Tuesday, November 18, 2008

Most of Our Medicare Money Is Spent on Cases We Don't Know How to Treat

Medicare spending is increasing at a rate the will bankrupt the system in very few years. Yet many are intent on expanding Medicare (or something like it) to cover an increasing percentage of the population as well as an increasing number of treatments. This trend is unsustainable.

Where do all those Medicare dollars get spent? Siri Carpenter reports, “Seniors with five or more chronic health problems account for two-thirds of Medicare spending….” Nearly all doctors (outside of pediatricians) treat patients in this category, but no clear guidelines exist for treating them.

Part of the reason for this is that patients with multiple conditions are excluded from medical treatment studies. Studies work well when variables are limited. Introducing multiple conditions complicates studies and can produce ambiguous results. With so many variables, how can you accurately derive the cause(s) of a given outcome?

So we are spending the vast majority of our Medicare dollars on cases for which doctors have no training or proven treatment strategies. Does this strike anyone as odd?

To make matters worse, Carpenter suggests that some of the conditions this group of people are experiencing result from the medications they are taking. Carpenter tells a horrific tale of how her once sharp mother slowly became mentally clouded and physically less able by age 61. She was taking 21 medications prescribed by five different physicians for a number of conditions.

I saw something similar with my Dad during the last two years of his life. I built a spreadsheet to help my Mom keep track of all of Dad’s meds following his stroke, but meds and dosages changed so frequently that it was a nightmare. Every doctor wanted a detailed list of everything Dad was taking. We did our homework and listed all possible side effects and drug interactions.

Every specialist insisted that Dad take the drugs they prescribed. When we pointed out potential drug interactions, our concerns were usually pooh-poohed. If you asked about anything another specialist was prescribing, the doctor would get this deer-in-the-headlights look and would clam up, out of professional courtesy. Each of these highly skilled and highly paid physicians knew about the drugs they dealt with every day, but didn’t know much about the multitudes of other drugs they were licensed to prescribe.

When we brought up specific questions about drugs, almost every specialist Dad saw told us to consult with Dad’s primary care physician. I liked Dad’s primary care doctor. He’s smart and dedicated. But he also rarely provided satisfactory answers about the horrendous drug cocktail Dad was consuming.

A couple of weeks after Dad was released from intensive care following a drug interaction that nearly killed him, he started getting seriously goofy. It was bizarre to see this man that had prized his sharp analytical mind acting in mindless ways. We were referred to a psychologist that specialized in treatment of seniors. After a very thorough examination, the doctor said that Dad was getting senile and that we simply needed to adjust to that fact. He strongly downplayed any possibility of drug induced mental problems.

A few weeks later, Dad went on strike. He simply refused to take any more drugs. Mom was beside herself. She argued that he simply had to take the drugs. He said he didn’t care if he died or had another stroke. If Mom gave the meds to him, he would just wash them down the sink.

Life was pretty harsh for Dad and Mom for about three weeks. Then Dad’s mental fog cleared and he became a rational person once again. I realized that he had been going through withdrawal symptoms during those weeks. Once it was clear that the drugs had caused Dad’s mental issues, I was pretty upset with the psychologist.

It turns out that this kind of thing is quite common. Like Siri Carptenter’s mother and my Dad, many seniors are seriously overmedicated. There is no competent coordination of all of the different prescriptions these people are taking. Each doctor knows little of the drugs prescribed by other doctors and each is afraid of saying anything for fear of offending another doctor. They’d rather see patients suffer than embarrass a colleague.

As Carpenter notes, doctors also tend to misdiagnose the problem of overmedication, assuming that the patients are naturally getting sicker. This leads to prescription of even more meds, causing a nasty spiral of diminishing life quality.

In our medical system, the patients are generally not the customers. In most cases, the actual customers are the government and/or the insurance companies. The patients are the products and system engenders extremely shoddy quality control. Cost control is pretty poor as well, although, the main role played by the actual customers is supposedly to contain costs.

What is lacking in this system is a concerned advocate for the patient. For most other products and services in our society the customers act as advocates for themselves. But in medicine, when the patient is not the customer, nobody adequately plays the role of the patient advocate, especially when a patient’s judgment becomes clouded.

Players in the system act to satisfy their own goals according to the incentives in the system. This is not to say that they are bad or uncaring people. In fact, most of them mean quite well and want to help people the best they can. But the system provides inadequate incentives and information for accomplishing that. And no matter how concerned a player might be, he/she simply cannot adequately replace the quality of concern that comes from proper customership.

We have screwed up incentives in our medical system today. More Medicare is not going to solve this problem.


bekkieann said...

You make a compelling case, and probably anyone reading this can offer a similar experience. But what is the solution? Do we start telling doctors how to treat and what to prescribe? I don't think that's the solution either. I want my doctor to be able treat me according to his professional opinion. But I agree I need to be my own advocate and a smart consumer. That's a lot harder for older people to do.

So you have ideas for improving the system? My young friend at work jokingly suggests euthanasia for everyone over 65. If we start arbitrarily cutting back on elderly medical care, it might end up being something close to that.

David said...

We cannot start "arbitrarily cutting back on elderly medical care." What we need is voluntary cutting back on end of life medical care. I remember reading somewhere that something like 80% of money in health care is spent on end-of-life care.

We need a culture where people work to maintain their health throughout there life (reducing their medical costs) and then know when it's time to let go. I think my grandmother was a good example of both of those principles. She was very healthy into her 70's and then she went on oxygen for a number of years (one of those tanks she could walk around with). She then caught pneumonia in the winter of 2005. After a couple of weeks in the hospital with complications steadily piling up she chose to be taken off of life support and she dies soon after. Her end of life care was much less expensive than it could have been because she did not need to cling to every possible avenue for treatment when she could see that her options were to die or to have an expensive but empty non-life.

We could never mandate such a thing, but we could develop a culture that knows how to let go so that individuals can make there own choices about when enough is enough.

Reach Upward said...

Careful there, David. It sounds too much like you're promoting euthanasia. While I don't believe that a culture of life means that we have to unnaturally keep ourselves alive past our time, it is important the proper respect for life be built into the system.

Bekkieann, the answer is less government intervention in health care. We do not today permit the market to dictate how many of which kinds of doctors we can have. Government regulations control how many of which kinds of doctors can go to med school.

Couple this with the government and insurance companies dictating minute details of what doctors must do and how many patients they must see, and you end up with shortages, such as the shortage of primary care physicians and OBs. It's getting harder to attract people to these jobs because work life and business life stinks for these people.

We need less government control of the system. We need less insurance coverage. We need to scale back to insurance being for catastrophic issues and not garden variety medical issues. We need to remember that insurance is not the important commodity here; actual and valuable service provided to the patient is.

You ask what I would suggest instead of the quasi-socialist mess we have today. I had an entire series of posts on that earlier this year. Rather than re-hash those, I'll put up a list with links to those posts.

phreighter said...

I agree with certain aspects of what both David and Beckkie said. I have been a registered nurse since '83. I have been in the medical field since 70. I have extensive ICU and ER experience. A long time ago, I lost count of how many times I had to do CPR and defibrillate someone who had no chance of surviving because of Goverment regulations. Just in case you dont know, defibrillation is the process of electrocuting the heart to "kick start it". It hurts like nothing you can imagine. It's worse than sticking your finger in a socket....lots worse. We need to cut the expenses of end of life expenses and stop govermental interference as well. The medications you refer to are amazingly complex and diverse. I've met very few people in my life that have a good understanding of more than half of the medications currently in use. I definitely agree that many elderly individuals are overmedicated and have medication interactions that are detrimental to the patient. You have to stop for a minute and realize that although our science is quite advanced, we still have a lot to learn. At this point in time, we know more than any one individual can grasp, yet we have much more to learn. This issue is somewhat like the energy crisis we are now it. We have the ability to use energy very efficiently at this point in time, but are generally unable to do so. I am of the belief that governmental restrictions on ANY type of scientific research are inappropriate. Of course, I do understand that if you are studying something that might make a big boom and large hole in the floor, that should be monitored, but not restricted. Perhaps one day humans will be able to accept the fact that we all die. Perhaps our governments will develop the compassion to let our doctors and nurses allow the individuals to die as well. Until the government changes the laws, the medical profession is required to keep you alive at all costs until you are brain dead or a relative tells them to stop. The pain and suffering an individual goes through at the end of life due to the medical professionals keeping them alive is immeasureable.

Reach Upward said...

Phreighter, thanks for your insightful comments. A recent study shows that patients and families far prefer to be leveled with about a realistic prognosis of life-threatening conditions than strung along with hopeful vagueries. Not only does this help with proper planning, it helps with the grieving process. There is far less anger.

Fortunately for my family, last spring Dad's cardiologist leveled with us kindly but forthrightly. Dad's heart was gradually decreasing its functionality. He said that Dad should only take the meds he needed and wanted in order to be comfortable, since all other meds were pretty much without purpose at that point. He urged us to coordinate with hospice.

Within a couple of weeks, Dad's condition had declined to the point that we couldn't adequately care for him ourselves. We wanted to go to a care facility, but Medicare rules required us to take him to the hospital for at least three days first. After three days in the hospital, it was clear that the end was near, so we just kept him there for a few more days until he passed.

I am somewhat chagrined about the Medicare rules, which were partly influenced by hospitals and insurance companies wanting to make sure they get a cut of the action before dying people go to a care facility. Politically motivated medical decisions are rarely in the patent's best interest.