« Freakonomics Radio

217. Are You Ready for a Glorious Sunset?

2015-08-27 | 🔗
We spend billions on end-of-life healthcare that doesn't do much good. So what if a patient could forego the standard treatment and get a cash rebate instead?
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In our previous episode, we talked about a set of tv commercials that use behavioral research, self financial products like life insurance. it's great to think optimistic, but let's plan for whatever the future might bring this the thinking about how you might sell a different kind of insurance when that doesn't even exists gap and what kind of ad you'd make for it. Ok, here's what I would show that Steve he's my for economics friend and co author. I would show a sick old person, but not the way sick. people are usually shown as being in a reasonably b and FED, but what really people who are dying? Look like deformed can't breathe suffering
play and and then at the bedside would be a bunch of children in tattered clothing, looking kind of hungry and seeming its if they could really use a cartridge case, there's something and, and then the voice of God coming over. What would somehow make the point that another two weeks of pain, so bad. It distorts two faced lying in bed in a coma isn't worth the cost of your kids or your grandkids. I should say not being able to go to college So this tv might sound something like this
we all want to take care of mom, but the doktor says our treatments might cost hundreds of thousands of dollars and even social never fully were color, and we ve got two kids to put through college. Millions of families are struggling with these seem decisions. Now, a new health care plan. Put you in control, you can decide of medical treatments. Are right for you or your loved one and if you decide, Forego the standard treatment will put the money directly in your pocket tee As for what ever, you need college to wish him a new house or to take mom on one lasted venture to soak up some glorious sunsets thanks to Gloria Sunset Healthcare option. Mom won't have to suffer
We can make decisions that makes sense for our family. Isn't it time for you to think about a glorious sunset role today. So what do you think? Is it time for you for all of us to think about the glorious sunset on this episode? We will put this idea through its pieces and solicit of righty of opinions from economists. I love that idea to physicians. It would be a public relations nightmare. Two physicians who are also public intellectuals, it's so cold blooded itself calculating it's so utilitarian that it's not american and we hear from you prisoners. My name same: oh, I'm, forty years old, first, I would like to know was the heartless person who thought of this? Second of all, I it's pretty genius hash I'm happy
from the w and my see this is free economics, radio, the package that explores the hidden side of everything. Here's your host, Stephen Governor, the proposal. Your consideration today comes from a listener. Send an email. I'm TIM Price, I'm chief investment officer for E Mits Ice public pension fund Ok, you want a name: the Public Pension fund force. I've been asked not to This is a personal idea in not a at a organizational idea bear enough In other words, that's a good hint that idea were about to discuss, is so repugnant that your firm is smart enough to do not want to be anywhere near what I should say repugnant by its em
but eventually unpalatable, potentially unpalatable. That's a good way putting price lives in the Bay area. Zealously thirty's got a wife to kids. Kids are into ok and what are their names? I'm just curious sure. Calvin Anne Elliot, like I said, we first heard from TIM Price be email. I asked now to read the email allowed. Why dont health insurance companies offer bonuses to patients who are willing to forego standard and of life. Medical care when a patient received a terminal diagnosis, I have to believe that the healthcare companies have actuaries in data sets. That would give him guidance and what the next six twenty four months of medical care, would cost patients willing to skip this type of care. My ideas for a bonus according to falling formula and immediate bonus of approximately fifty percent of the difference between the actual underwriting standard medical affair in hospice, palliative care, the patient.
trains control over the opportunity, but an immediate benefit opens up to them. One last grand- creation of lasting legacy for the next generation, etc. The health issues an actual gain it makes progress towards disincentive, rising excessive consumption of healthcare in the final months of life seems like a noble, economists to me, though my sociologist wife, thinks I'm completely cold blooded. The idea came up. Price tells us when he- and if you can, these were doing what they always do at work, kicking round investment ideas, Were we kept coming back to the idea that depending on the steady look at forty Six to eighty percent of liked and medical care its expended in the file twelve months or at the end of life generally, and once you go down that road, a thinking you get to an obvious sport, here comes down to this idea of
are you up to mice and quality of life right you optimizing quantity of life in under the current structure. It looks like, from my perspective, you're optimizing quantity of life as a proxy for quality of life. How long into this conversation, did you realize that a lot of people when they first here and idea like this, are disconnect immediately hate it pretty much immediately I mean it touches on a lot of taboos right, you do touching on death. You touching on money, your touching on healthcare, which clearly, third rail, lemme. How do you like that idea? The end of life surrendering end of life care for cash reader idea from the insurance company? I love that idea. I have so long railed against the kind of spending that we do at the end of life.
what did hard about anti life if someone's gotta decide if it's really end of life rights Oats, it's really easy after someone dies as they owe that was the last month of their life, but but before the person dies is not so easy to town and so if you, if you leave a decision about end of life care up to the government, then the problem is people say: oh no, that's death! Panels that I wasn't that person duck gonna die. We could still save them, but if the, if the patient, himself or herself says. Look. This is the end of my life. I dont want this expensive care I'd. Rather The money go to my kids or to charity. Then I think it's a really the way to get around the natural impulse to fight our concern about not giving people the kind of care they deserve.
If it's so brilliant. Why haven't we seen it? But for starters, my hunters, it's probably not legal and somehow you get into trouble for doing it. Because there's a lot of things, we don't let people do like. We don't really let people commit suicide and we don't let others oh states, do assisted suicide, so there is this amazing. unwillingness for the living to let people who want to die die. So I think that part of the the repulsive nature of this programme that many people would wait here about it, and I M too, I don't like the feeling of that My name is Ryan and from South Carolina. Probably if this was enacted, it would be a firestorm. negativity from people who worked faced with that decision. Decrying, it is putting a price on human life
There are both legal hurdles and it would be a public relations nightmare. That's Thomas Psmith he's an on I will just stand prominent cancer researcher. He runs the palliative Medicine programme, it John Hopkins Sidney, Kimmel Comprehensive Cancer center. I dont think Signa Edna The gun really want to deal with that you'd have to figure out what you would with the money. You would pay the patient. How does it get taxed state by state? How does it get tax by the feds and it's a public relations nightmare? because it looks like the insurance companies, are trying to keep Well, out of the hospital, keep them from getting. There came a therapy it might help them keep them from getting their left. Ventricular says device or artificial heart just to save money. It really is a nightmare. harness so because healthcare isn't just economics, its ethics, its partly religious, and that is over Reinhard
I teach economics prints in university. Reinhardt is among the most prominent healthcare economists in the world. He thought long and hard, but the many ways in which health care, which has been creeping towards twenty percent of GDP, in the U S, a unique animal. It is absurd that people seem to think the market works in healthcare and, as an economist s head, how could any market work when the buyers dont know prices and quality ahead of time you go into a hospital, you don't have a clue. If you allow, when you come out, you don't but to the wheel in a machine. What's this echo Gram Mohammed to discuss the nurses? How would I know imagined? You got a counter NASA his and my shirt. How much is it the sales clerks is? How would I know
but this is how we, by health, that's how we by healthcare in large part, because consumers often don't pay the costs directly their paid for by and ensure private firm or in the case of Medicaid Medicare government plan, once you bundle that lack of transparency with the end of a person's life. Well, plainly were not just talking economics here, but it's a good place to start. First of all, there is fair amount of money in and of life care. That's Ezekiel Emmanuel, not Rama, manual marrow Chicago, were Aria manual. Co, ceo of William Morris Endeavour. Those are his brothers. This Zeke, I'm vice provost of bull initiatives and chair of the Department of Medical ethics and health policy at the University of Pennsylvania, Emmanuel is also a physician who, you may recall, helped the White House formulate the affordable care
also known as Obamacare in the Medicare system about dollar twenty five. Twenty seven percent of the Medicare budget actually goes to patients who die in the less within the year. I saw its big in Medicare. That's because people who tend to die and to be over sixty five and on Medicare, but spending a lot doesn't mean you can save a lot and I think that's where we often get confused. I think, rather than focus on the dollars and sense, we should really focus on patient and families and try to make this traumatic event as smooth and comforting as possible, and we haven't gotten it right in the health care system. You know and instead of talking to a patient. Getting it right? We should a pound on their chests and try to resuscitate them. Even when that made happy what they want an end, I think tried to get what patients want. Gotta, be our primary focus,
when's. The last time you heard about a doctor dying in the ice to you with advance cancer or against heart disease or against congestive heart failure. Emphysema thats Tom Smith, again from Johns Hopkins, just doesn't have because doctors really bar again for how much good Gonna. Do me: is it really? worth that. If you look at the data on doctors, most doctors don't want a lot of these interventions for themselves, so There is actually a sort of a paradox here that we do this for patients, but when you ask us, how do we want to be treated it turns out? Now? That's not really for me. Leave me alone how old you doctor Menu five thousand eight hundred and fifty eight. Now you in the in the Atlantic. You wrote not long ago that you only one who lived until the age of seventy five and used how in what's out exactly what I said. We should know that
the Atlantic article was headlined. Why I hope to die at seventy five. We should also note that writers, often don't you to write your own headlines in any case in the article Amanda spells out all the things he wouldn't want done to him. No cancer treatment, no cardiac stress tests, certainly no pacemaker or implantable defibrillator, and I, like you know if I get to seventy five and everything still firing that that's great, but I'm not trying to live forever. It's about quality of life, and then you know it sir. I dont want all these interventions at a really done for the reason of prolonging my life. So the reason I dont want the different later I would take cancer chemotherapy is there for prolonging my life and I will say, a number of people have said to me, including my father. I might
he says. Well, you know you change your mind and my father's, unlike most people, recognizes that I can be stubborn about these things and he says I think the one thing which is going to change your mind is having grandchildren and that that's an experience, have not had an maybe maybe he'll, be right, he's a very, very smart guy. Does your dairy he's eighty eight Benny I will use the argument has taken. This is a little bit of other. Hey. Are you know: hey hey pops! In others, last thirteen years you didn't really you didn't really need. I mean now accept that he didn't need em, We ve had a lot of a number of long discussions about this, and he he reminds me we don't agree, but we don't agree on lots of things who they Reinhardt. The Princeton economist also has a story about his father. Reinhardt is from Germany. That's where his father was diagnosed with pancreatic cancer,
So I actually call that german physician and I said so. What are you gonna do about it and he said nothing message. You kidding me he said not honour we'll make him as comfortable as we can but He will pass away in a couple of weeks. I called my Harvard friend and told shouldn't. I fly my dad over here and you guys can do something. And he said earlier. We could do something we could probably I am another three four months and he'd be in an icy you full of tubes and a lot of pain. He said I could do that. But do you want me to do and the many said you know this rough german physician actually did you a great favor by simply communicating to you. Don't even tell me,
what to do. I'm the dark and I'm telling you for the patient it is not a quality life worth doing that for and here's. This american physician telling me he's a very good doctor because it didn't put that burden on your shoulder. He took it on his shoulder. So this is really the core of TIM prices idea glorious sunset proposal, just because life can be medically extended, doesn't mean that in a surly should be or be that the quality of life during that extension is in any way desirable, and yet, if you ve, essentially already bought and paid for all that end of life treatment through your insurance plan, aren't you entitled to us something hello. My name is David singer, I'm thirty, eight years old and I live in, Regarding the content I would take, the cash rebate insurance company, and I would seek treatment,
for my condition in a country that had significantly lower medical costs in the United States. Possibly in the airports of Europe. Coming up on economics. Radio would the glory is sunset plan, be just another form of healthcare rationing, very rich. guy who runs a hedge fund, wouldn't even consider deal, because what you're talking about? Maybe five thousand bucks behind a decimal forward, these guys at work and things are changing subtly, but they are changing in here our health care system looks at death. You know, as I like to say, to talking about the end of life- is the hardest thing it after dark, and one more thing. On Monday August 31st, I am launching a new podcast with my friend James out that your little side project, we called question of the day James and I sit down, and we have to each other questions like what's the most, so advice? You can give some one in ten minutes. What's the best way to
a conversation with a stranger and you, so many people hear the sound of their own voice. The first five episodes will go up on August, thirty first after that will put up three episodes every week. That's question of the day on Itunes, or wherever you get your podcast from W and Y see? This is for economics, radio, here's, your host Stephen dampener, the proposal on the table. Today we are calling it the glorious sunset
would allow a terminally ill patient to forego standard and of life care in exchange for a cash rebate from his or her insurance provider. A lot of people who listen this programme thought this idea not work so well, my name sand and thirty, four, and I mean Cargo hey you're gonna get the insurance companies to agree to it in and how you smooth out the final. kinds of what happens if a particular patient changes their mind or if they get admitted to the house, Other found unconscious, or something like that. I forgot My name is Israel, the Berne and I'm from the Lahti right away. When I heard your question, the first thing that I thought about was that there would be some people out there who did really feel like they have much of a choice in the matter and would feel obligated to make the choice to take the cash rebate
because of their financial circumstances or their families financial circumstances I could even imagine it coming, but because it is just another form of rationing, healthcare or life years by income glass right. It's movie right! the health care economist, a very rich guy, who run the hedge fund? Wouldn't you, consider deal because what you're talking about, maybe five thousand bucks behind a decimal forward. These guys are worth. While, if someone were lower middle class, It would have a very torture debate around the dinner table. Should we do this? Let's put for a minute that you are not economics, professor, but that you are that say the ceo of a private health care insurance provider
would you even consider trying to craft a proposal to make this kind of offer to your customers? I wouldn't for the simple reason: what's in it for you as a sure you you're just passing through a hospital in doktor, build. And you you get a little margin, animates actually usually three to five percent, so you're incentive is actually in many ways to increase health spending right so because, then you get your three percent on a higher throughput, which is why the guys traditionally have never regulated and controlled costs at all. So this lot going against our glorious sunset plan there, the economics, the healthcare rationing argument, but I bet that even more people would be turned off by its resemblance sort of resemblance, at least to the infamous death penalty.
It Zeke, Ale, doctors, Eagle, Emmanuel, Doktor, Ezekiel Emmanuel believes that we should calculate the value of human life and the amount we should spend to keep that life alive, and here that would be the architect of Obamacare has a respected doctor, but he's been under a lot of fire and since this law was born, this is DE kill a manual you were very involved in the formulation of the affordable care act. One of the most controversial issues, whether warranted, if not was the so called death panel formulation of the way that end of life care would be kind of accounted for and and dealt with
and other end of life care is letting care system like clarify. That's always do there was never ever ever in any draft of the affordable care act, anything about end of life care it never made it into the draft. What ended up happening is that there were some ideas, floated or hound, and discussions had and that people said, while they're gonna introduced that panels into the bill dispatches, including on the other side of the iron, from what I recall- yes, yes, oh absolutely, I mean that the other great irony of the whole thing is that New Gingrich had been a long advocate of advanced directives and actually having doctors talk to patients about advance, directly Johnny Isaacson, a senator from Georgia during that time similarly had introduced a piece of legislation exactly like what was
being discussed in terms of encouraging doctors, to have conversations paying doctors, Sarah Pale and when she was governor of Alaska, had a whole month devoted to getting alaskan to fill out advanced directly. So the Republican Party had always endorse this until it became convenient not to endorse it and to vilify it. That was then now. Wealth the centres for medical care and medical services has just proposed regulation that would actually paid doctors to do nothing more and have a conversation with patients about their impending death. You now talking about the end of life is the hardest thing a doctor does and its emotionally charged it physically draining it takes time, and we need to recognise that increasingly that these kind of conversations they require a lot of scale as much skill is
be doing a colony ask, appear doing a surgical procedure. It's not physical manual skill, it's not about dexterity, but it is about something probably just as important, if not more important, about emotional understanding of patients and it ought to be compensated. The way we compensate for other skills and talent, there's a potential that Medicare will pay. Doctors like me a fee for spending really difficult our talking with patients about end of life care, Betsy, oncologists, Tom Psmith none of that is trying to get people not to be coded not to be in the house. Little, but just to discern their wishes, because we can't honour peoples because unless we know what they are about resuscitation a later being on dialysis. So that's a start. Psmith acknowledges the potential conflict of interest in how some doctors have historically treated dying patients.
We ve worried a lot that the incentives are miss aligned for the use of chemotherapy in the last month, life because up until recently, oncologists got paid a lot more to give chemotherapy than they did to spend time talking with patients, when Ronan Kelly and I actually looked at the patterns of chemotherapy use around the world, they were exactly the same somewhere between twenty and thirty percent of all patients. in Spain, Portugal, Japan, ITALY and the? U S, get chemotherapy and last month the life and bore, absolutely no relationship to the fact that the UN colleges did or did not make money on it. I can't speak the hospitals, but oncologists like me: don't give chemotherapy to make money. So, as a doctor whose had to tell Truman people that their time has come and that, yes, he can give them some expensive and not very effective and often very punishing drugs. Tom Psmith understand
we're TIM Price are listeners coming from with his proposal to let people opt out and split, the unspent dollars with the insurance company that's good on paper. I agree with him that it sounds like it should work Smith. In fact, once toyed with a similar idea for treating terminal, lung cancer, patients wicked Try to set up an experiment like that back in the mid nineteen nineties, when much like now costs of health care, particularly cancer care, were gliding through the roof, there were two Primary options one was to stay, the regular features or risk insurance and the I can was to get a complicated indemnity payment. Competition means health care provider receives a fixed fee for treating each patient at the time of Smith's experiment. It was eighteen thousand dollars because that's what we call
later. The average lung cancer patient would spend on chemo in radiation in the last twelve months life its triple that now. So we set up the trial, the patients who went on the indemnity arm. They get the eighteen thousand dollars. They got the best supportive, Kara Hospice care that could be provided and would spend the eighteen thousand dollars on came or radiation if they wanted to or they could keep it and use it for a grandkids education for by vote on Vacation Smith was enthusiastic about the idea, but it didn't work for a couple of reasons. The first reason our patients were actually interested, but their doktor providers or it's pretty hard look at those two very different choices and decide what to do it's very difficult trying to decide
first of all, when somebody's gonna die, we are actually pretty good at making gases for populations, but for each individual person it can be really hard to tell when they are in spiral, and I'm going to die. There were as a second reason, it's really hard for consumers, also known as people with an illness and their families to figure out. What's the best treatment for them, we thought it would force yours and patience to really bargain on either the prices or to bargain on how effective is this? What's its chance are really shrinking my cancer? What's its chance of making me live longer how longer? Will I live what the quality of life, the those are all really the questions and we think that should be asked by anybody contemplating non curative
therapy anyway, these are really Conversations to happen, when you add in the cost it gets even tougher Tom Smith, would propose something completely different. I would propose that Doctors be very honest with their patients about, what's gonna happen to them, there were actually working on a temporary tattoo that goes on the doctors, inner left form, and the first question you look at is: how do you like to get medical information and none two is? What's your understanding of the situation? Number three is what's important to you over fours. What are you hoping for a number others have you thought about it? Fine, when you might be sicker when you might you an advanced directive living? Well, if you do that, if you have conversation, it really.
changes, how people pursue end of life and it gets regular people and their families actually behaving the way. The doctors do because doctors really bar again for how much good Just gonna! Do me: what is it really worth that in Smith's experience. The failure to talk about death even with the patient, was plainly dying. Big problem, he'd like to see more widespread palliative care. That is easing the symptoms. of serious illness either. Parallel to or instead of treating the, itself. It turns out if you get palliative care involved early at the start of a diagnosis of advanced cancer at the start of bad heart failure at the start of when somebody needs a heart transplants,
the whole scenario changes people have better pain, simply management their families are markedly less distressed. They end up. living longer, that's right, living longer, not shorter, and a good side effect is that most end of life, Hospitalizations are avoided. People They don't come to the hospital because I want to do they come into the house. But because it's three o clock on a Thursday night and their loved one in short, a breath for having pain, and they don't know what to do, how much better it would be. If you could have had. a palliative care team available to them and a hospice nerves come out. And see them on Tuesday at four o clock in the afternoon. adjust their pain, medicines, adjusters, shortness abroad, medicines, but he didn't need to come to the hospital and that
one way that you can actually reduce health care costs substantially in the last month or two of life, while actually improving care, and so for a lot of reasons. Tom Psmith cannot sign up, until prices. Proposing isn't time for you to think about warriors Sunset role today, because it's not just about medicine or economic sort, ethics or religion. Even politics is about all of them. And more. I think these are really really tough decisions and I think trying to do what Mr Price says would be very good what I think is: sociologist wife. Has it right, it's too hard to choose and it's much better if we define a set number of treatments for each disease,
Have external bodies, rather than individual doctor and impatient decide what's good quality of care? start monitoring ourselves start, providing the best care that we can dawn actual measurements, rather than based on what we think and holders was accountable. It's gonna get more more difficult. With the amazing increasing costs costs for drugs in some of the new drugs or two and three times what they ve ever been before, and that would make that what exhaust most medical savings accounts very quick
that's where it's time for us as a society to sit down and figure out how much we should be spending on cancer at the end of life versus curative cancer therapy, heart disease therapies and from my pediatrician wife, making sure that every kid gets a good head start making sure that every kid gets her vaccinations, making sure that we give people a decent chance to succeed in this life. Tim price for his part, still thinks he idea has merit. So I'm going to ask you to envision a horrible scenario that involves you in your death, you can handle it or no, I can handle it are so you're late, Thirty's, you said you have two young kids six and to correct I so that say I hate to even say this in a way because it feels like it's tempting fate, but I don't really believe in that. So I'm going to go ahead and say, let's say, God forbid-
Everybody forbid, whatever you believe and forbid, that you TIM price are diagnosed with something like lung cancer. Ok, tomorrow and year, told But you have probably six months to live and your told that, with the available treatments you might have nine months to live. Let's just say those are the numbers, and you're, not paying for those for those treatments. Treatment are those are covered theoretically by your insurance, but I say to you TIM: you know if you decide to forego that standard treatment, I, the insurance provider, will essentially split the cost with you. Thank you certainly have to take a look at what the difference in your life would be with treatment. Without what The probability is that those edition months are going to be what I would surgery valuable months and making them
able to be with my family. be. With my son's, I get more the horror my going to be It might be agitated and not able to engage in interact with my family verses what with those additional dollars allow me to do today with an extra over the next couple of months. I dont know if I would do it or not- but I know I would like the option of doing that of having that conversation with my wife in thinking about the legacy I want to leave for for my family I think, they'll kill long and difficult conversation. You know it's
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either Stephen Double again one more thing, if you like for economics, radio, I think you'll also like the latest episode of people, I mostly admire the podcast hosted by my free economic, spreading co, author, Steve Levin, here's what it sounds like a guest today, Sue bird. She collects championships. as for W Nba championships, five euro, the best about championships too, and see a championships for international basketball Federation, world cups and four olympic gold medals. I'd love to talk about the economics of professional basketball so the average player in the NBA made eight point: three million dollars in two thousand and nineteen
in the W Nba the average with eighty thousand is frustrating just now. I think actually If you look at twenty twenty, our minimum is now higher, but we all, in the same amount of work? So is it a heart swallow knowing that somebody else's work is being rewarded at times by I live in reality. I understand business and economics. Some people look at us as like charity. The goal will help them out like an it in a terrible what sense, not unlike this business investment way. Everything do look at us as an investment immediately its talked about how we don't make money and it's like fifty years about the NBA did either, but people are willing to me that investment get behind it and growing its people. I mostly admire you can find it on your favorite podcast app
here there Stephen dubbing again one more thing. If you liked the episode you just heard, we think you like something else in the freedom of trade. Work. Look for this interview on the new podcast people I mostly admire with host. Steve Letter on my guest today Sue bird. She collects championships she's fine or W Nba championships. Five euro, the best about championships to end C h: championships for International Basketball, federation, world cups and four olympic Gold medal. I would think that, in order to be the player you are, you would have to be a person who acted gets better. under pressure rather than worth well. Obviously, there are people, who are known for hitting big shots are known for playing while in big games that exists for sure, but I think we kind of frame it there.
Why? It's not that you're gonna make nine out of ten. It's that you might make three at it. But somebody else is making zero its Andrews. most successful. It's like who's the most Several of the least successful. That is, people mostly admire. You can find it on your favorite podcast app subscribe now, so that you don't miss Single Epps
Transcript generated on 2021-01-30.