Paul Levy, over at Running a Hospital, is mulling over the war cry of the interventionist: Too much is not enough!

My favorite example from the Dartmouth Atlas project which Paul discusses is the angioplasty/stent epidemic at a cardiology practice in Ohio (4x national rate of stenting). That would never happen today, though, post-COURAGE, right?

As far as end-of-life care goes, why not establish case rates as insurers do for the beginning of life?  It is SOP to pay providers a fixed fee for prenatal care and delivery.  As in any such system, some cases are "winners" for the payors and the others are "winners" for the providers (to be crassly commercial). I know, I know, easier said than done, and when do you draw the line/pull the trigger?  The Medicare hospice benefit is just a baby step in that direction.  Bottom line, once you raise chronic disease and terminal illnesses, we’re talking about personal and ethical issues, not "just" health care financing.

But assuming we can talk about this and maybe even get somewhere, what about shifting the assumptions that get us bolloxed up?: e.g., assume hospice or comfort care election unless specifically stated otherwise — and if aggressive care is elected by the patient or delegate, include a requirement that a physician certify that the care is not futile before it is continued, just as a physician certification is required before  a patient may qualify for Medicare hospice benefit; assume consent to organ transplant unless specifically stated otherwise; etc.

Paul, it’s never too late to wade into this river.

David Harlow