"game" or manipulate a system that conditioned coverage on signing advance directives by later revoking the directives (assuming that such directives would continue to be revocable). As Callahan has pointed out, "advance directives were designed to assure the private good, not the public … to give patients a safeguard against being overpowered by overzealous physicians or institutions" (Callahan, 1996).

Consumer Choice Strategies

A market-oriented strategy to reduce health care spending proposes that those who wish aggressive but marginally beneficial treatments (or, in some versions, aggressive beneficial care) should be allowed that option but only if they absorb some of the additional costs that such a choice might entail (Eddy, 1991a; Havighurst, 1992, 1995). People could contract for a different "intensity" or "quality" or "extensiveness" of coverage as provided in different health plan options. The differences might be set forth in alternative clinical protocols for specific health care problems. Thus, one person might choose a health benefits package that covered only palliative services for persons with prostate cancer of a certain stage and prognosis, whereas another person might choose (and pay more for) a package that also would pay for curative or life-extending care under the same circumstances.

It may be unrealistic to expect people—particularly those not immediately concerned about life-threatening illness—to analyze and understand how health plans differ in their protocols for caring for myriad different illnesses and combinations of medical problems (IOM, 1993b). Nonetheless, with the support of clinicians and others, people might be helped to understand a choice—similar to that involved in electing hospice care—between an option that allowed for aggressive, curative or life-extending care for conditions with a poor prognosis and an option that provided for palliative services appropriate to the person's disease stage and prognosis.

Medicare Managed Care

Managed care strategies have the potential to reduce costs for end-of-life care in much the same way that they appear to reduce costs for healthier populations, in particular, by reducing the use of inpatient hospital services. For example, patients admitted to the hospital but determined to be likely to die within a few days may be discharged to die elsewhere if they do not meet the criteria for acute inpatient care. The overall impact of such strategies on the cost and quality of care would vary depending on the regard given to the wishes of patients approaching death and the alternative care available (e.g., hospice, nursing home, home health care). Alternative care



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