Wednesday, December 23, 2009

Medical Culture and Costs at UCLA

An article about the cost of end-of-life care in this morning's New York Times focuses on the Ronald Reagan UCLA Medical Center. UCLA has a national reputation for high quality/high tech care, but also for high costs. According to the Dartmouth studies, Medicare pays UCLA $50,000 during the last 6 months of a patient's life compared to $25,000 at the Mayo Clinic.

The article quoted CEO David Feinberg as saying “If you come into this hospital, we’re not going to let you die”!

I have memories that shed light on the story.

From July 1964 to June 1965 I was a medical intern at UCLA, before returning to Boston to train in psychiatry. I don't remember any limits being set on the tests we ordered until the chief resident came to us in the spring to say "folks, we're running out of money for tests, so cut back where you can." He was apologetic for having to cramp our style. The question of when tests were medically important to do, when they were wasteful, and when the risk of false positive results or otherwise misleading findings was so great that doing the test would be, in medical jargon, "contraindicated," was never discussed. UCLA was probably not unusual in that era, but in retrospect it seems that a cost-unconscious ethos was already part of the culture.

The article in the Times also discussed UCLA's ethic of doing everything possible for patients - sometimes with extraordinarily beneficial results. I experienced this in a very positive way as an intern. During one of my ward rotations a young professor was admitted for a heart attack. He was stable, but the physician in charge had me sleep in the same room with him as an additional element of safety. My skills at cardiology were, to put it politely, "developing" at best. But the message of concern and caution embodied in my assignment made a strong impression on me. (I was also aware of the absence of equity - we didn't have interns sleeping in the rooms of our other heart attack patients.)

Dr. Feinberg, the CEO, is a child psychiatrist. Prior to becoming CEO of the UCLA hospitals he was medical director for the Neuropsychiatric Hospital there. Psychiatry has always been subject to limits in ways the rest of medicine hasn't. In addition to his medical training, Dr. Feinberg has an MBA. I trust that his comment about how UCLA is "not going to let you die" is a wry way of tweaking a culture that has been overly technology-driven and underattentive to the ethics of medical costs.

(See here for a profile of Dr. Feinberg, here for the New York Times story, and here for "Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care," a paper I wrote in 1994.)


David said...

This is a sad day for those who allowed a President to sail into the White House on the wings of change.

It seems to be forgotten that this is a human need. The ability to be self-directive and receive care when needed would increase with an easy taxation system. Doubling the Medicare tax is a fair and equitable solution.

Everyone needs a buy in.

Currently, young Americans are paying for Social Security and Medicare without any assurity they will exist upon their retirement. We have built so many empty social contracts and now wish to punish a single mother without a means to purchase a product.

The question becomes: Do we really value labor? If so, isn't it a conflict of interest to allow an able bodied American to become ill-equipped to work when this could be prevented.

Clearly, there are implications for national defense. It seems, though, we are happy to ignore practical utility of nonprofit healthcare.

Jim Sabin said...

Hello David -

Thanks for sharing your thoughts.

I agree that "an easy taxation system" would be more fair and equitable. Unfortunately the idea of a tax - even for a basic social good like health care - is so toxic in our political discourse that we resort to a workaround like the combination of mandates and financial support for meeting them.

I also agree with you about the preferability of not-for-profit structures in health care. I don't think the problem is "profit" per se but rather equity ownership and the market's demand for short term returns. For most of my clinical career I was on salary, which I preferred, but when I conducted a solo fee-for-service practice it was, in effect, a small for-profit enterprise. But I could conduct it in accord with my own clinical and ethical standards.