Aggressive care to the end: Who pays?
Every night before closing his eyes, while lying on a hospital bed in his living room, Francis Massco pleaded to his wife of almost 60 years: "Pray that God takes me home tonight."
Three years after a diagnosis of prostate cancer, followed by costly, invasive treatments, Massco, 82, decided in February against more chemotherapy.
"I wouldn't be mad if I fell over right now," he told the Tribune-Review last month.
The one-time corporate attorney resisted a little-known tenet of medicine: Hospitals and doctors make more money by aggressively treating terminal patients than by keeping them free of pain and letting them die with dignity. Some doctors derisively call the practice "flogging" — as in, beating a dead horse.
Medicare, which paid most of Massco's bills and is the nation's largest health insurance program, spends about $113 billion a year, or a quarter of its budget for people 65 and older, to treat patients during the last year of their lives. As lawmakers argue about ways to cut costs, many experts say the government wastes billions of dollars on unnecessary care for dying patients.
This is not about death panels, the fictitious health arbiters that supposedly would decide whether there's money to pay for Grandma's care.
"It's all about patients deciding the care they get," said Dr. David Goodman, co-director of the Dartmouth Atlas of Health Care, a New Hampshire medical policy group.
Doctors and hospitals typically err in favor of aggressive, expensive care, according to Goodman, other experts and medical studies. Too often, physicians fail to ask patients how they want to die. Then, even when people choose to die without intensive care, their doctors might order it anyway.
"Doctors and hospitals shouldn't decide unilaterally the care patients get, especially when it's in their own financial interests," Goodman said.
Experts said doctors often overlook palliative care, an approach that aims to relieve pain and suffering. In a 2008 simulation study at the University of Pittsburgh involving a mock patient — described as a 78-year-old man with cancer and shortness of breath who wanted palliative care rather than intensive treatments — fewer than half the 27 doctors involved followed the patient's wishes. Among those who admitted the man to an intensive care unit, three-quarters acknowledged they knew that went against the patient's wishes.
It's impossible to remove money from the discussion because doctors are paid more to treat — not talk, said Dr. Gail Gazelle, assistant clinical professor at Harvard Medical School and medical director for a hospice agency in Norville, Mass.
"Physicians are reimbursed much, much, much, much less for actually communicating," she said. "It's very scary, and I don't think it serves patients' needs as well as it could. It's very problematic."
If a doctor decides on aggressive treatments, that determination should be based on medical judgment and not on how much money can be made, said Dr. Charles Geyer Jr., director of the Allegheny Cancer Center at Pittsburgh's Allegheny General Hospital.
"Someone who's doing that (for money) is not providing the service that physicians are supposed to be providing," Geyer said. "That would be a cynical view, I would hope, of what really goes on."
AGH at the top
Allegheny General ranked first among 137 cancer hospitals and academic medical centers nationwide for the days Medicare patients with cancer spent in intensive care during their last month of life, according to data the Dartmouth Atlas released in November.
The hospital ranked near the top for admitting those patients to intensive care, for giving them life-sustaining treatments and for having a high percentage who saw 10 or more doctors in their final six months.
Some oncologists might have a more aggressive perspective, Geyer said, but they do so because they believe something about the patient's condition could be reversed. The problem with studies such as the Dartmouth Atlas, he said, is that they look at data but miss the individual patient who recovers to live another six months.
"It's more about clinical judgment," Geyer said. "We do what we do because we genuinely believe that it helps people."
AGH was not the only Pennsylvania hospital that favored aggressive treatment practices. The Dartmouth Atlas ranked Lankenau Hospital in Wynnewood, Montgomery County, and Thomas Jefferson University Hospital in Philadelphia among the top five cancer centers in the country for the number of days that dying Medicare cancer patients spent in intensive care. Lankenau ranked high for the percent of cancer patients seeing 10 or more doctors in the six months before death.
Officials at Lankenau and Thomas Jefferson said they provide hospice services and work with patients and their families to determine care based on their wishes.
Penn State Hershey Medical Center ranked among the top third of the nation's cancer centers for some aggressive end-of-life treatments. A spokesman declined comment.
To make money, hospitals must do more than put patients in beds, Dr. Christopher Olivia, president and CEO of West Penn Allegheny Health System, told the Trib.
"If we admitted somebody and never did anything, any procedures or the like, we couldn't charge you," Olivia said. "You could stay at the Ritz in New York and get a better hotel rate and have a nicer bed than what you get from us."
At UPMC's Presbyterian and Shadyside hospitals, the Dartmouth Atlas study found aggressive end-of-life care occurred less often. Even before the medical system started a program this year to talk with patients about palliative care, Medicare patients spent more days in hospice — nearly doubling over five years to 16 days per patient in 2007.
"If you stop doing aggressive care," said Dr. Steven Shapiro, UPMC's chief medical and scientific officer, "then the hospital or the physicians potentially could be hurt. But that's OK."
Enough is enough
Francis Massco found out in 2008 he had prostate cancer during a routine visit to his primary care doctor. Like many people diagnosed with cancer, he fought back, undergoing five chemotherapy treatments and 10 sessions of radiation on his right hip. Medicare and supplemental insurance covered his medical bills.
He planned to get more radiation in December at Allegheny General when he went into cardiac arrest. He recovered and returned to the hospital a few weeks later to have a titanium rod placed in his weakened hip. Afterward, in recovery, he realized death was inevitable.
Before going back to the doctor, Massco sat in the family room of his O'Hara house and told his wife he did not want more cancer treatments.
"Don't let him talk me into anything," Massco said of his doctor, with tears welling in his eyes.
"I agree," she responded.
Massco enrolled in Forbes Hospice. Instead of receiving treatments to fight the cancer, palliative care kept him comfortable and pain-free. His medicines were limited to painkillers and appetite stimulants. Nurses visited him at home twice a week and a respite worker stayed with him when his wife needed to run errands.
Months after ending cancer treatments, 70 pounds lighter and barely able to walk, Massco believed in his decision.
His wife, Carmel, said each person must make the choice — whether to battle an illness until the last moment or choose palliative care.
"I don't think anybody can say one way or the other," she said, "but I think you just come to a point when you just know, enough is enough."
River of money
End-of-life care costs vary widely around the United States.
Medicare spent $63,870 per patient in Pittsburgh during the last two years of life, slightly above the national average of $60,694, according to Dartmouth Atlas data for 2007. By comparison, the government insurer spent $94,000 per patient in Miami and as little as $45,000 in Syracuse, N.Y.
If end-of-life costs everywhere were the same as in Syracuse, Medicare would save about $17 billion a year.
Higher costs come with extra care. Compared to Syracuse, dying patients in Miami were about twice as likely to spend time in intensive care or to have 10 or more doctors.
"Money is an unconscious influence that we as professionals can't pretend doesn't exist," Goodman said. "It's like being in a slow-moving but powerful river, where the current is hard to overcome. You might not even be aware of it, but you can't deny that it's there."
Some differences can be explained by sicker or older patients in one region over another, said Jack Hadley, a health services researcher at George Mason University in Fairfax, Va. But spending on treatments without medical value — such as end-of-life cancer care that doesn't prolong life in a meaningful way — happens everywhere, he said.
"Where payments for a specific procedure or a particular test are high, where there's a lot of implied profitability, the physicians are more likely to do them," Hadley said.
Even when doctors do not focus on money, hospital systems often do, said Dr. Brenda Sirovich, an internist at the Veterans Affairs Medical Center in White River Junction, Vt., and a researcher at Dartmouth College.
"I do think that there are explicit directives that are given," Sirovich said. "You know, 'We're in the red. If we don't do more orthopedic surgery and more MRIs this year, we're not gonna be able to survive... .' "
One evening in mid-May, Massco's bedtime prayer was answered.
He'd felt weaker and asked for his daughter, Marci Hudson, who lives more than 200 miles away in Perrysburg, Ohio. He waited for her to arrive, and they talked. He called her "sweetie pie," as he always did. Then he drifted away.
Massco died May 16 the way he lived: on his terms. No machines worked to keep him breathing, and he didn't have radiation burns on his skin. He was at peace, his wife said.
"We were happy with our decision," she said. "We're glad we did what we did."
At Massco's funeral Mass in St. Joseph Parish in O'Hara, Hudson sat next to her mother and prayed. When the service concluded, she stood up and spoke about her father in a firm voice.
"Even in death, he made life's journey most pleasant," she said. "It will be difficult to navigate my life without him."