To Save Medicare, Talk to Patients and Stop Spending on Things That Don’t Work

Just about every discussion on the Hill about “saving Medicare” these days is talk about decreasing reimbursements to providers and health plans.  There’s also a lot of talk about preventive care — and yes, I’ll say it — prevention has little potential of saving money in Medicare.  You can’t prevent away heart disease or diabetes in elderly patients; you might postpone it but you will eventually pay.  Medicare is still, fundamentally, an end of life program — 1 out of 4 Medicare dollars are spent in the last 6 months of life.  And it’s unsustainable in its current form.  So there’s only two real solutions: to talk to beneficiaries about their wishes for their end of life care; and to stop spending money on things that don’t work. 

Last week in The Lancet Harvard researchers found that among 1.8 million Medicare beneficiaries who died in 2008:

• nearly 1 out of 3 had surgery in the last year of life;
• nearly 1 out of 5 had surgery in the last month of life;
• nearly 1 out of 10 had surgery in the last week of life.

Those are astounding numbers, and controversial.  Of course many of those procedures were performed to relieve suffering or to prolong life.  But the researchers said they know from experience — as all of us do in eldercare — that doctors often operate to fix something but that will not save a dying patient — to avoid the difficult conversations with patients and caregivers about their prognosis and what they want.  So often it’s “cut to cure” fix-it docs and adult children, with too much drama and way too little information, driving these decisions — not the patient, long in advance of the care episode. 

The New York Times noted that In the last year alone, what researchers have found both useless and harmful, according to leading medical journals:

• Feeding tubes, which can cause infections, nausea and vomiting, rarely prolong life. People with dementia often react with agitation, including pulling out the tubes, and then are either sedated or restrained.

• Abdominal and gall bladder surgery and joint replacements, for those who rank poorly on a scale that measures frailty, lead to complications, repeat hospital stays and placement in nursing homes.

• Tight glycemic control for Type 2 diabetes, present in 1 of 4 people over 65, often requires 8 to 10 years before it helps prevent blindness, kidney disease or amputations. Most don’t live long enough to reap the benefits, and so endure needle sticks and diet guilt in their last days.

We all have our own experiences and anecdotes.  Medicare routinely pays for hip replacements for Alzheimer’s patients, even though most couldn’t complete physical therapy for rehab and resume activities of daily living.  Last year my 96-year-old grandfather suffered through a $120,000 back fusion surgery he didn’t want or need (he hasn’t been out of his motorized scooter in 5 years) but his doctor and local community hospital insisted he have.  What did he want? “A lethal dose paid for by Medicare Part D.” Last month he failed his second suicide attempt.  We just want him to find some peace — and he’ll never find it at the end of a surgeon’s blade.

We don’t talk enough about how we want to die in this country. I think we honor one’s life by allowing them to die with dignity, the way they want to go.  These are not conversations most doctors like to have, but they must occur if we’re to bring any sense to Medicare expenditures. We no longer have the luxury of a wide-open entitlement program.

Since the Terri Schiavo circus we have lived in an age of distortions like “Death Panels,” where open dialogue on end of life is politicized and limits on what Medicare will cover are demogogued as rationing.  But Medicare Advantage plans are uniquely positioned to advance the cause of professional counseling for beneficiaries on their last wishes, preventing unnecessary surgeries based on the patient’s preferences and likely clinical outcomes, and promoting the enthusiastic use of palliative care.  A number of plans are leading quietly in this area, like UPMC in Pittsburgh, Excellus Blue Cross/Blue Shield in upstate New York (which actually has dedicated medical directors for end of life and palliative care), and any PACE site like On Lok in San Francisco.  We have much to learn from them — they should be applauded and emulated for their courage in the face of the politics of end of life care.

There are few more personal issues than end of life counseling and care.  These are thoughts … I’d love to hear yours.