Saturday, July 8, 2017

The Smart-Medicine Solution to the Health-Care Crisis - WSJ

The controversy over Obamacare and now the raucous debate over its possible repeal and replacement have taken center stage recently in American politics. But health insurance isn't the only health-care problem facing us—and maybe not even the most important one. No matter how the debate in Washington plays out in the weeks ahead, we will still be stuck with astronomical and ever-rising health-care costs. The U.S. now spends well over $10,000 per capita on health care each year. A recent analysis in the journal Health Affairs by the economist Sean P. Keehan and his colleagues at the federal Centers for Medicare and Medicaid Services projects that health spending in the U.S. will grow at a rate of 5.8% a year through 2025, far outpacing GDP growth.


The Patient Wants to Leave. The Hospital Says ‘No Way.’ - The New York Times

Why would an older person essentially discharge himself from a hospital, defying a physician's recommendation and signing a daunting form that acknowledges he is leaving A.M.A. — against medical advice?

Attend the tale of William Callahan.

He nearly fainted last spring after walking down the block to visit a neighbor in his New Jersey suburb. At 82, he had a long history of cardiac problems and was several years into Alzheimer's disease, but remained mobile and sociable.

He quickly revived, but the neighbor called 911. His daughter, Dr. Eileen Callahan, a geriatrician at Mount Sinai Hospital in New York, met her dad at the local emergency room.

"He was fine, sitting up and chatting," she found. "CT scan, blood work, heart rate, vital signs — all totally normal." He'd probably gotten a bit dehydrated, she figured, and he insisted on going home.

Dr. Callahan promised the E.R. doctor that she'd stay with her father overnight to be sure he was O.K. No dice.

"The doc said no, he really should stay overnight to be monitored and to see the cardiologist in the morning and get cleared."

In hospitals, she knew, her father was prone to sleeplessness and delirium. In unfamiliar surroundings, he might fall.

Still, "I succumbed." The hospital provided an aide to stay with Mr. Callahan overnight until another daughter arrived in the morning.

It did not go well. Mr. Callahan paced for hours, peeled off the heart monitors and grew increasingly confused and agitated. By the next afternoon, despite family calls and complaints, the cardiologist had not materialized and the hospital still wouldn't discharge Mr. Callahan.

Dr. Callahan's sister was growing frantic. "I said, 'Maureen, just do it,'" Dr. Callahan said. "Sign him out."

Her sister signed the A.M.A. form that hospitals typically demand before releasing patients against physician recommendations, acknowledging that patients understand and assume the risks, medically and legally.

Mr. Callahan went home and went to sleep, but his physician daughter remains livid.

"He should have been discharged right from the E.R.," she said. "This was cookbook medicine, done without thinking. It was very adversarial."

Such events happen more commonly than one might think. Though A.M.A. discharges occur far more frequently in younger patients, a recent study in The Journal of the American Geriatrics Society analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges.

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