December 08, 2017

Better Watch Out, Better Do Cry

          The new tax law hasn’t passed yet—the Senate and the House still need to reconcile their disparate versions of the legislation—but odds are that we will have a bill very soon. And whatever compromise is reached is going to feature a major cut in the corporate tax rate, a big cut in the income tax rate for the wealthy, and modest or minimal reductions in the tax rate for the middle class, with a resulting whopping $1.5 trillion projected increase in the deficit over the next ten years. There’s only one way to compensate for that kind of deficit, and that’s cutting federal expenditures. And as Paul Ryan, Speaker of the House, acknowledged just this week, that’s exactly what he wants to do. “Frankly, it’s the health-care entitlements that are the big drivers of our debt,” he said in an interview. “We [will] spend more time on the health-care entitlements—because that’s really where the problem lies, fiscally speaking.”
            Now I’m all in favor of reforms to the Medicare program. I’ve argued many times on this blog that Medicare is still too focused on acute care, on hospital-based care, and on technologically-intensive care, despite its recognition that chronic illness, in fact multiple chronic illness is what afflicts much of the older population. But Ryan et al aren’t talking about modifying Medicare; they are talking about slashing Medicare. I thought it might be a good idea to look at just what Medicare covers now, enabling us to better advocate for keeping what matters. I figured I’d start with a benefit about which there is widespread ignorance and much confusion, the home health benefit. It’s only a small slice of the Medicare pie—something like 3 percent, but when total Medicare expenditures top $632 billion, even 3 percent is far from trivial.
            As luck would have it, the AARP Public Policy Institute just last month wrote a brief report called “Understanding Medicare’s Home Health Benefit.” It’s important to realize that this affects a great many people—3.5 million, in fact, as of 2015. And as is always the case, protestations about “socialized medicine” notwithstanding, Medicare doesn’t actually provide any services—it just certifies home health agencies as meeting federal standards and reimburses them for their services, in accordance with Congressionally mandated criteria. In fact, there are over 12,000 home health agencies in the U.S.
            The services that Medicare authorizes under the Home Health benefit are intermittent. They include principally professional services, or what Medicare calls skilled care:  nursing care, physical therapy, speech therapy, occupational therapy, and social work. They also pay for limited home health aide care and some durable medical equipment, supplies such as wheelchairs and walkers.
            Not just anybody enrolled in Medicare qualifies for these services. To be eligible, you have to be homebound and a physician (it has to be an MD) has to certify that you’re homebound and that s/he has approved a “plan of care” for you that spells out what services you will receive and why you need them.  “Homebound,” in turn, means that you cannot leave your home without “considerable and taxing effort” and you need the help of another person or specialized equipment to go anywhere. A couple of years ago, Medicare introduced the requirement for a face to face visit to certify eligibility. A nurse practitioner or physician assistant working with a physician can make the face to face visit, but only the MD can sign off on the certification. Certification must be renewed every sixty days but can, in principle, continue as long as the services are necessary for the individual to maintain his level of functioning or to improve.
            Medicare has already invoked “re-balancing” to downwardly revise its payments for home care services. Another change under consideration include charging a co-pay of $150 or more if the home care service is initiated without a prior hospital stay. While this is meant to deter fraud and abuse, it sounds much like the notorious “three-day rule,” that says Medicare will only pay for a skilled nursing facility stay if it is preceded by a hospitalization of at least three days. The problem with that rule, as has been pointed out, is that far from assuring that patients don’t unnecessarily use SNF facilities, it promotes unnecessary use of the hospital as the only legitimate means to gain access to inpatient rehabilitative services! Similarly, if home physical therapy is what a patient needs, not hospital care with orthopedic consultation, MRIs, and other procedures, why should Medicare deprive patients of that option?
            Other strategies for slashing the home care budget may well be adopted unless we are vigilant. So you better watch out, better do cry, the Grinch is coming to town.



December 03, 2017

Medical Care: Fast and Slow

Victoria Sweet is the kind of doctor I wish my mother had. For that matter, she’s the sort of doctor I’d want for myself or my husband: she’s knowledgeable, she’s compassionate, she’s thoughtful, and she’s thorough. Her new book about her evolution as a physician, Slow Medicine: the Way to Healing.
 is a kind of prequel to her earlier, highly successful book, God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, which tells of a remarkable if a bit anachronistic institution, the Laguna Honda Hospital, where she worked for twenty years. Laguna Honda is a chronic disease hospital, a place where people who are too sick for a nursing home but not sick enough for an acute care hospital spend their days. But, in Dr. Sweet’s telling, it is also a place where physicians can practice medicine in a way that is seldom possible elsewhere, with the result that many patients stay at Laguna Honda even when they do become acutely ill, and some can be discharged to the community. God’s Hotel is a paean to “slow medicine,” the movement, like “slow food,” that challenges the contemporary tendency to focus on efficiency, technology, and science rather than deliberation, reflection, and art.
The new book, Slow Medicine, describes Dr. Sweet’s journey from psychology graduate student to staff physician at Laguna Honda. She explains, using many delightful case examples, how she came to understand what slow medicine is and what it has to offer. Her account serves to highlight the differences between slow and fast medicine in actual practice. While Dr. Sweet is at great pains to emphasize the importance of both fast and slow medicine, and in fact is herself able to move effortlessly from one to the other—to “think out of the box” by administering a surprising medication, the opioid-antagonist Naloxone, as part of an otherwise fast-paced resuscitative effort—the point of the book, as with its predecessor, is to glorify slow medicine. Without the deliberative, questioning, comprehensive approach to patients at which she excels, Dr. Sweet assures us, our highly regulated, protocol-driven technological medicine will disappoint.
But there is a problem with this view. It assumes that the reason so much of medicine has become fast medicine is that it has been commodified—“healthcare”  has replaced medical care and “providers” have replaced physicians. Dr. Sweet is partly right: device manufacturers and drug companies are in fact concerned with selling their wares, and economists do promote the reimbursement system for physicians and hospitals as the key to improving health outcomes. They view the interaction between a physician and a patient as a transaction rather than a relationship. But the regulations and the forms, the oversight and the accountability that she so maligns are a response to a reality that she glosses over: in times past, before medicine became so fast, quality was mediocre. It’s simply not true that in the good old days, physicians were healers and now they are technicians. In the bad old days, many physicians used remedies that didn’t work, even though scientific studies had shown they didn’t work, and failed to use treatments that did, even when there was ample evidence for the newer approaches.
What Dr. Sweet neglects to mention in the “slow medicine manifesto,” with which she concludes her engaging and provocative book, is that she can be a superb physician without the rules and the bureaucracy because she is very, very smart, and endowed with an outsize measure of both perspicacity and empathy. Victoria Sweet, as she reveals in her bio but not in the book, majored in mathematics at Stanford University (not an easy thing to do) while minoring in classics (quite likely an unprecedented combination). Then she was accepted into a PhD program in psychology at Harvard, but decided to go to medical school instead. When she became intrigued by Hildegard of Bingen, a nun in the Middle Ages who practiced a kind of holistic, herbal-remedy-based medicine, she didn’t just read what she could about Hildegard, she decided to pursue a PhD in the history of medicine (while continuing to work as a physician). 
Victoria Sweet has much to contribute to the world, and her description of her patients—how she examines them “from stem to stern” and, when she is puzzled by what she finds, spends hours in the library trying to figure out what ails them—is inspiring. But there’s a reason we have rules and regulations, and it has as much to do with the reality that most physicians aren’t like Dr. Sweet as with the commodification of medicine.

November 26, 2017

Down, Down, Down

         The most important recent development affecting older patients, without a doubt, is the issuance of new guidelines for the diagnosis and treatment of high blood pressure. The Wall Street Journal proclaimed “Nearly Half of US Adults Have High Blood Pressure Under New Guidelines,” and venerable health columnist Gina Kolata of the NY Times wrote: “The nation’s leading heart experts on Monday issued new guidelines for high blood pressure that mean tens of millions more Americans will meet the criteria for the condition, and will need to change their lifestyles or take medicines to treat it.The report, which took me a while to track down and read since most of the references are to summaries of the report or commentaries on the report but not to the actual document, is 175 pages. It was issued or endorsed by eleven organizations, whose initials actually form part of the name of the report: its full name is the “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPCNMA/PCNA Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.” The subtitle is: “A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.” Now that I’ve had a chance to digest this—what should we make of it?
         I remember the day in 1991 when JAMA published the results of the “SHEP” trial, a study of the treatment of isolated systolic hypertension in the elderly that upended what I’d been taught in medical school. Gone was the belief that high blood pressure was good for older people because they needed greater force to push blood through their stiff arteries; suddenly, there was compelling evidence that high blood pressure was dangerous—it caused strokes and heart attacks. Keeping the systolic blood pressure below 160 reduced the risk of stroke by 36 percent and the risk of a cardiac event by 27 percent. Overnight, the practice of medicine changed.
         To be sure, there were skeptics. Wouldn’t lowering the blood pressure cause older people to become dizzy and to faint? Just how far were we supposed to lower blood pressure anyway? But to me and many others, the choice was clear. Stroke was one of the worst fates that could befall older patients: sometimes it killed them, but more often, it left them impaired, often profoundly, significantly diminishing the quality of life.
         But I also remember a book by physician and historian of science, Jeremy Greene, published in 2008 and called Prescribing by Numbers: Drugs and the Definition of Disease. Greene argued persuasively that the pharmaceutical industry has a vested interest in lowering the cut-off for treatment of a variety of chronic conditions, such as hypertension, high cholesterol, and diabetes. Defining “pre-diabetes” as a real condition warranting treatment or repeatedly dropping the threshold for treating cholesterol with statins had clear implications for the drug companies: they would sell more pills. More volume, more revenue, more profits. So are the new guidelines just another instance of “diagnosis creep,” a way for Pharma to make more money?
         It’s important to realize that what tipped the scales for the guideline writers, what’s different now from the last time they wrote a guideline, three years ago, is the 2015 “SPRINT” study (Systolic Blood Pressure Intervention Trial), a randomized trial of high risk patients over 50 to either a systolic blood pressure target of 140 or 120. The study, which was reported in the New England Journal of Medicine, found a 25 percent reduction in cardiovascular events (such as stroke or heart attacks) when physicians tried to reduce the blood pressure to the lower value.
         As Gilbert Welch of the Dartmouth Institute, co-author of Overdiagnosed: Making People Sick in the Pursuit of Health (2012) and Less Medicine, More Health (2016), commented, that 25 percent sounds pretty good, but it’s the relative risk reduction. In fact, the rate of cardiac events fell from 8 percent in one group to 6 percent in the other—an absolute difference of only 2 percent. Or, looked at differently, 92 percent of people in one group and 94 percent of people in the other group did just fine. Suddenly, the impressive results don’t look quite so impressive. Moreover, all these patients were already at increased risk of cardiovascular disease because of other factors such as cigarette smoking or diabetes. Presumably, had the same study been carried out in people of average or lower risk, the benefits would have been correspondingly smaller.
         So if the new guidelines are based predominantly on the findings from one study, and the one study isn’t quite as compelling as it seemed at first glance, what should we make of the new recommendations? Should we really treat everyone with a systolic blood pressure over 120 who has at least a 10 percent risk of cardiac disease in the next decade? 
         The answer, I think, is yes, but with caveats. First, the guideline writers are at great pains to insist that blood pressure be measured the way it was measured in the SPRINT trial—in a way that it’s almost never measured in the doctor’s office, namely after sitting quietly for five minutes and averaged over three readings. They also advocate use of home monitoring to confirm (or refute) the diagnosis of high blood pressure, as well as to guide medication adjustment once treatment is started. Next, physicians need to be prudent about what medications to use if they’re going to embark on pharmacologic treatment. We have ample numbers of cheap, effective medicines that have been around for years, such as diuretics and beta blockers, and these should be tried before pricier medicines. Finally, both physicians and patients need to be vigilant about medication side effects, which means doctors need to tell their patients what to look for, patients need to report their symptoms, and doctors need to change course if symptoms develop. In addition, non-pharmacologic treatment should be attempted, including exercise, weight loss, and a low salt diet. If we follow all these steps, we can be confident we will be changing how we deal with blood pressure because it’s what’s best for patients, not because it’s what’s best for the pharmaceutical industry.

November 02, 2017

Persistent Confusion About Confusion

The modern concept of delirium or an acute confusional state has been around for decades, but physicians are still confused about it. A recent review article in the New England Journal of Medicine summarizes what we know about delirium: what it is, how to treat it, and how to try to prevent it. “Delirium in Hospitalized Older Adults,” as the title says, does not address delirium outside the hospital, i.e. in the skilled nursing facility, where it is even less well-recognized, but despite this limitation it is a welcome update of an important topic.
            Older patients—most of the studies define “older” in this context as at least 70—are at high risk of developing the acute onset of confusion after they are admitted to the hospital. Lumping all older people together, regardless of age or reason for admission, roughly one-third will become delirious. Among people who have certain operations such as hip fracture repair or cardiac surgery, the rate is more like 50 percent, and among older patients in the ICU on a ventilator, it rises to 75 percent. What’s particularly striking is that once delirium strikes, it’s hard to get rid of. At the time they are discharged, nearly half of all patients who got delirium in the hospital still have it, and a month later one-third still meet the criteria for delirium. It’s not always “hyperactive delirium,” the agitation we usually think of when we hear the word delirium; in fact, nearly 75 percent of the time it’s the opposite, or “hypoactive delirium,” a more insidious, quieter form of the disorder.
            The article goes through the major triggers of delirium, with medications (especially sedatives, opioid pain medications and other mind-altering substances) at the head of the list. Out-of-whack blood chemistries (technically known as electrolyte disturbances) and infection are two other leading offenders, but the bottom line is that almost anything can result in delirium, from a heart attack to severe constipation. Treatment consists primarily of removing or curing the underlying precipitant—for example, getting rid of the implicated medicine, limiting the heart attack damage, or getting the bowels moving. The author is at pains to tell us that among twelve randomized controlled trials of antipsychotic medications in the treatment of delirium, none of them resulted in decreasing the severity or duration of delirium, none of them lowered mortality rates or length of stay in the hospital. Nonetheless, he indicates that antipsychotic drugs may be prescribed if needed to control particular symptoms.
            Most interesting are the reminders about what works best to prevent delirium. The gold standard is still the 1999 HELP study (Hospital Elder Life Program) that used trained volunteers to make sure older patients wear their glasses and their hearing aids and that they get a back rub rather than a sleeping pill if they have trouble sleeping at night. Another approach that also makes a difference is a proactive geriatric consultation. Especially when initiated on a surgical service, this can assure that older patients are not prescribed sedating medications, that they receive round-the-clock acetaminophen whenever possible instead of as needed opioids, and that they get out of bed and moving as soon as possible. A related approach that the author doesn’t mention is use of the ACE unit (Acute Care for the Elderly), a specially designed inpatient unit that builds anti-delirium measures into its mode of operation.

            But what’s important to emphasize is that even the best delirium prevention strategies are only moderately successful. Delirium is a nasty disorder: it is extremely unpleasant, it’s dangerous, and it lingers. Some people never recover fully, some die. For older people who have some degree of cognitive impairment, those who have significant trouble carrying out daily activities, and those with multiple problems on many medications, the best approach may be to avoid the hospital altogether.