Medicare Two: We’re All Being Tested

U.S. Ranks Last in Health Care Performance Among Seven Countries (from The Commonwealth Fund - 2010)

Our previous post demonstrated a number of Medicare’s most significant design flaws: fees for service rather than for success, open-ended health care subsidies and a system that fosters unconstrained spending. These flaws are at the heart of the system; the best way to fix Medicare, therefore, would be to start from scratch. As a practical matter, those with vested interests in preserving the current system and the money to influence Congress (insurance, pharmaceutical, medical supply companies and AARP) will fiercely resist wholesale changes. Given the present political climate, only piecemeal alterations may be feasible. Many ideas have been offered since the Affordable Health Care Bill debate. Those that close Medicare’s funding gap, provide incentives for Medicare enrollees to limit their medical expenditures and encourage the health care delivery system to be more efficient and results-oriented are all worthy of serious consideration. As a headline in a recent NY Times opinion piece pointed out: “Spending More Doesn’t Make Us Healthier.” 

Some changes would have to be phased in to give beneficiaries and providers time to adjust but the sooner we start the easier the transition will be. A few specific – though controversial – changes that could save significant money and could be implemented relatively quickly are offered below.

First, we must reduce the amount of diagnostic testing. Just since 2000, the number of tests and imaging studies – many unnecessary and avoidable – per Medicare beneficiary has risen about 85 percent. Growth in diagnostic testing is due to a lack of clear guidelines, fear of malpractice litigation and physician and patient habits that are hard to break. As an example, the American College of Physicians found strong evidence that X-rays, CT scans and MRIs don’t normally improve the health of patients with lower-back pain. Contrast that with the personal experience of a doctor who had an episode of lower-back pain and decided to see a specialist. He was required to get an MRI before even seeing the doctor. The scan was interpreted as possibly showing a mass in his liver. This led to an ultrasound that was inconclusive, another MRI that was of poor quality, another MRI that ruled out a liver problem but showed “something on the kidney.” Finally a CT scan showed neither his liver nor kidney had any problem. The bill for the five tests – all of which were unnecessary and did nothing to help the patient – was more than $6000. This is far from an isolated experience. While it is hard to get precise data, some estimates are that excessive testing costs between $200 and $250 billion a year.

A recent study from Israel concluded that examining patients and taking a medical history are more helpful to hospital doctors than high-tech scans. There is also research showing that the radiation from multiple CT scans may increase the risk of cancer. It is time for the medical profession to identify where testing is overused and misused, develop more precise testing guidelines and educate doctors and patients about the costs, benefits and risks of medical tests.

Second, far too much money is spent on patients at the end of their lives. For instance, a recent poll showed that nearly half of U.S. primary care doctors would recommend a mammogram to a patient with inoperable lung cancer. This despite the fact that the average life expectancy with lung cancer is about 10 months and breast cancer testing, like the PSA test for prostate cancer, can give false readings, cause needless anxiety and lead to additional tests.

A recent study shows that one in three Medicare patients undergoes surgery in the last year of life and one in five undergoes a surgical procedure in the last month of life. In addition, many terminally-ill patients are provided with expensive treatments and drugs that may only marginally improve life expectancy while compromising their quality of life. Spending “whatever it takes” of other people’s money is a questionable practice at best and one that will, if not reformed, bankrupt the Medicare system for everyone.

Third, Medicare recipients (and the population as a whole) must be given education and incentives to take greater responsibility for their own health. Specifically, in order to be eligible for Medicare, seniors should need a physician to certify that their patient is taking concrete steps to maintain a healthy life style. This would include maintaining a healthy diet, engaging in regular exercise and making a conscientious effort to break unhealthy habits such as smoking and alcohol addictions. Medicare pays for a yearly preventive visit at which time the doctor could develop a personalized plan to help prevent disease. Medicare also pays for some tobacco cessation counseling and nutrition therapy services. Neither perfection nor immediate results are required or expected but there is no reason taxpayers should subsidize expensive medical remedies if patients aren’t trying to do their part.

A few statistics should demonstrate the magnitude of this problem and, therefore, the necessity for people to take greater responsibility for their health. The 28.5 million people who are currently diabetic spend $174 billion on medicine and treatment and according to a recent study they will spend $3.4 trillion in the decade ending 2020. Reducing calories cuts the risk of diabetes. In addition, exercise that burns calories and strengthens the heart reduces the chance of heart disease, the nation’s number one killer. Medical bills to treat heart disease could exceed $1 trillion by 2030 and more than half of those costs will be borne by Medicare and its taxpayer benefactors. Healthy life style counseling and other preventive programs are investments that will more than pay for themselves and need to be strongly encouraged.

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