Friday, June 3, 2011

The battle over cutting Medicare costs

A few months ago, I wrote a blog entry on new trends to provide cost-effective healthcare in the US. These trends are largely aimed at consumers, with the goal of allowing individuals to purchase high-quality services on a budget. However, the economic crisis around healthcare isn’t simply limited to individuals– with growing concern over the national debt, healthcare costs have become a political debate, with both parties agreeing that Medicare costs must be cut. Despite bipartisan agreement that the problem must be dealt with, arguments over how to cut Medicare are explosive – when Obama proposed cuts in 2009, he was branded as proposing ‘death panels’, and when Republicans proposed cuts to Medicare this year, they were treated to a similar backlash.

Emotions run high in the debate, and what makes sense on a global scale is hard to accept on a personal one. The majority of the proposed cuts are around medically unnecessary treatments, and most of those treatments occur in the last year of life as a person is dying. While it may be easy to acknowledge from a distance that prolonging life for a few weeks, weeks that will be spent in intensive care units, is unnecessary and in some ways only prolongs suffering, many people would hardly make such a judgment in the heat of the moment.

This discussion intersects somewhat with the issues posed by the Death With Dignity movement, which has raised questions about end-of-life care. For many imminently terminal patients, prolonging life at this phase is merely drawing out the agony, and in addition, it is remarkably expensive. Though Death With Dignity remains a small movement at this point, many of its beliefs intersect with those of the much larger hospice care movement. Hospice care provides nursing and medical care to the terminally ill and dying in a comforting, quiet, relaxed atmosphere – for many, it’s a welcome departure from the chaos of the hospital. An emphasis is placed on comfort, palliation of symptoms, and minimal medical treatments, rather than high force efforts to postpone death.

In addition to the amount of money spent on prolonging the lives of the dying, there are questions about money spent on medically unnecessary treatments and screenings for the elderly. The New York Times recently ran an op-ed article in their ‘Room for Debate’ series, which solicited opinions from doctors, economists, and other professionals on their opinion of what ought to be cut. The various authors point to a wide number of costly but unnecessary procedures that are performed largely with profit in mind. Examples include hip replacements for Alzheimer’s patients who would be unable to perform physical therapy after the replacement, and prostate cancer screenings for elderly men against the recommendations of the AMA.

The final missing piece of the puzzle, in my mind, is the crucial role to be played by primary care providers. Primary care is less expensive than specialty medicine, and keeps patients in their homes, rather than in hospitals. Additionally, the oversight provided by primary care physicians would prevent some of the unnecessary medical procedures performed. For example, a few months ago I saw in my practice a woman who had recently gone to the hospital complaining of chest pain. Given her age and family history, it was important to rule out a heart attack, and so a barrage of basic tests were run, all of which came back normal.  Up to now, everything had gone well – an elderly woman complaining of chest pain was assessed for a heart attack, which was ruled out. Unfortunately, as this woman lacked a primary care provider, no one was on board to let the hospital staff know that she suffered from anxiety attacks characterized by chest pain, and that, so long as it wasn’t a heart attack, she was fine and could go home. As a result, increasingly expensive and invasive imaging studies were perfomed, each indicating no abnormalities. Several thousand dollars later, I can conclusively say that this woman wasn’t having a heart attack, wasn’t having angina, and will probably live out the rest of her days happily free from cardiovascular disease of any sort.

This is, of course, just a story, and it doesn’t factually prove anything. But it does illustrate some of the broader problems in Medicare. Abuses are possible in part because of lack of oversight by primary care physicians, but also, as the New York Times points out, because the definition of ‘medically necessary’ is vague. Tightening the budget too much is likely to cause problems, but even so, significant amounts of money can be saved by eliminating medically unnecessary expenses.

I hope you enjoy the Times’ Room for Debate. A few months ago, the Times published an excellent interactive feature entitled You Fix the Budget. I recommend taking a look at it, not only to gain a sense of what programs contribute to our national debt, but also the proportion of the national debt that Medicare contributes. In our national effort to improve health, profiteering and irresponsible spending not only don’t improve health at the moment, but will probably have long-term negative health effects, as they may saddle our country with massive debt, which in turn may lower living standards.