The Public Looks at Health Care Reform

              Sometimes it is useful to look at health care issues from outside the medical loop. An opportunity was provided by publicationof a headline story in USA Today that “15% of seniors account for nearly half of medicare spending.”[1] The newspaper had analyzed the recently released Medicare data on spending for hospital and physician services,  They reported total spending of $324 billion for 34 million patients, with $261 million being spent on 28 million persons over age 65. They found $246 million was spent on 19 million persons with “two or more chronic conditions,” and $135 billion was spent on 4 million persons with six or more chronic conditions. They concluded that 2/3 of Americans over age had chronic conditions, and the most common were hypertension, (54.4%), hypercholesterolemia, (44.9%), arthritis, (29.2%), heart disease, (27.7%), and diabetes, (26.9%.) The prevalence of all of these conditions had increased except for heart disease.

            These statistics are not new to physicians, of course. And to us, there is some difference between say one drug hypertension, and four drug hypertension. And, of course, some of the increased prevlanence of these “conditions” reflects a continued lowering of the threshold for both diagnosis and treatment in hopes of staving off late complications, such as heart failure. Taken as a total, though, they reinforce the notion that a lot of spending is being spent on very sick people. This might be a story of “inefficiency,” but I think some of it reflects the system's inability to deal with chronic disease narratives in the face of acute decompensation.

            The human interest stories laced into the articles illustrate common themes to physicians as well. The biggest of which is the impact of major disease on the caregivers, who are often not in good health themselves, and the needs for home care that are more intense than are readily available. This is part of the larger theme of the loss of neighborhoods that was explored earlier.

            Most interesting was the sidebar on the gerontology program at Monmouth (NJ) Medical Center's South Campus. Victor Almeida, M. D., the medical director of the Emergency Department was quoted as saying:


The goal is to see elderly patients quicker, to admit fewer of them and get them the services they really need ...Often that means home care or subacute care, rather than a hospital stay.

 
            The article also quotes Jessica Israel, who is director of a gerontology program designed to improve care coordination and communication among care givers, families, and resources.  The team also includes representatives from a long-term acute care facility, nursing homes, and hospice care.  The program received a grant from the Robert Wood Johnson Foundation and studied 640 patients enrolled over a two year period. Their efforts at care coordination reduced the readmission rate by 39% and both patients and caregivers reported high rates of satisfaction with the program.

            So what should we learn from this article in USA Today? I think the main point is that we need healthcare reform not so much to save dollars, although that is clearly important. But we really need to reform healthcare because the nature of our work has changed and a lot of what we do does not meet the needs of our patients. It is not that we are not working hard, it is that we are working hard on issues that really don't matter. A lot of the needs of our elderly patients are more social than medical. What they need from us is an honest assessment of how much we can preserve or reverse functional decline and frailty that are inevitable parts of growing old.  What do you think?

15 June 2015


[1]USA Today, Wednesday, 10 June 2015, page 1A and page 8A.

Further Reading

Trust in Physicians and Healthcare Reform
Public trust in physicians as a group is quite low, despite the high regard patients have for their personal doctor. The implications for the physician's role in the health care reform debate are considered.

Restoring the Commons
 A consideration of the interactions of patient preferences, evidence-based medicine and peer review.   

The Tragedy of the Commons
Recognizing the Commons is critical for success in an era of rapid change.

What Business Are We In? 
All healthcare organizations have both a clinical and a business function.  The proper balance is crucial for success.

What Do I Owe? 
A discussion of unexamined assumptions about what physicians owe their hospitals.