Medicare: Why Is Death So Costly?

The New York Times, April 7, 2008, p A17 reports that Dartmouth researchers found there is a huge unexplained variation "in the amount, intensity and cost of care provided to Medicare patients with chronic illness at the nation's top academic medical centers, raising the possibility that the government could save large amounts of money." The article focused on U.C.L.A. Medical Center and Mayo Clinic's main teaching hospital in Rochester, Minn. but the study included others facilities such as Cedars-Sinai in Los Angeles, Cleveland Clinic and New York University Medical Center in Manhattan.

The President of the Mayo Clinic interpreted the findings as consistent with his institution's practice of paying physicians a salary, which he claimed removes incentives for more aggressive treatment and fosters collaboration among physicians, staff, patients and their families. The chief medical officer at N.Y.U pointed to "a culture of physicians who have been very aggressive in their care and a patient population that has desired this type of care."

Were there other factors not discussed? A number of immigrant ethnicities have a strong culture of refusing assent to action which may shorten the life of a family member. In this era of "culturally sensitive" or "culturally competent" care, physicians, hospital staff and administrators have been trained to be highly respectful of the many cultures which their patients and patients' families hold dear and may prolong a patient's life to accomodate family wishes and to avoid adverse publicity, a complaint to Medicare by the family, or the threat of litigation.

If such conduct contributes to Medicare's unexpectedly high end-stage of life medical care costs, identification of key trusted cultural interpreters, who work with physicians, hospital staff, patients and their families, may help families and patients to accept appropriate medical care, and through appropriate care, to help prevent Medicare bankruptcy.