The Role of Culture in Cost Control

David Brooks has an interesting piece to today’s NYTimes. I know from writing op-eds that the writer doesn’t write the headline, but I think the headline assigned by the Times “Death and Budgets” doesn’t really get at his full point. I would title his op-ed “Cultural and Political Barriers Keep us from Facing Limits in Health Care.” I know, it is too long, but it better captures the essence of his piece, as do his last two sentences:

My only point today is that we think the budget mess is a squabble between partisans in Washington. But in large measure it’s about our inability to face death and our willingness as a nation to spend whatever it takes to push it just slightly over the horizon.

I focus quite a bit on hospice and palliative care policy and ‘the end of life.’ However, it is wrong to think that the only spending problems occur at the end of life–the last days or weeks. We have a profound inability to consider limits in medicine that are a mixture of cultural and political. By cultural I mean we have trouble facing the idea of limits. Since everyone dies, eventually you hit diminishing returns in spending designed to forestall the inevitable. It is hard to figure out when that will happen in a given case prospectively, but culturally we shy away from even entertaining this general idea.

Politically, it is a very effective political strategy to play upon this general cultural fear of death to argue against any health policy which you oppose. This is bipartisan in nature, even if it is not used as commonly by both sides.* In the end, the most direct political argument used against both IPAB and Paul Ryan’s Medicare plan is that it will kill granny.

In fact, granny will die (and you and me as well). It is only a matter of when and from what.

The way out of both the cultural, political and policy trap is for us to learn to ask the 3 questions I posed back in May:

  • Does it improve quality of life for the patient?
  • Does it extend the patient’s life?
  • How much does it cost?

Asking the questions are of course much simpler than figuring out the answer, and far far simpler than deciding what to do with the answer.

The first step is not demonizing even the asking of the questions. This would represent a profound shift in our culture, and is needed. We need to grow up and learn how to talk about limits in medicine. Then we will have to learn how to give practical answers to these questions, and the answers will have to be knowable and usable at the bed side as doctors and nurses are caring for actual people–you, me, my parents, grand parents and kids. These are not just technical policy questions, but need to become cultural ones as well, asked by all of us, no matter what type of insurance we have.

Then we will have to decide what to do with the answers. None of this will be easy.

I have concluded that what we most need in health policy is a political truce. We have got to come up with a political deal that makes health reform and the need to address health care costs a bipartisan problem/issue. If so, I am confident that we can muddle through on the policy and take some practical steps to slow our rate of health care spending to a sustainable rate. Without a deal, I fear we are doomed.

*vote in the comments which side uses this argument most; left vague so you could mutter to yourself–The Other Guys!

Update: this post I did with Amy Abernethy in Health Affairs blog from last summer is on point here.

About Don Taylor
Professor of Public Policy (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute), and Chair of the Academic Council at Duke University . I am one of the founding faculty of the Margolis Center for Health Policy. My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

2 Responses to The Role of Culture in Cost Control

  1. Floccina says:

    I do know which side uses the fear of death most, I would assume that it is the same because politics strongly selects for those who use it.

  2. George says:

    What people do with their own money is their business, but we need to define medical necessity for publicly funded programs. We might,, for example–strictly as an example not a recommendation–, as a tiny step in this complex issue define medical necessity as any procedure that has a 1% chance of extending a person’s life by at least 1 month. The definition of medical necessity for publicly funded programs is an ethical question that should be addressed through the political process. The question of whether a procedure meets that definition, whether it gives someone that 1% or greater chance for example, then becomes a scientific question.

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