November 10, 2013

Putting Teeth into Medicare

Teeth matter. Not just to chew food, although that is critically important to older people, who are at greater risk of undernourishment than of obesity. Not just for esthetic reasons, although appearance is an important part of self-esteem and teeth are an important part of appearance. Oral health is a significant ingredient in the overall health of older people. For years, geriatricians have recognized poor dentition as a risk factor for pneumonia--the bacteria that build up in dental plaque can get into the lungs and cause infection. The Journal of the American Geriatrics Society, the leading professional journal dealing with medical issues in older individuals, has a special section each month called “Dental and Oral Health,” much as it has a section on”Ethics, Public Policy, and Economics” and one on “Educating and Training.”  In October, the article in the “Dental and Oral Health Section” was on oral health in old people with diabetes (it’s poor). So if teeth are so important, why isn’t dental care covered by Medicare?

It turns out that lots of arguably important services are not covered by Medicare. In large part, what is covered and what isn’t is still governed by the original 1965 legislation enacting Medicare (Title XVIII of the Social Security Act). Medicare excluded then, and still excludes today, eye exams, refractions, and eyeglasses, as well as auditory exams and hearing aids. It excludes “services that are not medically reasonable and necessary,” although nobody knows what exactly is reasonable and necessary and Congress has assiduously avoided defining the term, resulting in the exclusion of cost from consideration in determining Medicare coverage. Some of the services excluded from the original legislation have since been added in: for example, prescription drug coverage is available thanks to the Medicare Modernization Act of 2003, and certain preventive care such as colorectal cancer screening, Pap smears, and prostate cancer screening have been added. But dental care remains an exclusion: “Items and services that are furnished in connection with the care, treatment, filling, removal or replacement of teeth” are off the table.

Older individuals can have private dental insurance, just as younger people can. But this raises another problem. Dental insurance itself isn’t really insurance at all. It covers routine preventive and maintenance care but specifically excludes the costliest treatment. Typical policies have a $2000 per person annual maximum. All it takes is one or two root canal treatments and the bills start to mount up. So dental insurance has it backwards—it covers the small stuff and leaves you vulnerable to the big bills. The essence of insurance is supposed to be that it protects against extreme loss: as Wikipedia puts it, an individual assumes a guaranteed and known relatively small loss (the premium paid to the insurance company) in exchange for a promise to compensate the insured in case of a far greater loss. 

Medicare includes neither reasonable dental insurance (payment for costly care such as dentures or root canals or extractions) nor conventional dental insurance (payment for routine preventive care  and filling simple cavities but minimal coverage for anything else). The reason that Medicare doesn’t cover teeth or a whole host of other services that older people need is that Medicare was designed as insurance for hospital care. While it has gradually expanded—originally, it wasn’t even going to pay doctors—it is only slowly adapting to contemporary reality. What Medicare is still best at is providing comprehensive coverage for acute illness: all the high tech diagnostic procedures and treatments, from PET scans and cardiac catheterizations to surgery and intravenous chemotherapy. What Medicare is not so good at is addressing chronic disease. And most older people suffer from chronic disease. Over two-thirds of people on Medicare have more than one chronic condition; 21% have four to five chronic conditions and 14% have six or more. 

Good geriatric care has to be coordinated, integrated, and patient-centered, but Medicare does little to foster any of these features. Medicare still does not pay for case managers to facilitate integration; it is largely fee-for-service, undermining any realistic possibility of integrating physicians, hospitals, and nursing homes; and it does nothing to encourage patients to discuss their goals of care with their physicians. A few experimental programs are underway to remedy these deficits, such as Accountable Care Organizations (to promote integration) and disease management programs (to promote coordination and self-care). But we’re a long way from having a truly modern Medicare program that serves the needs of frail elders and near-frail elders along with those of their more robust counterparts.

So the critics are right that we need to do something about Medicare. But what we need to do is not to privatize the program or cut benefits. If we want to put teeth into Medicare, we should add true dental coverage— and overhaul the program so that it focuses more on chronic care rather than acute care, more on home care than on hospital care, and more on human care than on technological care.

1 comment:

Unknown said...

I appreciate the subjects you tackle in your blog, Dr.Gillick. Having just left the work force and entered the Medicare system, the fact that it provides no dental coverage is concerning. Even more concerning to me, however, is the fact that Medicare, and private insurance for that matter, does not cover the cost of hearing aids. Hearing loss is disabling. Before I lost my group insurance, it paid for a new CPAP machine, yet neither it, nor Medicare, will pay for hearing aids. What's wrong with that picture?