Wednesday, October 19, 2011

Jane Gross on the Failings of Medicare

In the most recent Sunday New York Times, Jane Gross gives a devastating critique of Medicare's Failure to support the needs of the most vulnerable elders. It is must reading for all who care for frail elders, policy makers, and Medicare officials.

Ms. Gross brings interesting perspectives to the workings of Medicare. She is one of the nation's best health journalists, who has long focused on the needs of older persons and their caregivers. She is founder of the wonderful New Old Age Blog at the New York Times. But she also has a deeply personal perspective, stemming from years as a caregiver for her mother who was severely disabled from numerous health problems.

Ms. Gross indicts Medicare for generously funding many services that are harmful to frail elders, but providing little support for services that would actually help improve their quality of life. She notes that Medicare will pay for virtually any traditional disease focused treatment, irrespective of whether the treatment will actually help the patient. But it pays for virtually none of the supportive services, like a home health aide, that would actually help a frail disabled elder with basic activities of daily living.

Ms. Gross points out a central problem with Medicare. While it is health system for older patients, it has essentially been designed as if it were caring for well functioning younger patients. It provides care on a disease by disease basis, but ignores that with advancing age, many older persons have many diseases, and the single disease model of care often fails the complex older patient.

The central focus of care needs to shift as older persons become more frail and disabled. What would be tradional care for each individual disease is sometimes unwise. The focus needs to shift from each disease on the problem list to impact of the illness burden on the elder's functional status. Ironically, in many of these patients Medicare will pay for traditional disease focused care that is ineffective or harmful, but will pay nothing for less expensive care that may improve a patients quality of life and functioning.

Also missing from the current Medi"care" model is any insight that as an older person becomes more frail, the traditional disease focused model of care needs to be complemented with a palliative model of care that is focused on quality of life. But Medicare resists supporting Palliative Care in patients who are not eligible for hospice.

Medicare is a program for old people, yet the program seems almost ignorant about principles of aging. If the Medicare program were informed by basic principles of Gerontology and Palliative Medicine, it would greatly improve the quality of care provided to our nation's older persons.

by: Ken Covinsky (@geri_doc)

8 comments:

Christopher Langston said...

Thanks Ken - I think Ms. Gross's piece is really important to talk about.

When I read her litany of complaint about tube feeding at the end of life, hip replacements for people with such advanced dementia that they won't ever walk again, etc., the term that came to me (not that she used it) was PROFITEERING - a hard term, but inescapable.

You can add to the list of quesitonable "care" the recent findings about surgery rates in the last year/months of life from the Harvard group (including Jah and Gawande) and the rate of double CAT scans in a single day reported earlier this year. You can tell why Atul Gawande termed it a "Primal Scream" in his tweet on the story. (I was thinking "Cri de Coeur" but I think it's the same thing.)

Still,I don't really buy into her dichotomy of "medical care" versus "care care." I think it is a false juxtaposition that many people seem to feel. High tech is bad, so low tech must be good. Highly paid MDs are bad, so low paid workers must be good.

It is still my hope that if people get good medical care (including both health promoting primary and preventative care and not getting harmful/excessive care) that they will be independent longer and need less custodial care. They will also probably have more money in their pockets to pay for their own custodial/supportive long-term care needs.

Just becauase some doctors and hospitals are taking the low, profiteering, road doesn't make those providing supportive services are saints. I think we all know that there are problems with quality and appropriateness of care in SNFs, ALFs, home care, etc. There are heros and villans on both "sides."

I agree we don't want a system that makes irrational decisions, funding what people don't really want and making some people very wealthy in the process. But if we wanted to take Ms. Gross really seriously as a policy matter (rather than a justified expression of frustration and reminder of what happens in real people's lives) - we would have to raise premiums/taxes by quite a bit to make things like in-home paid direct care workers a benefit. I just looked at the Federal Employee LTCI calculator and for me at 50, the monthly premium for a 2 year, $150 a day "long" term care benefit (with up to 4% inflation protection) is $63 a month, over 50% of part current part B premiums. Even if we could reduce this premium by saving money on unnessesary care, it would still be a lot. The rather cold decision we have made as a society is that for the first 90-percentile of us, we should first exhaust our families, our savings, and then go on Medicaid and get shuffled into lowest common denominator institutions if we have serious long-term care needs. Perhaps we as a society should make a different choice and make LTCI a non-voluntary premium or tax funded program. But I don't see the consensus on this point.

ken covinsky said...

Thanks for your comments Chris. I agree we have to be careful to not oversimplify these problems.

I totally agree we need to be careful about setting up "medical care" and "care care" as a dichotomy. Most older patients need both at once.

I think the more important part of Ms. Gross' article was the primal scream--the frustration she expresses that there is something terribly wrong about how Medicare functions and the medical culture created by the disease focused approach of Medicare.

On the one hand, simply saying we need to fund more long term and supportive care without discussing how to pay for it can be naive and simplistic.

On the other hand, Medicare pays far more for the care of older persons than is spent in other western democracies. Yet, the life expectancy of seniors in the US is among the lowest of any of these countries.

I am beginning to wonder if there is at a least a partially causal connection between these two statistics. Is our disease focused, overly invasive medical culture harmful to some patients? Have we reached a point on the cost curve where much of our spending is getting us worse health? Is it possible to spend less (and use some of these savings for long term care and supportive services) and improve health at the same time?

Christopher Langston said...

Thanks Ken - I think we are in agreement. But your comments raise an interesting empirical question: how is the US doing on life expectancy at 65? I thought we were doing well relative to the OECD countries. I know that life expectancy from birth is lower for the US, but I thought later life, life expectancy was one of our few good things. The new Commonwealth fund report should tell us.

ken covinsky said...

In answer to Chris' question, here is the most recent data I was able to find on life expectancy at age 65 for men and women.

Between 1990 and 2008, life expectancy at age 65 has improved in most countries, but has improved less in the US than many other countries. As a result, the US now lags many European countries.

http://www.census.gov/compendia/statab/2012/tables/12s1340.pdf

Christopher Langston said...

Exactly right Ken, I guess I was remembering old numbers. Thanks for the correction - good to know (if a bit depressing). I mean I expect to be beaten by Japan and I don't care (I don't like fish very much) but being beaten by Australia? (2 years for men!) Its just embarassing.

The OECD data http://www.oecd-ilibrary.org/docserver/download/fulltext/8109111e.pdf?expires=1319384364&id=id&accname=guest&checksum=614646640C215A586E98348B6A8A5698

shows the same story as CDC. We are (as of 2007) at 24th out of 30 in life expectancy at birth, but at 17th on life expectancy at 65 and clearly most other countries have improved more since 1970 (the OECD base year). Women's expected years at 65 is 20.3 and men's 17.4.

As a curiosity, women and men don't track perfectly over countries - there are lots of places where the rankings would be different. E.g., Korea is 20.5 for women but only 16.3 for men. I suspect that this may reflect variable "extreme" male lifestyles of working and drinking.

Thanks again.

Anonymous said...

can't seem to post a comment. help!!! jane gross

you can answer at https/:www.facebook.com/JaneGrossAuthor where i cross posted.

Meryl said...

We have to consider the (often invasive) impact of seniors' families. We all see the damage done, and tensions aroused, by "well-intended" family members making (or pushing the patient to make) decisions that are not in the patient's long-term interest. Medicare policies and hospitals' bottom-line imperatives are rooted in outdated economics and may take more time to change. How about educational interventions with elders' family members?

Doctors must take the lead in being straightforward with patients and families. Don't spare the brutal reality of unnecessary "therapies." Explain what "quality of life" means, experientially.Fewer people will chose chemo,radiation,surgeries, intubation.

Fredrick said...

yes I agree we don't want a system that makes irrational decisions, funding what people don't really want and making some people very wealthy in the process. But if we wanted to take Ms. Gross really seriously as a policy matter (rather than a justified expression of frustration and reminder of what happens in real people's lives) - we would have to raise premiums/taxes by quite a bit to make things like in-home paid direct care workers a benefit. But here i think I think the more important part of Ms. Gross' article was the primal scream--the frustration she expresses that there is something terribly wrong about how Medicare functions and the medical culture created by the disease focused approach of Medicare.Hope you will agree thanks