The Politics of Medicare, Part One: The Perils of Excess

With the Presidential elections upon us, I have written a 3-part series about the politics of Medicare. In Part One, we will talk about the salient political reasons that Medicare is failing older Americans, something not being tackled by current reforms, and none of which are being addressed by our candidates. As discussed at length in my book, these failures are tossing unwitting elderly patients in harm’s way, bankrupting the system, and preventing a more sensible approach to care, even as they enrich many doctors and institutions. The myth of aggressive health care as being beneficial to older Americans, something I spend most of my book debunking, has been highlighted by two recent articles, and we will start with those. The bottom line is that if we give patients more choice in their health care, and more information about how medical interventions impact them, then not only will Medicare be saved, but our health outcomes will improve dramatically. Making this happen would be easy, if only we had the political will.

Recently there has been a push to keep narcotics away from patients, with incessant headlines proclaiming that we are turning helpless patients into drug addicts. I had a recent elderly patient, who takes a puny dose of a narcotic, tell me she feels like a drug addict every time she gets her pills filled. That low dose, which gives her no appreciable side effects, alleviates her pain enough so she can exercise and feel comfortable. Without the medicine, she was barely functioning. Clearly narcotics are not for everyone, but when we provide individualized care based on scientific evidence and not hyperbole and protocol, we as doctors find that such drugs can help some people dramatically, with fewer side effects than other recommended medicines (such as medicines like Motrin, which actually send more people to the hospital than narcotics.) An older study showed that among people without an addiction history only 1/3000 people put on narcotics develop an addiction, and a newer study showed that among elderly people who take narcotics up to a year after surgery, only 4/1000 develop long term dependency. If we use narcotics judiciously, they can truly benefit certain elderly people, no less than do other drugs and with no more risk.

Why discuss drug addiction in this context? Because while the press and DEA focus their myopic lens on narcotics, our elderly are being drowned by a plethora of “good” drugs, poured into them by specialists and aggressive doctors, sanctioned by Medicare’s protocols, and causing more damage and side effects than the vast majority of narcotics. A recent article by Kaiser Health News highlights the real drug problem in this country: countless doctors prescribing too many drugs to our elders and using nebulous data and a lack of shared decision making to justify such excessive care. These doctors are considered thorough, because they treat every aberrant number, order every possible lab or test, fix every blocked artery or thinning piece of bone, and believe that the more aggressively they intervene, the better their patients will be. The only problem is that science has proved them wrong, and yet the press and Medicare continue to reward them for their over-treatment. They are paid very well to intervene. They are not paid well if they spend time giving patients real information, especially if such patients do not choose to pursue a highly reimbursed intervention.

In my book and on this and my other blog I provide ample evidence about the real drug problem in our country: over-treatment. The blame cannot lie solely with the pharmaceutical companies that peddle their wares. It must instead rest on the shoulders of over-zealous doctors who write the prescriptions and who believe in the benefits of excess. Most patients are skeptical of medicines, tests, and procedures, but when their doctors advocate these interventions, patients typically comply. Evidence shows that when doctors actually talk to patients about interventions using real risks and benefits, patients are less likely to pursue what we know to be ineffective treatments. But this is not what happens; Medicare, thought its payment system, encourages aggressive care. Until doctors are rewarded for using actual data that is individualized for every patient before exposing them to uncertain interventions, until doctors are paid more to think than to do, until doctors are not paid obscene amounts to perform procedures without being honest with their patients about their risks/benefits, Medicare will be doomed to squander its coffers hurting people in the name of thorough. This must be changed, and it time that patients and their doctors confront our real drug epidemic. CLICK HERE to read Carolyn Rosenblatt’s moving story in Forbes to get a sense of what doctors like me must confront every day in our over-specialized over-aggressive medical landscape.

This epidemic in excess is not limited to our over-treatment with drugs. A recent article in the New York Times demonstrated how three common surgical procedures have been shown not to benefit patients and yet they continue to be performed by doctors and paid very well by insurances like Medicare. Many more procedures and tests fall into that category, some of which we have discussed here, such as cardiac stress tests and stents, and doctors are becoming rich by convincing patients that these useless and potentially harmful interventions are beneficial. As long as Medicare continues to pay, and as long as the illusion of thorough can be tied to such over-treatment, then there will be no end in sight. A recent article sums up the scourge of overtreatment very well. The Institute of Medicine estimated in 2009 that we are wasting $750 billion a year in unnecessary medical interventions, money that insurances like Medicare are paying without scrutiny, money that is enriching many doctors and CEO’s, but money that is harming patients under the veil of thorough care. It is time that we as a society face this reality and assail it. It is time doctors are paid more for having honest discussions of risk and benefit with their patients, and paid far less to inflict harmful drugs and procedures on them. Medicare can accomplish this shift tomorrow if Congress and the President had the political will. In chapter 6 of my book I lay out a pragmatic plan to show how it can be done.

Nothing is more indicative of our culture of excess than hospitalization. Another excellent Kaiser Health story spells out what we in geriatrics understand innately and through our years of experience: that in the majority of cases, elderly people, especially those who are frail or who suffer from dementia, are more likely to do well if treated at home than if they are sent to the hospital. In my book I spend time discussing why this is so. The evidence is actually quite overwhelming. According to the Kaiser article and a 2011 JAMA article 50% of elders over 85yo leave the hospital more disabled than when they came in, and a quarter suffer hospital-induced harm at a cost of $4.4 billion a year. Given that home care is far less expensive than hospital care, and that in many cases the outcome is superior, the cost to Medicare of excessive hospitalization is enormous. In fact, a quarter of Medicare’s entire budget is spent providing unnecessary excessive hospital care to people who end up dying, even though 85% of seniors clearly state they do not seek that type of care. A recent analysis discussed on NPR estimated that the cost of dying at home for the last month of life was $4700, while in the hospital that cost was $32,000. The difference was that in the hospital people were exposed to incessant tests, procedures, and doctor visits that were ineffective. Many have written about the trauma of dying in the hospital, and those of us who work in geriatrics have seen it time and time again, as I discuss in my book. But the hospital is unsafe for even those hoping to recover. A recent BMJ study finds that medical errors--many of which occur in the hospital setting—account for 250,000 deaths a year. Hospital acquired infections are not far behind in their lethal impact. By any definition, the hospital is not a good place for elderly people to be.

Why are we sending so many of our elders to the hospital? At the most basic level, the myth of thorough care continues to characterize the hospital as the best place to be when someone is sick, despite the overwhelming evidence to the contrary. But what is much more basic, and fixable, is one simple fact: Medicare pays very well for hospital care, and does not pay for home care. Even though Medicare would save billions of dollars every year if it allowed people to be treated at home, even though the vast majority of elderly people want to be treated at home, even though outcomes are better and harm is reduced with home care, Medicare simply will not pay for it. How could that be? Are the hospital lobby, doctors groups, and others who are enriched by the plague of excessive hospitalization calling the shots and preventing Congress from doing the right and sensible thing? How difficult could it be for Medicare to alter its payment formula to actually provide care for those who choose to be treated at home, especially given how much Medicare would save? Again, such a simple fix requires political will, and thus far such will is lacking.

In the end, we will need to push our government to fix Medicare by changing what we know to be so very wrong with the current system. It all starts with coming to terms with the dangerous excesses we generously finance, and paying instead for the care seniors want and need. The fix is easy, the obstacles more phantom than legitimate. But in politics, nothing is as easy as it should be. In the next segment, we will talk about the current Presidential race and how that may impact Medicare’s future. Of note, I did send my book to both candidates, and I am waiting for a response.