Modernizing Medicare

The Medicare Modernization Act of 2004 didn’t really modernize Medicare. It took the important step of creating coverage for prescription drugs, which are the backbone of medical treatment of older individuals. But apart from this one change, albeit a major one, Medicare was pretty much intact. The problem with the approach to healthcare enshrined in Medicare, a program that turns 40 this year, is that it assumed that most illness is acute illness that requires hospitalization. In fact, it including coverage for anything other than hospital care in Medicare was more or less an afterthought. But today, most illness is chronic illness and the sickest, costliest patients typically have multiple chronic conditions.

The good news, as summarized in a perspective in JAMA this week entitled “Optimizing health for persons with multiple chronic conditions,” is that Medicare has made a number of changes that move the program into the modern world. The article indicates that the government report, “Strategic Framework on Multiple Conditions,” released in 2010, articulated 4 goals: fostering health systems change, empowering individuals, equipping clinicians, and enhancing research. Funds from the Recovery and Reinvestment Act and the Affordable Care Act have gone a long way to supporting initiatives in each of these domains. For example, in the realm of health systems change, the Centers for Medicare and Medicaid Services (CMS) is financing integrated models of primary care; to empower individuals, government funds have supported widespread participation in Stanford’s Chronic Disease Self-Management Program; to help clinicians, many professional societies have issued guidelines that are modified for patients with multimorbidity; and to enhance research, the Patient Centered Outcomes Research Institute (PCORI) was created and is a primary source of research funding. But there’s a problem.

The problem is that the patients we really need to worry about—because they get poor quality care, they cost a great deal, and despite all the money we spend on their medical care, they don’t even get treatment that is consistent with their preferences—aren’t patients with 2 or more chronic diseases. As the authors of the JAMA article comment, we need to focus on patients who are at greatest risk of poor outcomes and high costs. The patients we need to pay most attention to are those who are old and frail. And while many people who are old and frail also have multiple chronic diseases, not all of them do; moreover, having multimorbidity is not sufficient to qualify as frail.

The trouble with frailty is that we don’t have a good way of measuring it. And the measures we do have, which include such things as how strong a person is or how quickly he can walk, aren’t anything that doctors routinely test for, let alone record in the medical record. Insisting that all doctors use electronic medical records won’t allow us to keep track of who’s frail if we don’t enter frailty (or the various measures that define it) into that record. There is now a way that primary care doctors can screen for frailty by asking patients 5 questions, and their answers, while subjective, seem to correlate quite well with more sophisticated tests for frailty. But right now, doctors don’t ask those questions (they include things such as “are you able to walk up a flight of stairs” and “are you exhausted all the time”). Unless we can determine who is frail, we are not going to be able to test the effectiveness of special programs intended to provide medical care for them.

I think a solution may be on the horizon—and it’s not shipping special calipers to measure grip strength to every primary care doctor in the country. The answer, I suspect, is to use a proxy measure for frailty. That surrogate measure is multimorbidity plus functional impairment. It turns out that the people who are hospitalized most often, who take the most medications, and who go to physicians most frequently are people who have at least two chronic diseases and who have trouble with one of their activities of daily living.  

We can refine this group even further by focusing on those who get help with a basic daily activity: 14% of the population or 42 million people have at least one chronic disease and a functional limitation, but only 14 million of them need assistance to get by, and of those, 8 million are 65 or older. And those who have 5 chronic diseases and get help (regardless of age) have average per capita health expenditures of $22,380 compared to $12,749 for those with 5 or more chronic diseases and functional limitation but no help and to $9,723 for those with 5 or more chronic conditions but no functional limitations. 

It’s time to track patients who are over 65 by the number of chronic conditions they have, whether they have functional limitations, and whether their functional limitations are sufficiently severe to require assistance. Only then will we able to determine if these measures define who is at highest risk for adverse reactions to hospitalization, for progressive disability, and for death, and who costs the health care system the most money. Only then will Medicare be able to pay for the right kind of care for all older people. Once we do that, we will have truly modernized Medicare.

Acronyms of Doom

When I was in medical school, U.S. hospitals were plagued by only one kind of “superbug” or antibiotic resistant bacteria. Methicillin-Resistant Staphylococcus Aureus, abbreviated as MRSA and pronounced “mursa,” was the Enemy and it had been around since the early 1960s. I remember the yellow precaution signs on the door of rooms housing patients infected with this organism and the ritual donning of a yellow gown and surgical gloves before entering those rooms. Staph colonizes the skin of healthy people; if it enters the body through a break in the skin it can cause a serious infection, and if the staph is resistant to what was previously the best drug for treating it, the patient can be in trouble.

Then in the late 1980s, along came another bad actor, Vancomycin-Resistant Enterococci (VRE). Enterococci normally inhabit the gastrointestinal tract; sometimes they escape and when they do, for example through fecal contamination of a wound, they can cause significant mischief. Enterococcal infections had come under control with the antibiotic vancomycin—until they developed resistance. Now, MRSA and VRE have been joined by a new threat: Carbapenem-Resistant Enterobacteriaceae (CRE). According to a study published this month, the rate of detection of this infection has jumped five-fold in 5 years. And the mortality from these infections ranges from 48% to 71%. The Centers for Disease Control and Prevention (CDC) in Atlanta took the extreme measure of classifying CRE as an urgent threat. Only 2 other organisms currently share this honor.

The newest superbug, like MRSA and VRE before it, is something that healthy people don’t normally contract. Its victims are patients in nursing homes and hospitals, especially people who are connected to a medical device such as a ventilator or a catheter (whether urinary or intravenous). Debilitated older people are at particularly high risk. The CDC offers a 4-prong strategy for attacking the problem (preventing infection in the first place, tracking resistant organisms, improving the use of today’s antibiotics, and promoting the development of new antibiotics). I suggest an additional strategy that is rarely discussed: keeping frail, old people out of the hospital altogether.

From the time that the hazards of hospitalization were first recognized 50 years ago, the main way doctors have proposed dealing with them is to try to make hospitals safer. Old people become confused in the hospital? Don’t give them sedating medicines that make them confused. Old people fall in the hospital? Use bed alarms and chair alarms to alert nurses that they are getting up. These tactics and others can be helpful, but they don’t eliminate the dangers of the hospital and some interventions, such as side-rails on hospital beds, increase rather than decrease risk. Similarly, our first impulse as we try to control superbugs such as CRE is to reach for the precaution gowns to keep nurses and doctors from spreading the germs. Because antibiotic resistant bacteria are so great a problem, we need to respond with a multi-prong strategy. So yes, educating physicians to use antibiotics judiciously (preventing the development of resistance in the first place) and encouraging pharmaceutical companies to design new effective antibiotics are important. But let’s not forget that in most cases, the patient would not have gotten the infection if he or she hadn’t been in the hospital—these are generally hospital-acquired infections, not the reason for the hospitalization. Sometimes, frail old patients can be treated satisfactorily outside the hospital. Finding an alternative to hospital care is a way to avoid a growing list of “adverse reactions to hospitalization,” including delirium (acute confusion), incontinence, falls, and all those acronyms spelling doom, MRSA, VRE, and now CRE. 

Pursuing Palliation

We’ve known for a long time that breaking a hip can be devastating for an older person. It often leads to a loss of independence and it's associated with a substantial increase in the risk of both nursing home placement and death. While the rate of hip fractures declined in the US between 1990 and 2010, it remains stubbornly high: every year, 300,000 people fall and fracture a hip. A new study suggests the consequences of a hip fracture are especially severe in people who live in nursing homes.  In light of the high rate of disability and death in the 6 months after a hip fracture, an accompanying editorial recommends that breaking a hip in the nursing home signal the need for palliative care. Absolutely—but many of the patients reported in the new study should have been getting palliative care long before their fateful fall.

The authors of the study in JAMA Internal Medicine identified 725,000 Medicare fee-for-service patients who broke a hip during a 4-year period between 2005 and 2009; just over 60,000 of them, or 8%, lived in a nursing home prior to sustaining a hip fracture. It was these 60,000 who were the basis of the study:  the vast majority were women (75%), white (92%) and demented (91%). They also tended to have multiple chronic diseases and to have difficulty with many basic daily activities, which is hardly surprising, as their illnesses and their impairments were precisely why they lived in the nursing home.

After their hip fractures, many patients went downhill quickly. Fully 36% were dead within 6 months. Among those who survived to the 6 month mark, over a quarter had become totally dependent in walking. By the time a year had elapsed, just under half of the residents who had fractured their hip had died. Only 1 in 5 of those who started out being fairly independent in walking had regained their previous level of function. Risk factors for death or disability included male sex, advanced age, white race, multimorbidity, cognitive impairment, and dependence in basic activities. Of note, patients treated non-operatively (11.8% of the sample) did particularly poorly in terms of physical functioning and survival.

These findings fit with the results of earlier, smaller studies. But I couldn’t help asking, as I read this dismal portrait of life-after-hip-fracture-in-the-nursing-home, what happens to people who live in a nursing home who don’t break a hip? How many of them decline? The study in JAMA Internal Medicine had no control group, no nursing home residents with a comparable degree of physical and mental impairment, cared for during the same time period, who happened not to sustain a hip fracture.

I turned up another study also published this year entitled “Natural course of dependency in residents of long-term care facilities: prospective follow-up study.” The study was carried out in Dutch nursing homes and it included both people who had hip fractures along with those who did not. The population was reasonably similar to the US nursing home Medicare population: 75% were women and their mean age was 84. The Dutch have a system for reporting dependency that is different from (and more sophisticated than) the American approach: they report on the “Care Dependency Scale (CDS),” a 15-item scale that grades patients from 15 (totally dependent) to 75 (almost independent in eating, dressing, walking, and dressing). What they found was that among 890 Dutch nursing home residents, just under 15% had died at 6 months and another 18% had died by one year. But the degree of dependency at baseline was strongly predictive of the outcome, with higher dependency leading to greater likelihood of death, even after correcting for gender, age, and the presence of diagnoses such as cancer or dementia. Among residents in the low CDS group (that is, the most independent people), 20% actually improved over a 12-month period and the vast majority (80%) remained unchanged. Among residents in the highest CDS group (the most dependent people), no one improved, 64% remained stable over 6 months, and 36% got worse. The middle group, not surprisingly, fell between these extremes.

How did the nursing home residents in the Dutch study (some unknown fraction of whom fell and broke a hip) compare to the nursing home residents in the American study (who were selected based on their having fallen, broken a hip, and been hospitalized)? Those with hip fracture did worse: over the course of a year, 80% deteriorated markedly in their independence, compared to only 36% of the worst-off Dutch residents; and by 6 months, 36% had died, compared to about 20% of the worst-off Dutch.

These comparisons are approximate at best, but they give some hint of what the Medicare nursing home residents might have expected if they hadn’t broken a hip. So while a hip fracture does represent a turning point, admission to a nursing home in the first place also represents a turning point, a transition to life’s final chapter. Thus while it is eminently reasonable to offer palliative care alongside of surgery to all nursing home residents who break a hip, it would be even better to offer palliative care alongside conventional medical care to everyone in the nursing home.

The Robot Will See You Now

“Disease management” is all the rage. The reason? In the US and other developed countries, most diseases are chronic rather than acute and chronic diseases can generally be treated but not cured; ergo, they need to be “managed.” Interesting that it’s the disease that’s supposed to be managed rather than the patient. In any event, despite the popularity of the concept, disease management programs haven’t proven terribly effective: one review of 35 Medicare-funded projects in 22 states involving 300,000 patients showed that most did not improve the quality of care or reduce the cost of treatment.  Nonetheless, with the continuing growth in the number of people with chronic diseases—68% of Medicare patients have at least 2 chronic diseases and 14% have six or more—disease management remains popular as a common-sense approach that seems as though it ought to work. And a study in this week’s Annals of Internal Medicine suggests that maybe it does.

The article is a “systematic review and meta-analysis,” or an attempt to get at the truth by combining findings from many different studies. As an aside, the authors initially identified nearly 3000 articles about disease management, but ended up analyzing only 18 since the overwhelming majority were not of sufficiently high quality to be worth including. These 18 clinical trials all used “nurse-managed protocols” to guide the outpatient treatment of such diseases as diabetes, high blood pressure, and elevated cholesterol. The results? Use of these protocols by nurses led to small but statistically significant falls in blood sugar levels, blood pressure, and LDL (the “bad” cholesterol). The article concludes that nurses “are in an ideal position to collaborate with other team members in the delivery of more accessible and effective chronic disease care.” In other words, nurses should take over the function of managing chronic disease.

I have no reservations about handing over large chunks of primary care medicine to nurses—in fact, I think that nurses, particularly nurse practitioners, are better suited to primary care than many physicians and should do more than just follow flow charts. If all that's needed is to stick to clearcut guidelines, then a smart machine would be better than a nurse. But I do have concerns about the mindless application of algorithms to patient care, at least for older patients with multiple chronic illnesses. In younger, less complicated patients, preferably those with only a single disease that requires managing, simply following the optimized treatment strategy is likely to be a good idea. But in older patients with “multimorbidity,” as having multiple chronic conditions is increasingly called, practicing algorithmic medicine leads to disaster.

Suppose I’m seeing an 85-year-old woman with high blood pressure and diabetes and Parkinson’s disease. Call her Janet Dover. Optimal medical management of the high blood pressure means use of a diuretic. Tight control of diabetes means keeping the average blood sugar down, even if that means occasional dips to dangerously low levels. And control of Parkinson’s disease involves using a drug such as Sinemet. But there’s a problem with giving this patient a diuretic and a hypoglycemic agent and Sinemet all together, even if each individually would be a good idea. Both diuretics and Sinemet tend to make blood pressure fall when a person stands up and low blood sugar tends to make a person unsteady on her feet. So give Mrs. Dover all 3 medicines and the next thing you know, she will stand up, be dizzy and off balance—and then she will fall and break her hip.

Good geriatric care is all about figuring out how to treat someone like Janet Dover. It’s not easy and it depends both on her particular combination of diseases and on her willingness to make certain tradeoffs. But it’s not something that can be done by following a protocol, whoever is in charge of the protocol.