Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, March 16, 2003
    OK, let's talk Medicare reform. God knows we need it. With the population over age 65 continuing to increase, and the cost of drugs which can keep people alive and out of the hospital also increasing, something has to be done. As it stands now, many elderly have no drug coverage or insufficient drug coverage and are faced with very high drug costs; reimbursement rates to doctors for many procedures as well as general preventive care are being cut annually; many patients are being cut loose from their senior managed care plans (which offer drug coverage) with minimal warning, as insurers are leaving this market due to high losses.

    The plan as currently proposed by President Bush would offer three options:

    1. Stay in traditional Medicare. For those of you who don't know the details, currently Medicare has no drug coverage whatsoever. It also does not cover long term or "custodial" care. It will cover up to 100 days per year of skilled nursing care, if the patient qualifies (in other words, if the patient needs tube feedings, IV antibiotics, physical therapy, or special nursing care for wounds). Many screening blood tests and examinations are also not covered by Medicare - you must show medical necessity (in other words, certain blood tests will be paid for by Medicare if you have diabetes, but not if you don't). It mainly covers hospitalization costs, and most outpatient medical costs. It has a reputation as being the universal coverage that all doctors will accept; lately, however, that is no longer the case. Many doctors are refusing new Medicare patients due to falling reimbursement rates.

    Medicaid, the state health coverage plan, will cover drugs and also covers long-term custodial care. It's a backup plan and can be very useful, if the patient qualifies financially (essentially, you have to be broke). It's also possible to buy backup insurance for drug coverage, but this costs about $400 per month.

    Under the Bush plan, patients who stay in traditional Medicare would get little in the way of drug benefts. They'd get a discount card which would reduce drug costs by 10 to 25%, and annual drug costs would be capped at some amount between $5500 and $7000.

    2. Switch to "Enhanced Medicare," a proposed plan that would have patients join a private plan with some elements of managed care; would probably offer more drug benefits than traditional Medicare. There would be some restriction of access to specialists, namely, if patients chose to see an out-of-network doctor it would cost them more. The health plans would be able to design their own menu of drug benefits as long as they met a federal standard of required benefits (which hasn't been designed yet).

    3. Enroll in "Medicare Advantage" - an updated version of the Medicare+Choice program. This plan was begun in 1998 to offer managed care to seniors at a lower cost. This would be the cheapest of the programs to join. There would be fewer choices among physicians. This could work, but only if the government commits to offer insurers a guaranteed level of reimbursement; otherwise we'd see the same scenario as noted above, with insurance plans fleeing en masse from senior managed care due to financial losses.

    Meantime, in the news this week we now see that the FDA is backing the pharmaceutical industry in restricting the purchase of drugs from Canada. It's looking more likely that patient access to this means of reducing drug costs will soon be denied.

    So, Dr. Alice, how would you fix this problem?

    Uh. Well. I have a few ideas. Blogger keeps eating my posts, so I am going to try to condense this. The first thing is to face facts and realize that increasing coverage for health care will increase overall costs, pure and simple. So I would look at ways to reduce the cost of providing care in other ways.

    First, tort reform. I don't think this is the biggest cause of high healthcare costs, but it certainly is one of the main causes. Soaring malpractice rates are forcing doctors out of practice in some areas. Obstetric care is essentially unavailable in places like Nevada, where OB-GYNs are refusing to deliver babies (they can't afford the insurance; it can cost upwards of $200,000 per year). Tort reform would keep docs in practice and improve access for patients. It would also lower the cost of many valuable medical treatments such as vaccines, IUDs and pacemakers.

    Next, and I realize I may get flamed good for this... take a serious look at rationing care. I am serious. Let me give you one example: during my stint working in the hospital two months ago, one of my patients was an elderly woman who had been in Intensive Care for some weeks. She had been admitted with pneumonia, intubated and placed on a ventilator, then developed renal failure and was begun on dialysis, then developed fungal pneumonia (a death sentence). Every doctor involved in her care (and believe me, there were several) agreed that further treatment was futile. She was kept alive for another two weeks simply so that her son could fly out from New York to Los Angeles to make a decision on her care. By the time I picked her up, the unit team was marking time waiting for the son. I was there the day he arrived and spoke with him; it took him five minutes to make the decision to withdraw care.

    How many thousands of dollars were spent on this Medicare patient the last ten days of her life, in the knowledge that none of it would do any good? How many other people could have been helped with that money? I've discussed this issue with a lot of other doctors in the past few months. Every one of them has said, essentially, "The only way to lower health care costs is to lower our standards of care." Maybe that means we prioritize things like mammograms, vaccinations, well baby checks and Pap smears. Maybe that means that organ transplants go to the bottom of the list. Maybe that means that patients over 80 don't get the option to be intubated or put in the ICU or dialyzed.

    If we as a nation really want to reduce health care costs, that's what it's going to take. But it would be political suicide to admit it.



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