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Sunday, January 2, 2011

Medicare and the lemming-like desire for more government funded healthcare

This week in my hometown newspaper two articles from the Associated Press were featured, representing some major issues about Medicare’s ongoing viability. The first article presented numbers about how the average person’s Medicare tax contributions compare to their average Medicare expenditures. The most often quoted figure (this data is rapidly achieving viral status) is that an average couple earning $89K a year will contribute $114K to Medicare over their work life and require $355K in expenditures by the end of their lives through Medicare. The second article looked at a poll conducted in November of 2010 in which 1000 US citizens age 18 and older who were asked various questions about their feelings and preferences with regard to Medicare, given that it appears to be unsustainable without significant changes. The actual data can be accessed at this link:

Data from the AP poll showed that this randomly selected group of people had very different opinions about what to do with the need for change in Medicare. The articles that I can access online report the same things, in fact they mostly use the same words to report the same things, and report that most of those interviewed believe that although they don’t want to increase Medicare taxes or increase the age at which Medicare kicks in, they would prefer that to having a reduction in benefits. As far as I can tell, they were not told what these hypothetically reduced benefits would be, so that pretty much nullifies the value of that question, but so it goes.

The vast majority also said that they would like Medicare to cover hearing, vision and dental services. If they had been asked, I wonder if they would also have liked to have the government buy them a new car and decrease the work week to 3 days.

Perhaps they should have been asked “In the best of all possible worlds, would you like to have everything you want and be happy all the time?”

But I digress.

The real question, the interesting question, is why the couple featured above should require $355,000 in Medicare expenses after the age of 65. What changes could be made that would keep medical costs affordable while preserving or improving health and quality of life?

I am not a fan of making one-size-fits-all guidelines to decrease costs. Medical costs are huge, though. Each item we do or order to be done for a patient carries a very large price tag, and there are huge numbers of patients requiring these costly items which means that intelligent tailoring of doctors’ ordering behaviors can have a huge impact on overall costs.

In order to make choices that fit individual patients’ needs, doctors need to spend more time with each patient and need to get to know the patients and their families and social settings better. This means that in order to save money, we need to spend money, educating more doctors and paying them more for encounters that actually get the job done. A doctor bills heftily for an appointment in which he or she hears about a cough and prescribes (incorrectly) an antibiotic. For an appointment that takes twice or 3 times that long, in which a person is counseled about health, a connection is made that involves learning about that person’s situation and health related questions are asked and answered might be billed at 30% more, and might easily avert long term problems or expensive emergency room visits. In short, we doctors need to do a better job, and we need the system that educates and pays us to support that.

One of the things that is a costly part of Medicare benefits is the use of brand name drugs where generics will do, and using drugs at all when no drugs will do. That said, there are some patients who require the newest and fanciest drug due to intolerance of or ineffectiveness of the older drug, and a physician who spends time will help that person make decisions like this more effectively.

Another wickedly expensive thing that we do when under time pressure is to order imaging procedures where a good exam or the passage of time would do just as well in making a diagnosis. A CT (Cat) scan may be billed at $2500, and is associated with a dose of ionizing radiation equal to 300-500 chest x-rays, with associated significant risk of future cancers. Use of this kind of imaging is increasing rapidly, with major negative effects, both on our health and on our economy. And as for saving the busy doctor time, it does not, since these imaging procedures often show some irrelevant and often incorrect finding that requires counseling, reassurance and often repeated imaging tests. A thoughtful doctor who takes time, though, will order imaging tests for the patients who can benefit from them. Tests such as CT scans have expanded our abilities to detect serious conditions at a stage in which treatment is effective and less harmful, but trends such as ordering an abdominal and pelvic CT scan for every case of appendicitis is clearly out of line.

Blood tests are some of the least expensive items that we order, but we order them in profusion, often with no expectation that they will be helpful. People expect them at every physical exam, and there is no useful standardization to allow us to limit their use. They are usually confusing or inappropriately reassuring and are associated with many many millions of dollars of excess spending.

There are so many other ways in which good medicine is less costly. It frustrates me to see Medicare’s rising costs viewed as an unavoidable result of medical progress. It seems as if whoever wrote the questions for this AP survey is part of the conspiracy of ignorance that equates limiting health care expenditures with “reducing benefits.” It is just not true that more medical procedures and unneeded medical procedures are a benefit.

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