On end-of-life care

To respond to some of Jay's thoughts on this matter: In the same way that preventive care and lifestyle change are undervalued (in terms of their health bang for buck reimbursed), end of life care is overvalued--or more correctly, consumers are willing to pay a steep premium for immediacy. In other words, from a purely rational standpoint, an additional year of healthy life (sometimes measured in a unit called quality-adjusted life years (QALY)) should be worth the same number of dollars whether it was "bought" using services applied in the 30th year of life or the 80th year, but in practice, we pay much, much more to extend life in the later years than we do in the earlier years.

This fact is not necessarily due to an evil empire, or even an irrational market. In fact, couldn't you argue that aggressive, expensive end-of-life care does not only serve the needs of those who benefit financially, but also serves the preferences of consumers who pay healthcare premiums? This is just a very rough idea, but what if the healthcare system was designed to take advantage of the loose purse strings we see at end of life to pay for better prevention? Perhaps rather than cutting back on end-of-life health care service utilization, payers (or policymakers through taxation) could skim a percentage of the profit margin realized for end-of-life care to pay for better preventive services or even directly compensate (or subsidize) individuals for healthy lifestyle choices. Not only might this help delay the onset of end-of-life care, it could keep healthy people productive in the workforce (and paying into the system) longer.

As strange as this sounds in a country where Social Security benefits for retirees are paid out of the payroll taxes of the current workforce, the premium we pay on end-of-life care could be harnessed to support better prevention in the current workforce. There are countless practical considerations that would go into this, but in the same way that individual IPAs and HMOs subsidize necessary but poorly reimbursed services with revenues from high margin procedures, a rational system could take revenues from potentially higher-margin (and "irrationally" over-reimbursed) end-of-life care to pay for valuable, but under-reimbursed prevention.