In my own Advance Directive for Medical Care,
I have described two ways to limit the financial costs of my
health-care,
(1) a life-time million-dollar limit and
(2) a limit for each proposed medical course of treatment
based on the average cost of medical care for each American.
I quote from my own Advance Directive for Medical
Care:
"10. I have voluntarily decided to limit the cost of
my medical care.
My life-time total should not be more than one million dollars.
The
total cost of each proposed course of medical treatment
should not be greater than
the average annual cost of health care for 7 Americans
for each additional year of meaningful life
gained by that course of treatment.
These voluntary financial limits shall be implemented by my MCDC
if I am no longer able to enforce them myself."
[James
Park, Your
Last
Year:
Creating Your Advance Directive for Medical Care, page 198.
The paragraph above is the short version of Answer 10.]
I offer these two approaches to limiting health-care
for consideration by everyone who reads this essay.
Even before health-care limits must be imposed by others,
we can suggest what we
would regard as reasonable limits for ourselves.
1. THE MILLION-DOLLAR LIMIT FOR
LIFE-TIME HEALTH-CARE
Prior to 2010, most people who had private
health-care insurance
(perhaps provided as a fringe benefit of employment)
were not aware that they already
had a limit
on the amount of money the insurance company would pay
for any specific health-care problem.
Traditionally this limit was one million
dollars.
(Some policies put the cap at two million dollars.)
Once your insurance company had paid out one or two million dollars
to cover the treatments for a specific problem,
they said "no more":
The insurance company stopped paying.
Thereafter you had to pay out of your own pocket.
Or at least you were billed for costs above the limit on your policy,
even if you could not pay.
Before the health-care reform of 2010,
some health-insurance policies also had an annual limit:
Each year, the insurance company would only pay a maximum amount,
say $20,000 or $50,000.
After you reached your annual maximum,
your coverage had run out.
You were billed for any amount beyond what your health-insurance would
pay.
Normally you were not denied further medical care
after your health-insurance ran out.
The hospital and doctors would usually continue to care for you,
even if they were uncertain of how their bills would be paid.
One feature of the health-care reform of 2010
eliminated these caps on what an insurance company must pay.
As originally formulated, insurance companies can no longer deny
coverage
because you have already used up your annual or life-time benefits.
But with limitless liability,
what will happen to premiums for such health-insurance?
Greater pay-outs by insurance companies are certain to result.
The policy-holders must ultimately pay
for all health-care provided for everyone insured by that company.
Sometimes politicians assume that there is a
limitless amount of money
available
—either
in the US Treasury or in the bank accounts of insurance companies.
But this is manifestly absurd.
Every dollar paid out for health care comes from somewhere.
The source of that dollar is either premiums paid into an insurance
company
or taxes paid by the taxpayers of the United States.
Especially when we consider the huge costs
of maintaining bodies in persistent vegetative state
for indefinite numbers of years,
the costs of terminal care (when there is no limit on those costs)
could bankrupt a private insurance company
or become intolerably high for the US taxpayers.
But even tho all caps have been lifted by health
care reform in 2010,
we consumers of health-care can still apply our own voluntary limits.
We have the right to decide to
terminate treatments
at any time.
And one mile-stone passed might be $1,000,000 already spent.
If we cannot be saved from death after the expenditure of one million
dollars,
then perhaps it is time to call it 'quits' on further expensive
treatments,
which probably will be no more effective than the treatments already
applied.
Is it fair to other people who need medical care
if my body has already used up medical resources totaling $1,000,000?
I have made precisely this decision to limit my
health-care expenses.
I realize that it is very difficult to estimate my life-time
health-care costs,
since there is no one agency
that has paid all of the bills.
But, especially toward the end of my life,
the mounting costs of terminal care can be estimated.
Based on the amount of health-care resources already spent for me,
and based on the costs of all treatments now being applied to my body
and whatever it is costing to keep me in the hospital or nursing
home,
how long would it take to reach about one million dollars for my
health-care?
I do not believe that my body should use up
that much of the resources available for health-care,
even if the system then in place would continue to pay indefinitely.
The following is the way I explain this limit in my
Advance Directive for Medical Care:
"Question 10: Will you put financial limits on your terminal care?
Answer 10: Financial Limits on My Terminal Care
Because the last year of my life is likely to have
the highest cost and the lowest quality,
I hereby direct my MCDC to consider the costs of my medical care,
no matter what the source of such payments.
It is most likely to be the tax-payers—thru Medicare.
Here are some general guidelines:
My life-time health-care expenditures should be less than $1 million.
This will be an estimated figure,
since no single agency is keeping a total of my health-care expenses.
But if I am receiving very expensive care toward the end of my life,
my MCDC can easily guess if I am approaching my million-dollar limit."
[James
Park, Your
Last Year:
Creating Your Advance Directive for Medical Care, page 222.
This is the complete version of this part of Answer 10.]
If you
agree to limit the costs of your
own terminal
care,
you can create a statement similar to the one above
to include in your own Advance Directive for Medical Care.
All such statements would be voluntary rationing of health-care
dollars.
We citizens who might be receiving tax-supported health-care at the end
of our lives
might decide voluntarily to limit the amount of tax-money
that will be spent on our health-care—especially
on our terminal
care.
If public-opinion polling discovers that most
American
agree with such a million-dollar limit,
then it might be possible to include it in any revised health-care
legislation.
When a single agency of the US government is paying the bills,
then it should not be too difficult to estimate
when any patient is reaching his or her million-dollar limit on
health-care.
In fact, the point at which the million-dollars
limit will be reached in the
future
can be projected based on the current rate of expenditures.
And if there is no prospect for recovery,
the financial plug could be pulled before one million dollars
has been
spent.
For some patients, it will be clear
that more than one million dollars has already been spent.
How should we pull the financial plug for such patients?
For example, who should
decide to disconnect all life-supports
for patients in persistent vegetative state (PVS)
who have already absorbed more than one million dollars in tax-payers'
money?
Tax-payers should not be expected to pay one million
dollars
for the terminal care of each patient who ultimately dies.
How could we give $1,000,000 in health-care to each person?
Almost all of us will have some forms of terminal care.
What total cost would be reasonable?
2. THE COSTS FOR EACH ADDITIONAL
MEANINGFUL YEAR OF LIFE:
HOW
MANY ADDITIONAL MEANINGFUL YEARS OF LIFE WILL THIS TREATMENT ACHIEVE?
WHAT IS THE TOTAL COST OF THIS TREATMENT?
Another way to limit our health-care costs
involves considering the long-term benefits of each proposed course of
treatment.
In 1993-94, I was saved from dying from colon cancer
at an expense of about $33,000,
which was paid by the tax-payers of Minnesota.
(My thanks to all who contributed to saving me from death!)
Since I have now continued to live for an additional 16 years,
this expense was well justified by the results.
That expenditure spread over the resulting meaningful years of life
amounts to only about $2,000 for each additional year of life.
Of course, each of us continues to receive routine
medical care every year.
But this rationing limit ask only about the costs of specific,
expensive treatments.
In considering these years of my life,
there is no doubt that these have been meaningful years.
But there might come a time in my decline towards death
when merely extending the months or years
of continued survival
might not be as meaningful.
Such evaluations will have to be made at that time.
My Medical Care Decisions Committee (MCDC) is charged with
deciding what quality of life
remains ahead for me.
For instance, if I am in a persistent vegetative state,
then I have zero
quality of life.
And no further
medical expenses would be justified.
I have created a somewhat-complex formula
for making health-care decisions based on their costs.
Others are invited to create their own descriptions of limits.
When a new course of medical treatment is being
considered,
we should look as far into the future as we can.
If successful, will this medical care enable James Park
to return to a meaningful life as defined by him?
Will he be able to read and write?
Will he be able to pursue meaningful projects?
Will he still be a full person?
And how many additional years of meaningful life might become possible
if the current medical problems are successfully resolved?
If only one
more year of meaningful life would be
made possible
by a proposed medical treatment,
then the costs of such a course of treatment
might make it prohibitively expensive.
Say the cost of the proposed medical treatment would
be
$100,000.
Then, if it would grant only one additional year of meaningful life,
according to my own criteria, this expense should be omitted.
And I should be given supportive care until my natural end.
(Of course, there will be situations in which I will continue
to have a meaningful life even without the expensive treatment.)
Here is my basic formula:
For each additional year of meaningful life,
the total projected cost for proposed medical treatment
should not be more than
the average annual cost of health care for 7 Americans.
According to recent figures,
Americans now spend about $8,300 on health-care each year.
Thus 7 times this average cost is: $58,000.
For each additional meaningful year of life,
the total cost for a specific course of treatment
should not be more than $58,000.
In other words, if the proposed course of medical care
would cost a total of about $60,000,
then this expenditure would be justified
if it would result in at least one additional year of meaningful life
for me.
Of course, if an operation costing about this much
could offer me ten more
years of meaningful life,
then the answer would be an obvious "yes".
For example, any major surgery requiring
hospitalization
will cost $60,000 or more.
According to this voluntary limit on my health-care costs,
such surgery would be justified only if
it would add at least one meaningful year to my life.
The following are the exact words
I have included in my Advance Directive for Medical Care:
"Later in my life, any particular
form of treatment
will yield fewer additional years of meaningful life.
When I consider my own health-care choices while I am still able,
I will apply this standard to myself.
I will decline expensive medical care if the proposed medical treatment
costs more than 7 times the average annual medical cost per American
for each additional year of meaningful life that treatment will enable.
If I conclude that curative treatment is too
expensive,
then supportive care should be provided until the natural end of my
life.
And when my MCDC must make such choices
(because I have become a former person who cannot decide for myself),
it will probably mean that the meaningful part of my life is already
over.
Thus, expensive medical procedure would not be justified.
If no additional meaningful
years of life will result,
then all curative medical
treatments should end."
[James
Park, Your
Last Year:
Creating Your Advance Directive for Medical Care, page 222.]
Readers of this essay are invited to adapt anything
from these words
for their own Advance Directives for Medical Care.
Others who have proposed similar limits have
suggested
$50,000 for each additional year of meaningful life.
Such proposals are certainly very close to my own.
Organ transplants would be an obvious example of a
possible treatment
with a cost known in advance.
How many additional meaningful years of life would be made possible
by any proposed organ transplant?
If I decline an organ transplant because it is too expensive,
I might still have a few more meaningful years of life with my original
organs.
3. REASONABLE COSTS FOR MEANINGFUL
BENEFITS
The financial limits I have set for my own medical
care
will apply only to myself.
But I hope others will also consider how much should be spent
in order to achieve particular medical outcomes.
We all know of cases where outrageous amounts of
money were spent
on caring for a human body that ultimately could not be saved from
death.
With a bit more foresight and rational consideration,
we should be able to prevent such wastes of money
and other human resources on hopeless, terminal care.
Considering the costs of your own health-care,
what limits would you find reasonable?
How will you formally establish these limits?
Do you have an Advance Directive for Medical Care
where others might look to discover any limits you might have set?
If we think what limits we would set for ourselves,
we might be more willing to accept limits that might have to be set
by any tax-supported health-care system.
The tax-payers should not be expected to pay unlimited amounts of money
for terminal care that will result in almost no additional meaningful
years
of life.
Reasonable limits will have to be included in any
health-care system.
And it would be better for these limits to be explicitly stated in
advance
rather than to allow informal
decision-making to take place behind closed
doors.
Other advanced countries of the world do in fact
have tax-supported health-care.
And all of these systems have limited the costs in significant ways,
so that these countries have not put their whole national budgets into
health-care.
Under the current American system of health-care,
individuals who are paying for their own health-care
out of their own pockets are not
limited in the amounts they can spend.
But all tax-supported health care should have financial limits.
We Americans can learn from the workable rationing systems
now applied in all advanced countries with tax-supported health-care.
Should we replicate other reasonable systems?
Can we improve on systems that have informal, unstated rationing?
We can begin with our own voluntary
rationing systems.
Would most reasonable Americans who think about health-care costs
agree to limit the expenses for their own care?
If so, what limits should we consider?
When high-profile public figures establish limits
for their medical care,
everyone who learns about such decisions
will be inspired to set similar voluntary limits.
{Any such
declarations on the Internet can be linked from here.}
AUTHOR:
James Park is an independent existential
philosopher,
who has written extensively about medical ethics.
As mentioned above, his financial limits are publicly stated
in his Advance Directive for Medical Care,
which is available free of charge on the Internet:
http://www.tc.umn.edu/~parkx032/JP-LW.html
Scroll down to page 23.
Two related cyber-sermons are called:
There
is No Free Health Care:
Tax-Supported Medical Care .
Medical
Futility Monitor:
Avoiding the Million-Dollar Death
.
Much more information about the author will be found
on his website:
An Existential
Philosopher's Museum.
Created
July 10, 2009; Revised 7-15-2009; 7-24-2009; 7-30-2009; 8-1-2009;
3-31-2010; 10-9-2010; 4-23-2011