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Wednesday, 23 December 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.)


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