Who Deserves Health Care?

Rationing Becomes a Reality as Costs Skyrocket

By Geeta Anand
Staff Reporter of The Wall Street Journal

Angel Montanez Diaz, 69 years old, has spent 140 days in intensive care at Philadelphia’s Northeastern Hospital this year. Suffering from dementia, he needs a ventilator to breathe and a stomach tube to eat. The hospital needs his bed. His stay has already cost the hospital about $280,000, only a fraction of which will be covered by his Medicare insurance. The rest will end up as a loss for the hospital.

This, in a nutshell, is our health-care problem. The U.S. spends far more per person on health care than any other country, and it spends ever more each year. But there aren’t enough doctors, drugs and dollars to do everything for everybody.

So who gets the care? And who has the power to make that life-or-death decision?

In England, Canada and some other countries, a government health-care bureaucracy would supply some guidelines. In the U.S., it’s people like Lorraine Micheletti.

Ms. Micheletti is a nurse manager in the intensive-care unit at Northeastern. With her hospital facing a cost crunch, she’s under pressure to get patients out of the unit quickly. So each day, she makes battlefield decisions that influence whose lives should be prolonged and who should leave the ICU. While she can’t deny or withdraw care, she has other not-so-subtle means at her disposal, such as urging families to let some very ill patients die with less medical intervention.

Without any official rules, she uses only her judgment from 27 years of experience. “You get a feel for it,” says Ms. Micheletti. “Nine out of 10 times I’m right. Every now and then I’m proven wrong. There are always a few cases that are miracles.”

What Ms. Micheletti does every day is called “rationing,” and though it has long been seen as taboo in the U.S. health system, the truth is, it’s happening every day at hospitals around the country.

While there is no formal rationing system in the U.S., with its complex mix of private insurance and Medicare and Medicaid coverage, plus 41 million uninsured people who pay for their own care or get treated as charity cases, rationing is the underlying reality in thousands of big and small health-care decisions, made mostly out of sight of patients, according to rules that often aren’t consistently applied.

The Ones Who Say ‘No’

The people who make these decisions are harried doctors, Medicaid functionaries, hospital administrators, insurance workers and nurses. These are the gatekeepers of the American health-care system, the ones forced to say “no” to certain demands for treatment.

Four years ago, Northeastern, which serves mostly lower-income residents, was losing money and in danger of closing. To stay in business, administrators told the hospital staff that, among other things, they must get patients out faster. Since then, the average patient stay has been reduced from 4.9 days to 4.6 days. This year, the hospital’s goal is to bring the number down to 4.2.

That puts a huge responsibility in the hands of Ms. Micheletti and her 26 nurses. She works closely with a private-practice doctor whom the hospital pays to oversee ICU patients. “You could say I’m rationing care,” she says. She firmly believes that her decisions aren’t simply about money. In deciding how to dispense care in times of scarce resources, her “first question has to be, ‘What quality of life does he have? Is he going to live 10 years with a good quality of life?’”

This spring, she considered the case of John Ems, a 79-year-old former fridge repairman who was admitted with anemia and gastrointestinal bleeding. After three weeks in the hospital, Mr. Ems went into cardiac-respiratory failure. He was revived, but one of his lungs collapsed. Patients in this condition can die quickly, or linger in intensive care for a long time.

The next day, Ms. Micheletti talked to the nurse caring for Mr. Ems, looked at his chart, and within minutes, she says, determined his likely fate. Considering his medical history, and the fact that he wasn’t able to breathe without a ventilator, she concluded Mr. Ems was going to die. Her goal, she says, became to prepare the family to let go of him.

That same day, Ms. Micheletti told Mr. Ems’s son, Tom, that it was unlikely his father would ever come off a ventilator, which meant he would probably need to go to a nursing home, if he lived. “You have to think about what’s humane,” she told him.

A few days later, John Ems’s blood pressure plummeted. Nurses asked for permission to stop his blood-pressure medication and not to resuscitate him if his heart stopped beating. Tom Ems says he agreed because doctors told him his father was likely brain-dead. Without the medicine, Mr. Ems’s heart stopped beating. A few minutes later, he was dead.

The emphasis on moving patients along is a big change from the past, when cost-cutting pressures weren’t so great and nurses “never thought about insurance,” Ms. Micheletti says. “You just did what needed to be done. You dared not ask the question of when the patient would be released.”

‘Don’t Let Him Go’

At the same time, Ms. Micheletti sometimes finds herself fighting to keep a patient in the ICU. Sam Buoncristiano, a 55-year-old junkyard owner, came to her unit in May after suffering a heart attack. He needed special tests to determine if his arteries were blocked. Northeastern doesn’t perform these tests but offered to arrange for him to be transferred to another hospital. Mr. Buoncristiano wanted to go home first.

Ms. Micheletti was convinced his arteries were dangerously clogged because he continued to have chest pain. She went into his room and pressed him to stay in Northeastern’s ICU. Then she hovered by the door, waiting to speak to the doctor attending him.

“Doctor, don’t let him go home,” she told him. “If he goes home, he’s going to die,” she said. The doctor nodded, picked up Mr. Buoncristiano’s medical chart and went in the room. He came out a few minutes later and told Ms. Micheletti the patient had agreed to stay.

Since Northeastern put in place its turnaround plan three years ago, its fortunes have improved. In 2002, it posted a profit of $2.6 million, on an operating budget of $85 million. For meeting financial goals, and improving patient satisfaction, each hospital employee got a $300 bonus. Managers, including Ms. Micheletti, got a $2,000 bonus.

‘No Place Else to Go’

While Ms. Micheletti has worked hard to decrease the average patient stay this year, one person can throw off her numbers. “You can eat up all of your profits if one or two patients” linger in the ICU, she says.

On Valentine’s Day this year, Angel Montanez Diaz, the patient with dementia, showed up at Northeastern ICU with intestinal bleeding and pneumonia. As soon as he seemed stable, Ms. Micheletti pushed to move him back to his nursing home. She decided he would never be well enough to go home, though he might survive for many more months in intensive care, at a huge cost to the hospital.

Mr. Montanez Diaz’s brother and legal guardian, Moises, didn’t want him returned to the nursing home because he thought the care was inadequate. Hospital officials started calling around trying to find a different nursing home to accept him. It was a big problem.

“Either they won’t accept him or they don’t take his health insurance or they don’t have a bed,” says Ms. Micheletti. “He’s really here because he’s got no place else to go.”

The hospital eventually found a nursing home to accept Mr. Montanez Diaz—but he was shuttled back to the hospital several times with fevers and infections. When he kept coming back to the ICU, Ms. Micheletti began prodding Moises to stop keeping him alive. Angel was in chronic pain, mentally incompetent and unable to breathe or eat. “That’s not Angel in there,” she told Moises. “That’s just a shell of him.” Moises began to cry.

Moises says Angel raised him after their parents died, and he wants to repay that kindness by caring for him now. His goal isn’t to restore Angel’s mental capacity, but to get him off the ventilator so he can take him home.

Pressure on Moises is increasing. In addition to Ms. Micheletti, two hospital doctors and a nursing home have also urged him to sign a form saying his brother should not be resuscitated. “They want to put my brother out of his misery,” he says.

On July 29, Moises arrived at the hospital at 10 a.m. to find his brother gone. He had been sent to another nursing home.

When he stopped by her office that day, Ms. Micheletti hoped Moises would thank her and the staff for caring for his brother for so long. Instead, she says, he came up to her, smiled and said: “So you finally got rid of him.” She lost her temper, she says, and responded, “Yes, we got rid of him.”