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You are here: Home / Anderson On Health Insurance / Choose three?

Choose three?

by David Anderson|  November 7, 201411:10 am| 28 Comments

This post is in: Anderson On Health Insurance

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Engineers often quip that ‘better, faster, cheaper’ is a choose two  trilemma.
Project managers quip that ‘on time, on budget and on-spec’ is also a choose two  trilemma.

Duke seems to be showing a better, safer and cheaper method of approaching some cancer care cases.

Duke University Medical System studied how providing pallative care to oncology patients changed care decisions and outcomes. The results were significant.

The study reviewed 2,353 inpatient encounters that included palliative care physicians, who focus on alleviating pain, side effects, and improving quality of life for patients and their families during serious illness. After the model was implemented at Duke in 2011, the analysis showed, there was a 23-percent decrease in the number of patients readmitted to the hospital within a week of discharge. Patient transfers to the intensive care unit also decreased by 15 percent, and patients were discharged from the hospital about eight hours sooner, on average. During the same time, hospice referrals increased by 17 percent.

From an insurance and cost point of view, anything that can be done to avoid intensive care unit admissions is probably a massive net cost savings. Readmissions for problems within a week of discharge is a massive red flag for quality of care concerns as well. The Center for Medicare and Medicaid is penalizing hospitals for readmissions thirty days after discharge, so a week is an indicator of a potential problem.

Duke is not using capital intensive super high technology to reduce costs. They are having highly trained people talk to patients, ask them what they want, how they are feeling, and then devising plans to make them feel better while achieving their goals. It is a shocking system change. Talking works.

There is significant evidence that when people feel that they have control and input over their medical decisions, they tend to use less intensive services as their goals are not always survival at any cost nor effort. Some may want that. Others may want to feel good for as long as possible and then be willing to accept death if they are in their homes with loved ones. Others will want something in between. The medical system seldom asks what end goals are, and suffering is prolonged while costs are accumulated.

Follow-up 1: A valued commenter passed along a fascinating review of pallative care for advanced oncology patients at non-Duke locations.  It was a good lunch time read.

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28Comments

  1. 1.

    Ruckus

    November 7, 2014 at 11:23 am

    There is significant evidence that when people feel that they have control and input over their medical decisions, they tend to use less intensive services as their goals are not always survival at any cost nor effort.

    This is interesting. Just this week I was discussing my ongoing issues with my docs. And not once was I asked what my goal was. Towards the end of the discussion I volunteered what my goal was and it was very well received as it is not an unrealistic goal, all things considered. I don’t think that they (yes two, at the VA, lots of med school/resident training) had even considered my goal as an issue. Yet that can have a huge impact on how some diseases are managed or treated at all, even if cost is/was not an issue.

  2. 2.

    JCJ

    November 7, 2014 at 11:28 am

    They are having highly trained people talk to patients, ask them what they want, how they are feeling, and then devising plans to make them feel better while achieving their goals.

    These are the death panels we have been warned about! How could they possibly be good?!?

  3. 3.

    gratuitous

    November 7, 2014 at 11:30 am

    Ahhhhh!!! Death panels! You want medical professionals to *talk* to patients and find out what they want, instead of expending every (expensive) effort to prolong a life? I suppose you want to drive the manufacturers of the machine that goes “Ping!” out of business, don’t you, you commie?

    As soon as you start talking to terminal patients about managing their choices and treatment, Sarah Palin sees an army of nurses deployed across the landscape, smothering pillows at the ready, to snuff out all those precious, precious lives she doesn’t give a shit about. But somewhere in East Bumblefuck is someone watching an aged relative die by inches day by day, who isn’t ready to let go, who is desperate to try one more shot, one more pill, one more treatment because he or she can’t bear the prospect of life without Mee-maw.

    This is an issue that has to be approached with great care, but holy smokes, I’m tired of the discussion being driven by the most fearful and their grandstanding leaders.

  4. 4.

    El Caganer

    November 7, 2014 at 11:38 am

    Not only am I not asked for any input, I’m basically being blown off. My doc ordered a couple of tests at the beginning of October that required insurance co. approval before seeing me again; I’ve called the staff at the lung center who are supposedly responsible for getting this three times, only to be told twice that they’re too busy and once getting no return call. I was sort of under the impression that having PE, PH and COPD was a tad more serious than a chest cold. Apparently not. Time to try another lung center. Sorry for the OT rant; I’m just really frustrated.

  5. 5.

    Gindy51

    November 7, 2014 at 11:41 am

    Doctors are not trained to think of patient’s goals or even to think of their patients anything more than cash cows. All four of my daughter’s grandparents were killed by a doctor or hospital: malpractice, negligence, filth, and unnecessary surgery all for the bottom line. They line their pockets, push the patient out the door as fast as they can, and then be ready to get more cash when they show up even sicker than before. That’s been my experience.
    I avoid the hospital like it is a plague ship.

  6. 6.

    Cervantes

    November 7, 2014 at 12:00 pm

    About:

    The medical system seldom asks what [patients’?] end goals are, and suffering is prolonged while costs are accumulated.

    How did such a system arise? What problems did it address along the way? What did it ignore?

    Also, to whoever is doing all that quipping:

    Lemma. Dilemma. Even trilemma, if you like — but not trilemna.

    That is all.

    Quip away.

  7. 7.

    Eric U.

    November 7, 2014 at 12:01 pm

    @Gindy51: we don’t really talk to each other about providers enough. I think your experience is far from universal. Although here in Pennsyltucky, you’re better off getting serious procedures done elsewhere

  8. 8.

    Gin & Tonic

    November 7, 2014 at 12:09 pm

    @Gindy51: They used to be. A long time ago, in a galaxy far, far away, my father was a physician. Small practice (two docs), smallish town, he knew his patients sometimes for generations. Talked to them, knew something about their lives. Was able to make recommendations – “here’s what I think you should do”, not “here are three options you can’t possibly understand the implications of, which one do you choose?”

  9. 9.

    OzarkHillbilly

    November 7, 2014 at 12:10 pm

    I watched my mother go thru a long and difficult dying. In and out of ICU, to rehab back to ICU, back to rehab, briefly home, back to ICU, to rehab, to ICU….

    She had a Living Will and a DNR and yet never in all those months did anyone talk to her about what she wanted. The last time she went to ICU it was as plain as the nose on her face what the future held for her: More breathing machines, more dialysis, more tube feeding, more drugs, more more more, and yet still nobody had this conversation with her.

    So I asked. “Ma? Do you want to go home?”

    “Sure,” she replied, “when I’m able.”

    “But Ma, what if the day never comes when you are able.” She got this long thoughtful look on her face and nothing more was said.

    The next day, when I came in she said, “I’m ready. I want to go home.”
    When the Doc came in she outlined various treatment regimens that they had yet to try, but the only word about end of life care after Ma said no to all options was, “OK.” and the Doc left. And so I was alone to deal with it with her again. Eventually I had help from my sister-in-law who is a nurse in an extended care facility. She set up the nuts and bolts of hospice, but the hard conversations were mine.

    Even now, 8 hears later, there is a part of me that feels guilty, like maybe I pushed her into it, or for the relief I felt at the knowledge that it was finally ending. It would have been nice to have someone who was trained for it, to be a part of those discussions. Then I would not have been so on my own.

  10. 10.

    HinTN

    November 7, 2014 at 12:29 pm

    @OzarkHillbilly: There is no guilt in taking the decisions the system forced you to take without support from the system. The life at all cost system that modern medicine has become, for reasons too many and diverse to address here, has not trained doctors to address that question. Slowly, that is changing. In 1991 my mother’s oncologist was willing to prescribe a lethal overdose of pain killers, which I thought was damn enlightened, but that level of consideration of the condition and desires of the patient is pretty rare. Duke demonstrates it is changing.

  11. 11.

    burnspbesq

    November 7, 2014 at 12:30 pm

    According to the most recent Form 990 i could find online, the executive director of the Duke Cancer Institute makes almost exactly one-tenth as much money as Coach K. Make of that what you will.

  12. 12.

    PIGL

    November 7, 2014 at 12:36 pm

    @OzarkHillbilly: You’d have to be inhuman to not feel some guilt and uncertainty, but from your note, and your postings, I am certain as can be that you did the right thing for your mother. I hope you will be able to let yourself believe that.

    As for your larger point, that you should not have been abandoned as you were, well of course you are right. Not only is it heartless, it is harmful, in encouraging bad choices or causing needless pain in the making of good ones.

  13. 13.

    El Caganer

    November 7, 2014 at 12:42 pm

    @burnspbesq: Well, of course. How many NCAA titles has he won?

  14. 14.

    PurpleGirl

    November 7, 2014 at 12:49 pm

    @OzarkHillbilly:

    It would have been nice to have someone who was trained for it, to be a part of those discussions.

    Problem is most doctors have no training about end of life issues. They don’t know what to say. As doctors their training is to find something else to try and keep the patient alive. It is more likely a nurse or social worker who has the training to talk about end of life issues. The hospice worker has the training to work with terminal people. If a doctor works in hospice care, it’s because they’ve sort it out and took the training because they wanted it. It wasn’t part of medical school.

  15. 15.

    Eric U.

    November 7, 2014 at 1:10 pm

    @PurpleGirl: apparently, nobody does, even in nursing homes with critical care facilities. I was left with big doubts after my father died. If he hadn’t died of pneumonia because they weren’t treating it, I would feel a lot better. Maybe he would have died even with agressive treatment, but nobody would tell us. But he was a cypher by that time, effectively dead.

  16. 16.

    RSA

    November 7, 2014 at 1:19 pm

    @PurpleGirl:

    As doctors their training is to find something else to try and keep the patient alive. It is more likely a nurse or social worker who has the training to talk about end of life issues.

    Along with a slew of other issues. In dealing with my wife’s illness, I thought that the nurses and social workers were consistently the most helpful people involved in the process. We did have a few very good doctors who would explain what was going on and tell us about options, recognizing the human side of illness, but it was hit or miss.

  17. 17.

    Tissue Thin Pseudonym (JMN)

    November 7, 2014 at 1:26 pm

    I’ve followed this a bit since my aunt is one of the people engaged in this research, though she’s actually at UNC these days. It’s not just palliative care, either. She and others are engaged in all sorts of efforts to make hospitals more efficient, more effective, and more responsive. The extent to which no one has taken a public policy approach to evaluate outcomes in health care is truly appalling.

  18. 18.

    smedley the uncertain

    November 7, 2014 at 1:27 pm

    “The medical system seldom asks what end goals are, and suffering is prolonged while costs are accumulated.”
    And of course profits earned!

  19. 19.

    Mnemosyne

    November 7, 2014 at 1:30 pm

    @OzarkHillbilly:

    As PurpleGirl said, most hospitals have social workers who are supposed to help deal with stuff like end-of-life issues, because doctors are very bad with it unless they’ve had specific training. It’s good to have doctors who are all “never say die” and willing to do anything to keep their patient going, but after a certain point, they’re not helpful anymore.

    FWIW, it sounds like you correctly picked up your mom’s signals that she was done with treatment, but it sure would have been nice for the hospital to have a social worker available to help clarify things for everyone.

  20. 20.

    shelley

    November 7, 2014 at 1:32 pm

    I’ve heard some cancer patients saying the exact same thing. Also that it should be called ‘supportive care’ and not ‘palliative.’
    The latter makes people think it means the medical community is giving up on you; rather than improving your quality of life

  21. 21.

    Ruckus

    November 7, 2014 at 1:34 pm

    @OzarkHillbilly:
    So sorry about your mom, I really am sorry that you and she had to go through that, and wish that more docs were better prepared to handle the inevitable decisions that we all have to make.
    Had to do the same for my dad. He was unable to make any decisions on his own, and he had left me in charge. No it is not easy from my own perspective because hey it’s dad, but it was easy from a human perspective of this person is suffering, they will not get better, they won’t even stay the same, it will get worse, in his case much worse. His doc was great, he specialized in geriatrics, but a doc is not in a position to make those decisions. We sometimes would like that someone else makes that guilt lessen but this is one time that they can’t. That, did I make the right decision or not question will always be there and will always be valid.

  22. 22.

    Ruckus

    November 7, 2014 at 1:42 pm

    @Tissue Thin Pseudonym (JMN):
    We certainly don’t have a public policy but we do(did) have a cost policy. Insurance companies have been making life policy decisions for a very long time in this country. ER’s/hospitals have been making life policy decisions for about as long. They are made on the issue of cost but still, it is a decision. An example might be the hospital in Dallas who sent home the gentleman who died. Did they do it because they didn’t think about the possibilities or did they do it because they thought about the money?

  23. 23.

    Tissue Thin Pseudonym (JMN)

    November 7, 2014 at 2:05 pm

    @Ruckus: One of the things that public policy analysis is revealing is the huge number of ways that hospitals can both improve outcomes and cut costs. The ACA tries to push some of these and is almost the first attempt to do this comprehensively in government policy.

    A lot of it stems from the fact that hospitals have historically been terrible at even defining what their goals are. A lot of the “save the life at all costs” mentality is almost a default choice because it’s the obvious one to shoot for when no one has ever sat down and explicitly framed and answered the question of what the hospital is trying to do. Even getting them to think about this question is hard. If you don’t even know what “success” is, it’s hard to achieve it.

  24. 24.

    Matt McIrvin

    November 7, 2014 at 2:34 pm

    SCOTUS just decided to take King v. Burwell, which apparently means there’s at least four votes to kill ACA federal exchange subsidies on the Halbig principle.

  25. 25.

    richard mayhew

    November 7, 2014 at 3:40 pm

    @Matt McIrvin: there were 4 votes to kill PPACA on the “We don’t like the 20th or 21st Century principle”

  26. 26.

    burnspbesq

    November 7, 2014 at 4:21 pm

    @El Caganer:

    How many NCAA titles has he won?

    By that metric, Dan Brooks (the women’s golf coach) should make 50 percent more than K. He has six. And John Danowski’s three in men’s lacrosse should be worth around $6.25 million a year.

  27. 27.

    mch

    November 7, 2014 at 11:47 pm

    Very second hand here. While my son was in med school, he got weary of the endless “patient-centered” exercises he had to endure (“Yes, I get the point…”). Now that he is an intern in a different system in a different state, he’s been stunned by the absence of what he had come to take for granted as the ways you should try to relate to a patient.

    Just saying that all this starts early (as early as med school, at least) and varies enormously from doctor to doctor, hospital to hospital, state to state. People shouldn’t generalize to the whole vast system from their own or friends’ experiences. And it takes time to shift vast systems, like turning around an ocean liner….

    It would be nice to have the personal touch of the old days, the family doctor who knew you and your life in your community. But: having two friends who have been treated recently for leukemia, one rescued from an acute form at a cutting edge internationally eminent research hospital, the other being treated now for a “manageable” form at a less stellar but solid institution, I am happy for those aspects of today’s system which aren’t about your local family doctor who knows your dog’s name. (Not all that many years ago, both leukemias would have been quick and automatic death sentences.) We’re trying to work our way to the best balance.

  28. 28.

    Cervantes

    November 8, 2014 at 6:48 am

    @mch: Lansing, by any chance?

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