures that would have extended Dad's dying.
Sorry this has gotten so long. I have strong feelings on the subject, perhaps not expressed as well as I'd like.