One morning five years ago, my 91-year-old father took a hard fall on a tile floor. In less than a week, he was dead.

It was not a surprise. He had an abnormally slow heart rate and had just been accepted to a hospice program, where his treatment was supposed to be limited to keeping him comfortable at the end of his life.

But even under those circumstances, it’s still amazing to me how hard it is to die and how much of our medical system is devoted to prolonging the inevitable.

As we have another national debate about health care and how to pay for it, I’ve been thinking about the end of my father’s life: While some people are dying because they can’t get even basic care, he spent his last year refusing services, not always with success.

He was twice dragged to the hospital even though he’d signed a “Do Not Hospitalize” order. On one of those trips, he refused emergency surgery to get a pacemaker installed, saying that he didn’t want to do anything until he could talk with his doctor. After the consultation, he refused the operation again.

If he had said yes, he might be alive today. But would the device that made his heart beat regularly also have brought back his hearing, which had made normal conversation impossible? Would it have made the pain in his back go away? Would he have still desperately missed my mother, who’d died six years earlier?

Would the people in the nursing home — where he would almost certainly have had to live — have been able to understand his thick Eastern European accent better than the EMTs who dragged him to the hospital when he didn’t want to go?

Or would he have been a sad, isolated guy in a lot of pain, albeit one who had a regular heartbeat?

I don’t know what the right amount of health care is, but I do know that in this country we make sure that people get the wrong amount in more ways than one.

Some people don’t get enough and others get too much, and what camp you are in depends on a lot of things that have nothing to do with how sick you are.

How much money you have matters. How old you are matters. And weirdly, geography matters, too.

Researchers at Dartmouth have been compiling Medicare payment data for decades, and have been able to compare how a patient with the same condition might be treated in different places. They publish the Dartmouth Atlas of Health Care, available online, which shows that there are significant differences in the kind of treatment you receive depending on where you live.

For instance, southern Maine hospitals install pacemakers for people on Medicare at about the national average rate. They are used nearly twice as often in Lafayette, Louisiana, and half as often in Duluth, Minnesota.

The atlas shows it’s not just pacemaker installations that show up at different rates in different places. Heart specialists are not evenly distributed around the country, either, and the places with the most doctors are also the ones where the most diagnostic tests are ordered and procedures performed.

That’s not a response to real-world need. Doctors don’t usually move to the places where they think they’ll find the most disease. They go where they can make a living and tend to live where they trained and learned from practitioners who have established preferences about how aggressively to use a procedure. The culture of the hospital near you, whether it’s a university medical center or a small rural hospital, will affect how much care you receive.

So, is about the average number of pacemakers the right number? Or are they doing it right in Duluth and we’re pacemaker happy? Or is it Lafayette where they know what’s going on and we’re way behind?

I don’t know, but I do know this: At the age of 91, it would have been far easier for my father to accept much more care than he needed – all covered by Medicare – than it was for him to get the level of care that he wanted – simply to be kept comfortable. Meanwhile, 14,000 children in this state have no health insurance and won’t see a doctor unless they have an accident or disease serious enough to land them in an emergency room.

If you’re wondering why Americans pay more than any of our industrialized peers for health care and get worse outcomes, you don’t have to look much further than that.

Greg Kesich is the editorial page editor at the Portland Press Herald.


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