Archive for the ‘geriatrics’ Category

Update on cash medical practices.

Tuesday, October 29th, 2013

Titanic; Vancouver; 1912

I can’t resist this graphic as a metaphor for the present health care crisis.

Some time ago, in fact several years ago, I posted a piece on coming changes in health care. I didn’t necessarily recommend this for reform but it was something I saw coming.

Perhaps more than most people, Reitz, a senior HIV?AIDS scientist with the Institute of Human Virology in Baltimore, appreciated the need to be examined quickly. And thanks to a recent trend to help personalize physician care, he got an appointment the same day — but not because of his professional status.
Reitz, like any patient of Dr. Philip Henjum, can get a same-day appointment because Henjum and his partner, Dr. Robert Fields, practice retainer medicine in their Olney office.
Their patients pay a $1,500 annual retainer fee to see them as soon and as many times as they need to. They also make house calls.
As it turned out, Henjum diagnosed Reitz with Lyme disease, an infection from a tick bite, and prescribed antibiotics. If not diagnosed and treated early, Lyme disease can lead to severe headaches, muscle pain and serious heart problems.
Fields and Henjum are two of about a dozen doctors in Maryland and an estimated 600 nationally who won’t take insurance coverage. Instead, they charge a yearly or monthly retainer. Some work out of comfortable medical office such as Fields and Henjum, next to Montgomery General Hospital.

That was 2009. I added another post on Chicago Boyz in 2010. Here it is.

The reason why I believe this trend is growing rapidly is that some states, like Massachusetts, plan to pass laws requiring doctors to accept Medicare as a condition of licensure. If they were not worried, why write a law about it ? Medicare has a provision that they determine the price and there are no extra charges allowed.

A participating physician agrees that payment for Medicare services based on the fee schedule represents the approved and full charge. This means a physician cannot collect or balance bill an amount in excess of the approved charge listed on the fee schedule for services furnished to Medicare patients.

That, plus the rationing, drives most primary care doctors out of the field or, more recently, out of Medicare. Those who remain, hire Physician Assistants or Nurse Practitioners to see Medicare patients. That works for a while but PAs and NPs are still expensive.

With the passage of Obamacare, Forrest says he’s seeing more physicians aggressively search for alternatives, as he once did. Over the years, he’s helped a couple of dozen offices open across the country, and he’s started speaking at industry conferences about his practice. But in recent months, he’s been flooded with inquiries from fellow doctors. “Since the health care reform bill passed, you wouldn’t believe the number of doctors who have said they’ve had it and want to operate outside the system,” he says.

Now, Obamacare is here and we are seeing the first glimmerings of the problem coming into focus.

This was a week ago.

Health plans are sending hundreds of thousands of cancellation letters to people who buy their own coverage, frustrating some consumers who want to keep what they have and forcing others to buy more costly policies.

The main reason insurers offer is that the policies fall short of what the Affordable Care Act requires starting Jan. 1. Most are ending policies sold after the law passed in March 2010. At least a few are cancelling plans sold to people with pre-existing medical conditions.

By all accounts, the new policies will offer consumers better coverage, in some cases, for comparable cost — especially after the inclusion of federal subsidies for those who qualify. The law requires policies sold in the individual market to cover 10 “essential” benefits, such as prescription drugs, mental health treatment and maternity care. In addition, insurers cannot reject people with medical problems or charge them higher prices. The policies must also cap consumers’ annual expenses at levels lower than many plans sold before the new rules.

But the cancellation notices, which began arriving in August, have shocked many consumers in light of President Barack Obama’s promise that people could keep their plans if they liked them.

Just for curiosity, I did a search on cash medical practice in Orange County CA.

The results were interesting. Among other things, I found a bunch of family practices for sale.

I also found a long list of practices that accept cash. Quite a few have good Yelp reviews. For example:

regular physician normally does! And I was only charged $75 for the visit! (To put that in perspective, my PPO insurance copay would have been $60 had I waited another week for an appointment.

There are 15 pages of reviews. Children’s Hospital is even listed as taking cash: for his recent cold. Parking is underground $7 they take checks and cash only. Parking distance from emergency entrance is very close. We checked in soon after we were called, minimal wait… No mention of costs here but a good review.

The possible outcome of all this, and I don’t believe that employer health plans will survive, is a new system of cash payment for primary and routine care plus insurance for insurable events. That’s what we had in 1950 and it worked well. Doctors didn’t get rich but they often ran their offices with one person helping, sometimes the wife. I remember an orthopedic surgeon and family friend whose office had one large waiting room and telephone person for about 30 doctors. He was later the team physician for the Chicago White Sox so he was no slouch. He also did the first cup arthroplasties in Chicago. One of them was on my aunt.

The medical world will be changing.

The Lost Boys

Saturday, March 2nd, 2013

Belmont Club has an unusually good post for yesterday. I could say that more than once a week, if truth be known. This one is quite to the point on Sequester Day.

The NHS, which its creators boasted would be the ‘envy of the world’, has been found to have been responsible for up to 40,000 preventable deaths under the helm of Sir David Nicholson, a former member of the Communist Party of Britain. “He was no ordinary revolutionary. He was on the hardline, so-called ‘Tankie’ wing of the party which backed the Kremlin using military action to crush dissident uprisings” — before he acquired a taste for young wives, first class travel and honors.

The NHS is dealing with the shortage of funds by pruning its tree of life, so to speak. He also does not tolerate anyone telling the truth about it.

it emerged he spent 15 million pounds in taxpayer money to gag and prosecute whistleblowers — often doctors and administrators who could not stomach his policies.

The public money spent on stopping NHS staff from speaking out is almost equivalent to the salaries of around 750 nurses.

It has recently been noted that NHS staff no longer recommend their own hospital for family members. Also one quarter report being harassed or bullied at work.

The other half of the equation involves the youth.

The European Youth will remain outside the Death Pathways for some time yet. But they will spend the time waiting for their turn at affordable, caring and passionate medicine in poverty and hopelessness. With the exception of Germany youth unemployment in Europe is over 20%. “A full 62% of young Greeks are out of work, 55% of young Spaniards don’t have jobs, and 38.7% of young Italians aren’t employed.”

Unemployment exceeds even our own Obama economy for failure. (more…)

A big day tomorrow.

Wednesday, June 27th, 2012

The US Supreme Court will probably announce the decision on Obamacare, known by its supporters as “the affordable care act,” tomorrow. If it is overturned, as I sincerely hope, there will be the need to provide an alternative. I don’t trust Obama to accept the verdict anymore than he accepted the partial victory for Arizona. His antipathy to that state is palpable and is demonstrated by this laughable headline.

Official: Obama administration will enforce its priorities, not Arizona’s

The fact that Arizona’s priorities include US law enforcement notwithstanding.

Obama administration officials said Monday the federal government would not become a willing partner in the state of Arizona’s efforts to arrest undocumented people — unless those immigrants meet federal government criteria. And they said the administration is rescinding agreements that allow some Arizona law enforcement officers to enforce federal immigration laws.

The administration made the announcement hours after Monday’s Supreme Court decision on whether states can enforce immigration laws.

The fact that Arizona wants to enforce a federal law that the feds are not enforcing is ignored. There is a reason why CNN was called “The Clinton News Network” in the 1990s.

I expect something similar if the Court strikes down Obamacare. The law is massive, unwieldy and still a mystery to most of those affected.

Opinions on the law and its provisions are available here. Topics include age based medicine. Here is where rationing will be applied in spades.

It is unfortunate that one cannot engage in a dispassionate and objective analysis of the Progressives’ ideas on age-based medicine and end-of-life healthcare without being immediately accused of invoking “death panels,” and thus of displaying the dearth of sophistication, the lack of understanding, and the primitive logic commonly attributed by Progressives to Sarah Palin.

I must remind my readers that I have yet to use the term “death panel” to refer to any of the multitude of expert commissions created by Obamacare, whose charge will be to dispassionately examine the scientific evidence in order to determine which patients will get what, when and how. These bodies, in fact, will be explicitly aiming to optimize the medical outcomes of the entire population (titrated to the amount of money we’re allowed to spend on healthcare), and not actively prescribing death for anyone.

Judging from the histories of governments which have adopted a collectivist philosophy, if death panels should appear on the scene they will not be aimed at determining which patients may live or die. That job, of course, will fall to the doctors at the bedside, who will offer or withhold medical services according to the dictates (i.e., “guidelines”) handed down by those sundry expert commissions. Rather, any death panels which might eventually materialize will more likely be aimed at keeping those doctors themselves (and any other functionaries whose job is to do the bidding of the Central Authority) in thrall.

So why has the term “death panel” caught on to such an extent that conservatives so often use it as shorthand to express what they see as the “sense” of Obamacare, and Progressives so often use it to accuse rational and mild-mannered critics of Obamacare (such as your humble author) of belonging to the Neanderthal persuasion? Read the rest.

Anyone who has done some reading about health care in other countries, such as the UK or the Netherlands knows what this means. In the Netherlands, ten years ago, any physician who admitted a chronic lung (COPD) patient to ICU with respiratory failure would be looking for a job the following day. The burden will always fall on doctors, which is why we are so interested. The stories of delay in admitting critically ill patients to the ER in the UK are another cure for boredom.

The French have some interesting ideas about such issues as pre-existing conditions, which will no doubt be a prominent issue if the USSC acts tomorrow as I expect. In the French system, certain conditions that affect insurability are covered by the plan 100%. However, the coverage is ONLY for the condition, such as Diabetes, and not for unrelated conditions, such as appendicitis.

Some cases are eligible for exemption for co-payment. Serious medical conditions such as diabetes, cancer and AIDS are exempt. The exemption pertains only to the diagnosis and other conditions require co-payment. A cancer patient with appendicitis, for example, must pay the regular rate for the surgery. More complex services and hospital stays over 31 days are also exempt. The exempt class of patients, such as children, maternity and war pensioners are the third category.

I spent some time several years ago analyzing alternatives to what became Obamacare. Those blog posts are here. The history and evolution of the French health system are included. I think it offers the best model for the US to us for reform. Of course, Obamacare has nothing similar to the French plan. It was designed to appeal to rent seekers in the health care industry.

More will be added tomorrow.

UPDATE: Well, we now know that the Court upheld the constitutionality of Obamacare. This is disastrous for the health care system that we have, although it has deteriorated since 1978 when the government began trying to rein in health care costs under the guise of “improving quality.” The rationale for approving it was that the “Mandate” is a tax, not a fine. The politics of the decision are not yet clear and may not be before November.

No doubt Obama and his supporters will hail the decision as a victory and it may well be so. My concern is with the effects of the law, itself. It is not reform and it is not workable. The question I have is whether the law will be recognized as unworkable before it has destroyed the present system. I fear not. For those who want to understand the effects, I suggest reading this explanation of health insurance and why the insurers supported Obama. Note this statement:

In return for its support in the healthcare reform battle, President Obama offered the insurance industry the graceful exit strategy it so desperately needed. Under Obamacare, for at least a few years the insurers hope to get One Last Windfall – namely, profits from the influx of previously-uninsured Americans whose premiums will be paid, or at least subsidized, by taxpayers. Here, the insurers are relying on the likelihood that the inflow of new premiums will, for a year or two at least, greatly outweigh the outflow of money they will have to spend caring for these new subscribers. Obviously, they will use every trick in their well-worn book to stave off expenditures for these new subscribers for as long as they can, but if they actually knew how to avoid paying healthcare costs indefinitely, they wouldn’t be seeking a government bail-out today. In any case, an inflow of new subscribers will be a very temporary source of profit for insurers. Hence, at best it is One Last Windfall.

What happens to the insurers after they exhaust this last windfall is still up in the air. Obamacare may, of course, eventually transition to a single-payer system, an outcome which many conservatives desperately fear, and many liberals fervently desire. In this case, there may very well be some final compensatory buy-out (or a buy-off) for the insurance companies. But more likely, the insurance companies under Obamacare will continue to exist essentially as public utilities. That is, they will exist as companies chartered by the government, which administer healthcare under the direction of the government, with the products they may offer, the prices they may charge, the profits they may keep, and the losses they may incur, determined solely by the government. It’s not glorious, but it’s a living.

This, in fact, is the business plan of health insurance companies. They view HSAs and other conservative attempts to control costs by modifying behavior as the enemy.

Cash medical practice

Friday, May 21st, 2010

I am also blogging at Chicago Boyz and have a new post up there about the trend to cash practice. Rather than repost it here, I suggest you look over there for the post. That is a very interesting blog and I was flattered to be invited to be a member.

Guidelines, best practices and rationing.

Monday, February 1st, 2010

Jerome Groopman is an oncologist who has written many articles about medicine. He has a good piece in the New York Review of Books, a generally left wing publication. He is writing about “best practices,” which are the basis for many guidelines for care.

One of the principal aims of the current health care legislation is to improve the quality of care. According to the President and his advisers, this should be done through science. The administration’s stimulus package already devoted more than a billion dollars to “comparative effectiveness research,” meaning, in the President’s words, evaluating “what works and what doesn’t” in the diagnosis and treatment of patients.

But comparative research on effectiveness is only part of the strategy to improve care. A second science has captured the imagination of policymakers in the White House: behavioral economics. This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions; its adherents believe in policies that protect against unsound clinical choices. But there is a schism between presidential advisers in their thinking over whether legislation should be coercive, aggressively pushing doctors and patients to do what the government defines as best, or whether it should be respectful of their own autonomy in making decisions. The President and Congress appear to be of two minds. How this difference is resolved will profoundly shape the culture of health care in America.

Best practices may be derived in two ways. One is by clinical research, usually involving randomized clinical trials. In this sort of study, two groups of patients are chosen to be as alike as possible. One group is randomly selected from the total and given a drug or other treatment under study. The other group is given a placebo. One fact to be kept in mind is that placebos are quite powerful in some situations. They will produce up to 30% measurable improvement in most diseases. This, of course, is psychological but it still works. In World War II, Henry K Beecher discovered an interesting phenomenon while treating wounded troops at the Anzio Beachhead. He found that even seriously wounded men had little pain. When he investigated this, he found that most of them had been in combat in constant fear of death. The wound was seen as an escape from that risk of death and was seen in many ways as a beneficial event. The term “Million Dollar Wound” was a common term used for a wound that was serious enough to remove the wounded man from combat but not so serious that he would die or be crippled for life.

He later studied soldiers who had been seriously injured in other settings, such as road accidents similar to civilian injuries and found that they reacted much more like the civilians than like the combat soldiers. In 1955, he published a famous book titled “The Powerful Placebo.” Those who would choose what treatment should be approved and what should be rationed would do well to keep that in mind. Furthermore, people react in many different ways to the same drug.

The other principle method of writing best practice guidelines is by “consensus.” That means a group of experts meet and discuss their opinions until the group arrives at a recommendation. This may be better than nothing but may also be influenced by the life experiences and prejudices of academics, who comprise most of these expert panels.

Groopman goes on to discuss failures in rigid guidelines and whether the Obama administration plans coercive measures to enforce guidelines that may be faulty.

Medicare specified that it was a “best practice” to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this “best practice” was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).

There are many other such failures of allegedly “best” practices. An analysis of Medicare’s recommendations for hip and knee replacement by orthopedic surgeons revealed that conforming to, or deviating from, the “quality metrics”—i.e., the supposedly superior procedure—had no effect on the rate of complications from the operation or on the clinical outcomes of cases treated. A study of patients with congestive heart failure concluded that most of the measures prescribed by federal authorities for “quality” treatment had no major impact on the disorder. In another example, government standards required that patients with renal failure who were on dialysis had to receive statin drugs to prevent stroke and heart attack; a major study published last year disproved the value of this treatment.

His conclusions are that the coercion may very well be part of the health reform bill although that bill now seems to be on hold. All the parties to these new rules, of course, disclaim any interest in reducing cost by restricting access to free choice in treatments that may not be supported by best practice guidelines. The problem is that randomized clinical trials are only possible in a small proportion of health care choices. Surgery does not lend itself to such trials for obvious reasons although a few have been done. This topic reminds us of the authoritarian tendencies of the “progressive” and the threat to free choice in healthcare.

More on cash practice of medicine

Tuesday, January 19th, 2010

I have previously posted on the topic of doctors dropping out of Medicare and even private insurance and establishing cash-only medical practices. Here is another study of this phenomenon.

A few health insurers recognize the value of these services and reimburse enrollees for them, but concierge practices usually cater to cash-paying customers. Thus, they may be especially useful to patients who have a consumer-driven health account – such as a Health Savings Account (HSA), a Flexible Spending Account (FSA) or a Health Reimbursement Arrangement (HRA) – and to the uninsured.

A major consideration for the HSA patient is the fact that medical fees are grossly inflated by Medicare and insurance companies that draw up contracts with physicians including “discounts” from imaginary retail prices. When I retired from private practice, I had 176 contracts with various insurance companies and HMOs. Medicare will punish a physican who provides a cash discount to a patient. Balance billing is also prohibited.

The result has been reluctance on the part of physicians to see Medicare patents or HMO patients, both of which have poor reimbursement schedules.

* The proportion of people reporting problems seeing their primary care physician rose from less than one-quarter (23 percent) to one-third over the four-year period.
* Nearly one-quarter reported problems taking time from work to see a physician.

Here is one model.

Take DocTalker Family Medicine. This is the Virginia medical practice of Dr. Alan Dappen. Patients can schedule an in-office appointment or even request a house call, but about half of his consults are by e-mail or telephone.

Like an attorney, Dappen bases his consultation fees on the amount of time required. All patients must have an initial face-to-face consultation to establish care. There is no membership fee, but patients who prepay $300 annually receive a discount of about 25 percent. Each five-minute phone consultation or e-mail consultation costs $25. Nonmembers can buy services a la carte for $33.33 per five-minute block after a $150 initial check-up.

The office does not bill insurance companies for services, but most patients can easily file their own claim. Patient records are kept electronically for easy access.

The other common model is the “retainer practice” model.

Concierge medicine is normally associated with personalized services for the wealthy. These services can sometimes be expensive – in some cases more than $2,500 per year per person. However, in suburban Collin County north of Dallas, Texas, physician Nelson Simmons offers a version of concierge service for less than $500 per year. Aimed at small business employees who would otherwise likely be without employer-sponsored insurance, Simmons’ practice has attracted about 70 small business owners who pay $40 per employee per month. In return, employees get same-day primary care services and steep discounts on diagnostic tests and specialist care. Enrollees must pay out-of-pocket for specialist care, surgeries and diagnostic tests – but Simmons negotiates the rates, which are typically much lower than what others pay.

The $2500 usually includes all primary care services for the same annual fee. Doctors are starting to drop out of the old insurance model and this bodes ill for the corporate model of Obamacare.

Geriatrics and health reform

Monday, September 7th, 2009

The fastest growing segment of the US population is the elderly over the age of 85.

The fastest growing segment of the older population is the oldest old — that is, those ages 85 and older. They are projected to total 6 million as early as 2010, twice their 1990 level. Beginning in 2031, when the baby boomers will begin reaching 85, the number of oldest old will increase rapidly. The 85-and-over population is expected to grow fivefold, from 4 million in 2000 to 21 million by 2050.

This group is of particular concern to policymakers and planners because people ages 85 and older are more likely to be disabled than “young” elderly, ages 65 to 74.

In fact, I believe that the frail elderly, those over 85, are not the most expensive segment of the elderly to care for. They are the healthy portion of the population since those with poor genetic makeup or with bad habits are gone. They tend to be more fit than those with poor health, dementia and early death.

In 1995, I wrote a grant proposal to study the care of this elderly population by providing on-site care in assisted living facilities within an 8 mile radius of UCI medical center. Here are some basic data about Medicare beneficiaries in 1995. The changes since that time are chiefly a shift to the right in age in all studies.

In the fee for service sector of Medicare only 21% of beneficiaries used Part A services in 1995, although 84% of beneficiaries had Part B claims, indicating some covered medical service use. Median total expenditures per beneficiary were $884 per year in 1995, a modest amount indicating the small size of most claims. High expenditures are concentrated in a small percentile of the population. The top 2% of beneficiaries spend as much as the bottom 90% and the top 1% spend 19% of all Medicare expenditures. It is unusual for beneficiaries to remain in the very high expenditure group for more than one year. Patients in this category either die of an illness or recover after therapy and return to the low expenditure category. 47% of beneficiaries will be in the top quintile of expenditures for one year in a nine year study. 30% will be in the top decile for one year but only 10% are in the top decile for two or more years and only 1.2 % are in the top decile for four or more years. Mortality is high in this group and, for the beneficiaries who are in the top decile for two or more years, it exceeds 50% and is higher than that of the very high cost one year group. Individuals who have persistently high costs, while a very small group, account for a disproportionate share of expenditures. It is possible that multi-year high expenditures represent cases in which improved care could save substantial amounts of money. In addition, it is apparent that high cost Medicare beneficiaries, even in the un-managed fee for service sector, are a very small proportion of the total.

What about the frail elderly ? The group over age 85 ?

The frail elderly, usually described as those over age 85 and those with chronic illness, are estimated to comprise 10% of all Medicare beneficiaries. If all of the multi-year high cost beneficiaries were in this group it would still leave 88% of this group with costs close to the Average Annual Per Capita Cost over a multi-year span. It is unlikely that costs for this group exceed the average for other age groups and studies of end-of-life costs show a decline in costs after age 80 for decedents and after age 90 for survivors.

Remember this was 14 years ago. Our model was a demonstration project in San Francisco.

A program named On Lok began in San Francisco 25 years ago to care for frail elderly with low incomes, initially among the Chinese-American population of that city, and to keep them in their homes and out of nursing homes. It now operates five community service organizations in the city and has been the impetus for a national demonstration project called PACE (Program of All-inclusive Care for the Elderly). In 1983 On Lok became a dual capitation program funded by Medicare and Medicaid as an alternative to long term nursing home care which is covered, for Medicaid eligible individuals, by Medicaid. At present 15 PACE programs exist nationally as Medicare providers, 10 of which were mandated by OBRA in 1986 as a demonstration project (plus the five On Lok sites in San Francisco), and 40 sites are planned to be in operation next year. The program includes a four year demonstration project of up to 10 for-profit entities which, if successful, could qualify as permanent PACE providers. The PACE model includes a day care center which provides nursing care, case management, social activities, a nutrition program and respite for family care givers. Eligibility for the PACE program is income limited with a maximum income of $14,000 for individuals and $17,000 for married couples. It does not include pharmacy benefits but a new enhancement, called PACENET (Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier) will cover drugs after a deductible ($500) and copayment ($8 for generic/ $15 for brands).

An independent evaluation by Abt Associates in 1995 was critical of the PACE model in several respects and suggested that the replication sites may be less successful than On Lok for a number of reasons. The catchment area of On Lok was only 2.5 square miles at initial development and is still less than 10 square miles after expansion. The replication sites have, in general, larger catchment areas and are located in communities with less population density than San Francisco. Another problem has been the slow growth of the replication sites’ client volume. Some of the reasons for slow growth include resistance to four or five day per week visits, the need to apply for Medicaid and the loss of choice of physician and other providers. Family support is necessary for this model to succeed and this varies among the replication sites. The report emphasizes that all sites exclude some eligible patients in spite of a need for expansion and this suggests that selection is occurring. This selection process is described as “niche marketing” or “skimming” in the report and the conclusion is that enthusiasm for the model among providers is greater than among clients.

The greatest change since these studies has to do with the growth of assisted living homes and home care. It is much, much easier to care for frail elderly at home than it was in 1986 or even in 1995. A second option was considered as a model.

A similar program, at the University of Pennsylvania, called CARE (Collaborative Assessment and Rehabilitation for Elders), has been established since 1993. It is certified as a CORF (Comprehensive Outpatient Rehabilitation Facility) and functions as a day hospital similar to the British day hospital. This program found that nursing, mental health, social work and care management services are not well reimbursed in a fee for service environment. Certification as a CORF improved reimbursement. Other limitations included relations with other providers who might feel competition, transportation, limitations on the services reimbursed by the CORF structure, cost of the day care facility and time limits of the CORF model. They are dependent on referral from primary care physicians and have no managed care patients. Patients are seen by Advanced Practice Nurses at intake and needs assessment is completed. Typical problems include poly-pharmacy, depression and cognition. Patients are seen in a “day hospital” for four hours per day, two to three times per week for an average of six weeks. Then the patients are returned to primary care physician follow-up and the CARE program has no long term follow-up.

Here again, there is a model for treating frail elderly with intensive short term care, usually correcting medication problems, assessing psychological issues and coaching family members on proper care. A third model was considered.

The Veterans Administration studied the effectiveness and efficiency of an outpatient Geriatric Evaluation and Management (GEM) program with a randomized trial comparing GEM patients and the usual primary care (UPC) population. This program was based on studies of inpatient geriatric units which had shown improved care. Other outpatient GEM studies had shown little evidence of efficacy of the concept, as measured by consumption of medical services. Tulloch and Moore, in Britain, showed increased number of admissions in GEM patients but reduced bed days and an increased use of social and health services with no difference in prevalence of health problems. The VA study showed significant improvement of health status and quality, as measured by the SF 20, and a significant improvement in survival. No significant differences in costs were reported in the original publication of the study although the GEM patients were seen twice as often.

If elderly patients are seen more frequently, and the problems that have affected them are solved, thereafter, they are less expensive to care for.

In a long term follow-up of the study a potential “investment effect” was identified in that, during the first 8 months of the program, GEM patients incurred 35% more health care cost than the UPC group but in the later stages, after one year, the ratio reversed with GEM patients’ costs being 38% less than the UPC group. This suggests the possibility that initial evaluation identified deferred health needs which, once corrected in the early stage of the study, resulted in less health care expenditures later. If this trend continues it may indicate that early correction of health problems results in less cost in the long term and may support the cost effectiveness of the GEM concept.. Both the GEM group and the control group showed improved health perception and functional status. This effect on the control group was attributed to the “study effect” first noted in the 1920s in efficiency measurement. Control patients responded to the increased attention of the study by improved status. The VA GEM study with long term follow-up has not been replicated and their patients were all male.

Due to an uncooperative medical center administrator, we were unable to conduct this study and prove our thesis; that the elderly have specific issues that, once solved, are no more expensive to care for than younger elderly patients and may, in fact, be less expensive. UCLA did a small scale study that was similar:

A similar study of geriatric assessment but this time performed at home was reported in 1995 by a group at UCLA. The patients were selected from voter rolls of the city of Santa Monica for age over 75 and 37% of those contacted by telephone agreed to participate. They were randomized to an intervention group and a Usual Care group. After a three year study period the intervention group were more able to live independently, less likely to require assistance and less likely to be in nursing homes long term. There was no difference in acute care hospital admissions and the intervention group had more hospital days per year and more physician visits per year than the control group. The principle benefit of the program seemed to be in the reduction of long term nursing home admissions.

Why is this important ? The over-85 elderly group is the fastest growing part of our population. There will be enormous resistance to any attempt to deny them care. The studies above mostly focused on “day hospitals” and intensive evaluation upon intake into the program. The evaluation may include a psychologist and a pharmacist, both of whom are concerned with common issues of depression and polypharmacy. Once these issues are dealt with, the elderly are easy to care for and the care will increasingly be delivered at home or in assisted living facilities.

At the moment, Medicare and the Obama administration do not seem to be focusing on these issues. This may mean that private options may become more important. Note that the common theme in all these studies is more frequent physician visits to these patients, whether they are at home or in day hospitals. Medicare is not only refusing to fund these more frequent visits but is threatening to prosecute physicians who see their elderly patents more frequently than the Medicare rules allow. For this reason, some geriatric physicians are dropping out of Medicare and practicing in a cash setting. The patients seem to be willing to pay for this additional care, suggesting that they and their family members perceive value.

This report discusses the future for Medicare without reform. There are several reforms that could be done without overt rationing. Some of them are discussed above.