Our health care system devotes too many resources to prolonging life, and too few to improving its quality.
A case described by Lisa Sanders vividly illustrates what I have in mind:
A couple of years earlier she started “walking like a drunk,” [the patient] told the slender, middle-aged doctor. Her legs were weak and her feet were numb. The only feeling she had in them was a pins-and-needles sensation, as if her feet had gone to sleep and never woke up. A few months ago she started falling. She broke her ankle in a particularly bad fall; the ankle got better, but she didn’t. Now she was in a wheelchair.
Her internists referred her to a neurologist, who sent her to the hospital for an M.R.I. After the test she was so weak that the doctors were reluctant to send her home, and she was admitted to the hospital. And here she was, hoping for an answer.
After tests and more tests, one observant doctor hit upon the right diagnosis: the patient's dentures didn't fit properly. To keep the dentures in place, she had been using a tube of denture adhesive a day. But her brand contained zinc, which led to zinc poisoning, nerve damage, and a host of other medical problems.
The treatment? The patient was told to buy a different brand of denture adhesive, and sent on her way. What happened next?
It has been a year and a half since [the doctor] figured out what the problem was. While [the patient] hadn’t been able to afford new dentures, she was using a denture adhesive that didn’t contain zinc. Her blood count was back to normal and she felt better.
Why is there so much money available for high tech diagnostic services, when a few hundred (or thousand) dollars for a properly fitting set of dentures would have avoided the need for those services in the first place?
Dentures are just the tip of the iceberg. Glasses. Hearing aids. Wheelchairs. Respite care. Homemaking services. Long-term care. Each of Canada's 10 different provincial health plans, and the US's 50 different state-level Medicaid and Medicare plans have somewhat different coverage levels, so generalizations are difficult. But broadly speaking, if any coverage is available for assistive devices or long term care needs, it is limited and income tested.
How did we get stuck in this crazy situation, spending so much on care that yields so little in terms of quality of life, and so little on things like dentures that yield so much?
One explanation is institutional inertia - it's always been that way.
Another explanation is vested interests, or the lack thereof. Housekeeping services, for example, can vastly improve seniors' lives, and allow them to retain their independence and dignity. But I'm guessing that the providers of housekeeping services are often women, often new Canadians, and often have relatively low levels of education. Perhaps providers of quality-of-life type services are less likely to be vocal, effective, or well-organized lobby groups, agitating for higher levels of government funding, than providers of the latest high tech gizmos?
A final explanation is that quality-of-life services are not provided because of moral hazard: if these services were covered by insurance, people would demand so many that the costs would be unsustainable.
There's an episode in the Simpsons when the family visits Canada. Homer blithely crosses the street on a Don't Walk sign, saying "It doesn't matter, they have free healthcare!" When hit by a car he yells, "I'm rich!" Patient-induced moral hazard can arise for conventional health care services, but a number of factors limit its importance.
First, specialists act as gatekeepers, deciding who does, and who doesn't, need treatment.
Second, the risk of moral hazard is reduced by the unpleasantness of much conventional health care. No one would sign up for chemotherapy if they didn't really need it. Also, the conditions conventional health care treats - getting hit by a car, for example - are nasty enough that most people take basic preventative action to avoid needing care.
Third, it is not clear that we, as a society, want to eliminate moral hazard in conventional health care, especially end-of-life care. In a world without moral hazard, no one would receive health care unless the value they placed on living longer was greater than the cost of the treatment. I am not prepared to let Grandad say, "I won't undergo this treatment, the value to me of living another 6 months is less than the cost of the treatment". Forget it.
Yet patient-induced moral hazard is a serious issue with services that improve the quality of life. Consider depression, for example. There are four basic treatments: drugs, talk therapy, exercise, and getting a dog. Which is most effective is debatable, which is most subject to moral hazard is not. If our public health care system paid for depressed people's gym memberships, or gave out free puppies, lots of people would be lining up claiming to be depressed. But here, in contrast to say, cancer care, gatekeeping is difficult. Depression is a serious, debilitating condition - yet no one can look inside another person's head and know how they're feeling. Doctors can't always distinguish people who genuinely need help from those who are just there for the free puppy.
No where is this a more serious issue than with long term care. I hesitate to write about the subject because, quite frankly, it scares me sh witless. But demographics plus changes in medical technology mean that Canadians, both collectively and individually, are going to have to work out how we are going to care for increasing numbers of older folks who are no longer able to live independently.
Every society has social and legal norms dictating the responsibilities of parents and children, husbands and wives. Canada has decided that medically necessary physician and hospital care is a collective responsibility, while long-term care - the assistance with day to day living that so many of us will either be needing or giving when we get old - is, at least to some extent, the responsibility of an individual or his or her family.
The status quo makes no sense morally: there is no ethical difference between the the cancer patient's need for surgery and the Alzheimer's patient's need for comfort.
Lack of support for caregivers is problematic from a practical point of view also. People can only cope with so much. If hospitals offer the only source of respite for caregiving families, those needing care will end up in hospitals. A recent US study of children with autism found that Medicaid-funded respite care - giving families a break from caregiving - reduced children's risk of hospitalization. By way of contrast, Medicaid-funded therapy had no significant impact on hospitalizations.*
Family values make for fine rhetoric. Yet around the world women and men are opting out. The world's lowest fertility rates are found in societies like Hong Kong, Singapore and South Korea that place responsibility for caregiving squarely on women's shoulders. Where subsidized child care is available, birth rates are higher (study here).
I don't know what the ultimate answer is. But I do know that paying for a few more dentures and a few less MRIs would be a move in the right direction.
*Disclosure: I have a nephew needing long-term care.