To Cover or Not to Cover

A chest CT scan showing what is almost certainly lung cancer: the Centers for Medicare and Medicaid Services will decide soon whether to cover screening for lung cancer with CT scans. The debate heats up as the decision nears. My thoughts coming next weekend.

The Coming Cataclysm

Some time in the next 6 years the world will experience an unprecedented cataclysm. Not a tsunami or an epidemic or a large scale war, although those are possible, too. This seismic shift will go undetected by the majority of the world’s population and yet it will change our lives. Between 2015 and 2020, for the first time in world history, the population of people over 65 will be greater than the population of children under 4.

It’s all nicely laid out in a report issued a few months ago that didn’t get very much attention. I didn’t notice it at all. It was the US Census Bureau’s Report “65+ in the United States” and it consists of nothing but statistics. Most of the observations and the predictions are nothing new: the population of older people has grown (it reached 40.3 million in 2010); the median age is increasing (up from 22.9 in 1900 to 37.2 in 2010); life expectancy has shot up (going from 47.3 at birth in 1900 to 78.7 at birth in 2010 and going from 11.9 years at age 65 in 1900 to 19.2 years in 2010); more women than men make it to old age (in the over 90 set, there are only 38 men for every 100 women); the population is becoming more diverse: 84.8% of the population self-identify as white in 2010 compared to 86.9% in 2000).

But buried amid the welter of interesting but not novel data about the US are some striking statistics about the entire world. First and foremost is the unprecedented demographic shift that will take place between 2015 and 2020: the total number of people over age 65 will exceed the number who are 4 or younger. This is because both fertility and mortality rates have been falling. As a result, people over 60 went from 8% to 11% of the population between 1950 and 2011, but by 2050 they will make up 22% of the world's population--2 billion people. Looked at a little differently, the global population is projected to increase by a factor of 3.7 between 1950 and 2050, but during that same century, people who are 60+ will go up by a factor of 10 and people who are 80+ by a factor of 26. 

Today, the countries with the highest proportion of people over 60 are Japan (31%), Italy (27%), and Germany (26%) with 7 other European countries not far behind. But the countries that are aging most rapidly include 4 in the Middle East (UAE, Iran, and Oman) and 4 in Asia (Singapore, Korea, Viet Nam, and China).

Accompanying the shifting age distribution will be an ever more dramatic dependency ratio: the number of people over 65 for every 100 people aged 20-64. This means that fewer and fewer young people will have to sustain more and more old people. And it will be in the low and middle income countries that all this transformation will be occurring most rapidly.

The reason all this matters is that it will put an enormous strain—economic, medical, and social—on everyone, but especially on the poorest countries in the world. It will affect demand—for goods (more walkers than tricycles) and for labor (more personal care attendants than elementary school teachers). The net effect may be as destabilizing as nuclear weapons. As a position paper published by the State Department and the National Institute on Aging put it, global aging represents a “triumph of medical, social, and economic advances over disease”—but it also represents an enormous and most governments have not even begun to plan for the long term.

So we have one more thing to worry about, along with climate change and religious fundamentalism and infectious diseases. What can we do about it? We do not need to accept the doomsday scenario of massive workforce shortages, asset market meltdowns, economic growth slowdowns, financial collapse of pension and healthcare systems, and mass loneliness and insecurity. But we do need to take steps now.

There are lots of interventions that can make a difference. 

One is to raise the normal legal retirement age. Another is to use international migration. A third is to reform health care systems, incorporating new models of long term care. A fourth is to encourage businesses to employ older workers, enabling them to work part time and facilitating their continuing productivity through environmental modifications that address mobility, vision, hearing, and other deficits. Economists, sociologists, demographers, historians and physicians at places including the World Bank and the Stanford University Center on Longevity have come up with a menu of strategies.

It’s up to all of us to pressure both the private and public sectors to act. Contact your senators and representatives. Write letters to the editor to major newspapers. The time to act is now.

Crossing Over

See Sunday's post for a discussion of the coming cataclysm.

From Dust to Dust (or Dustbin?)

The new IOM report, “Dying in America,” is a masterpiece. Written in the matter-of-fact language typical of non-partisan reports by committees of experts, it makes recommendations with which no rational person could possibly disagree. Of course a few extremists have already gone on record as disagreeing: a spokesman for the National Right-to-Life movement was quoted in the NY Times as claiming that the report’s alleged focus on “cost slashing” would reinforce “well-founded fears” that advance care planning is intended to “push patients to accept premature deaths.” The truth is that the report says relatively little about cost and what it does say is simply that a side effect of following its recommendations, suggestions made in the spirit of improving the quality of care and assuring that patients’ wishes are followed, will likely be a fall rather than a rise in the cost of health care.

The report includes “clinician-patient communication and advance care planning” as the topic of one of its 5 recommendations, and it is presumably this section that is the core of the right wing critique. But the explicit goal of advance care planning is to enable patients to participate in decisions about their health care and to make those decisions in accordance with their values, goals, and (informed) preferences. The report rightly recognizes that this isn’t going to happen unless clinicians take the initiative and that all the planning in the world will be inconsequential unless it is implemented when you become ill. The idea that discussing what kind of medical care you want near the end of life is tantamount to suicide is patently absurd. It would be more accurate to say that failing to discuss your wishes is tantamount to assuring you will spend your final days in the hospital, tethered to machines, and in pain.

While the recommendations of “Dying in America” are straight-forward and unobjectionable, they are also cleverly designed to be “actionable,” to lead to concrete steps to promote change. Its recommendation regarding the delivery of care states that “government health insurers and care delivery programs, as well as private health insurers, should cover the provision of comprehensive care for individuals with advanced serious illness who are nearing the end of life.” This is in marked contrast to the language of the IOM’s 1998 report, “Approaching Death: Improving Care at the End of Life,” which addressed the same theme by urging that “people with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skillful, and supportive care.” The only way that patients can “expect” to receive this kind of care is if the delivery system provides it.

In a similar spirit, “Dying in America” tackles professional education and development by urging that certification, licensure, and accreditation of clinicians require evidence of competency in palliative care. By contrast,  the earlier report exhorted educators and other health professionals to “initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to care well for dying patients.” Without specifying what those changes are or requiring that they be reflected in licensing exams or accreditation processes, not very much will—or did—happen.

Finally, the new report singles out payment systems as critical to promoting change, suggesting that health care delivery systems—the networks of hospitals, doctors, and clinics that actually provide medical care—must provide the services that comprise comprehensive palliative care and health insurers must pay for them. The preceding report acknowledged the role of financing, but embedded its recommendation amongst a series of quality improvement measures and spoke in very general terms of the need to “revise mechanisms for financing care so that they encourage rather than impede good end-of-life care.”

The weakest recommendations of both old and new reports on dying are for ongoing public education and engagement. Other than the specific suggestion that professional societies should publish brochures and that government agencies should support relevant research, there is little beyond a vague exhortation that faith-based organizations, consumer groups and others talk about the end of life. Previous public engagement campaigns, of which the Robert Wood Johnson’s multi-million dollar “Last Acts” program was the most spectacular and the “Conversation Project” the most recent, proved disappointing. Perhaps the forthcoming campaign, to be supported by the same anonymous donor who subsidized (but had no control over the contents of) the current report, will elaborate further.

My main concern is that this spectacular report will be filed away, as happens with so many comprehensive, thoughtful reports on all sorts of topics Certainly the IOM has had some notable successes. “To Err is Human: Building a Safer Health System,” issued in 1999, did shine a bright light on medical errors and catalyzed efforts to make American hospitals safer. But the IOM has produced 898 reports, according to its website. How many of those have had an impact and how much impact have they had?

I could just as well ask: What makes a book a best seller? Why do certain fashions catch on and not others? Publicists have their own ideas about how to sell books (which, speaking from experience, tend to be pretty unimaginative and outdated); Madison Avenue has its model for advertising campaigns and marketing strategies. Malcolm Gladwell, in his book “The Tipping Point,”itself a bestseller, argued that to create a “social epidemic,” you need 3 crucial kinds of people (connectors, mavens, and salesmen), you need to make sure the content is “sticky enough” to be retained by those who are affected, and you need to be sure the context is right. 

“Dying in America” lays out the facts and the arguments. It offers "actionable" recommendations, but the question is whether anyone will act on them.  The implementation campaign must begin now, otherwise this magnificent report on “dust to dust” will go into the dustbin.

On September 17, the Institute of Medicine will release its report, "Approaching Death: Addressing End of Life Issues," which will be the subject of my next post.

The Methuselah Prize

A startling new project was unveiled last Tuesday in the San Francisco Bay area. No, not Apple’s iPhone 6 or its watch, but the Palo Alto Longevity Prize. Never heard of it? Well, you still have a few more months to sign up to enter the competition to win $1 million for unlocking the secret to immortality. Is this just hype or is there some hope here for an important scientific breakthrough?

The basic idea is this: what we are doing now, attacking the maladies of old age one at a time, is simply trading off one bad disease for another. We’re already succeeding: the death rate from cardiovascular disease has fallen over the past several decades—and the death rate from Alzheimer’s disease has risen. As long as human life expectancy remains stable, we’re talking about a zero sum game in which you fix one problem and substitute another. So far, it looks as though dementia will be the big winner, which makes research aimed at turning off the switch that triggers all the diseases of old age very appealing. The underlying assumption of longevity research is that the degenerative diseases such as cancer, heart failure, and dementia are the result of the aging process. Preventing all the conditions that both limit life’s duration and impair its quality seems far more attractive than the disease-specific approach. But is it feasible and is it ethical?

The majority of credible scientists believe that life-extension is a very hard problem whose solution is not around the corner. The Palo Alto Longevity Prize, to the credit of its mastermind at Palo Alto Investors, Yoon Jun, is focused on somewhat more modest and potentially achievable goals. Part one of the prize is $500,000, to be awarded in June, 2016. It will go to a team that can restore the adaptive capacity of a laboratory animal; specifically, an aging animal will need to regain the heart rate variability characteristic of its youth. Part two of the prize is another $500,000 award, to be granted a year later to a team that increases an animal’s longevity by 50%. In both cases, the scientists will have to achieve their goal by enabling the animal to preserve homeostasis—the ability to maintain the status quo (temperature, blood pressure, etc) in the face of a stimulus, a capacity that is gradually lost with aging. Is this a worthwhile goal?

Impaired capacity for homeostasis is at the heart of frailty. The reason people lose their balance and fall easily, or get pneumonia when they contract the flu, or become confused when they are hospitalized is that they are vulnerable to modest “stresses.” So the key to physical frailty, and quite possibly to cognitive frailty (dementia) as well, is maintaining homeostasis. The Longevity Prize seeks to figure out how to do just that, but it is not without risks. As the Struldbrugs of Gulliver’s Travels showed, immortality without eternal youth is tantamount to hell-on-earth: failing vision, declining hearing, impaired cognition with no escape through death. Suppose unlocking the key to immortality does indeed prevent cancer and heart disease—but not arthritis and visual loss? The idea is to prevent all the degenerative conditions of old age, but suppose there isn’t just one switch, but several?

Even if we had confidence that achieving a longer life would not create a race of Struldbrugs, is it a good idea to devote scarce resources to trying to find the key to immortality? As NIH funding shrinks and the need to prioritize research questions grows, surely there are more urgent medical questions than how to live longer. Most people would opt to prevent premature death (infant mortality, teen suicide, cancer deaths in middle age) before they seek life-extension past the biblical allotment of three score and ten. Most physicians who witness the numerous ways patients suffer throughout life’s trajectory would recommend focusing on quality of life before quantity. And many people worry that if researchers did come up with an elixir of life, it would be so expensive that only a very small number of people could afford it, creating a new elite of Immortals.  So perhaps government should not fund longevity research, but what about the private sector? Google invested in Calico, a biotech startup devoted to finding ways to reverse aging. Earlier this month, Calico opened a new research facility in San Francisco where many talented scientists will search for the elusive spigot that can turn off the aging process. People in a free society choose to do all kinds of surprising things: they go bungee jumping, they sign up to travel to Mars, they smoke cigarettes. If Google wants to invest some of its advertising revenue on preventing the degenerative conditions associated with aging, why not?

If it’s reasonable to work on longevity, is offering a prize the right way to go? This approach got quite a bit of media attention a few years ago when Netflix promised $1 million to an individual or team that could improve its predictions of the movie ratings of individual viewers by 10%. This challenge stimulated a great many computer science graduate students and faculty members to spend hours trying to solve the problem. I know because my oldest son was one of them and he wrote about the math underlying the Netflix challenge for the on-line science journal, Science 2.0 when, after 3 years, a winner was announced. It turned out to be a good strategy for Netflix: for a relatively modest investment, the company recruited many fine minds to work on what would prove to be a difficult problem, without having to pay benefits or to pin their hopes for a solution entirely on one individual. Other organizations have issued similar challenges: the Millennium Prize, for example, announced by the Clay Mathematics Institute in 2000, offers $1 million for the solution to each of 7 great unsolved mathematics problems. As of today, only one of the 7 has been solved (and the individual to whom it was awarded, the reclusive and quirky Russian mathematician Grigori Perelman, declined the prize).

Perhaps the earliest use of a financial incentive to solve a scientific problem was the “Longitude Prize,” offered by the British Parliament in 1714 for an answer to how sailors could correctly establish their position at sea. Sailors had long used the stars to determine their latitude, but until the clockmaker John Hunter got his 20,000 pounds (worth about $5 million today) for solving the longitude challenge in 1765, they had been unable to determine their longitude. In recognition of the success of the first Longitude Prize—it was probably the last great breakthrough in navigation before Global Positioning Systems—a public private partnership in England recently launched the Longitude Prize 2014. This competition took an old approach and added a new wrinkle. A panel of experts came up with a list of 6 scientific problems in desperate need of a solution, and then asked the British public to vote on which one to sponsor. The election was held in June and the winner was the problem of antibiotic resistance: designing an easy to use, cost-effective way to test for antibiotic sensitivity at the point of care (which in turn would prevent doctors from giving a drug to which the relevant germ would not respond, an all too common scenario that both fails to cure the patient and also promotes further antibiotic resistance). The winner will receive 10 million pounds (about $16 million). Whether the competition will achieve its objective remains to be seen.  In many such competitions, including the Millennium Prize discussed above, nobody ever wins.

In sum, I doubt very much that the Longevity Prize will result in immortality and I’m glad that it’s a hedge fund and not the NIH that is sponsoring the competition. That said, it’s entirely possible that there will be valuable spinoffs from the kind of research that the prize is fostering, much as 19^th century anti-aging experiments using animal gland extracts led to hormone replacement therapy and tissue transplantation was stimulated by early 20^th century experiments in rejuvenation through grafting. 

Fountain of Youth

For an update on plans to locate the Fountain of Youth, see my next post.

Is Medicare on the Mend?

A buoyantly optimistic Paul Krugman proclaimed recently that Medicare’s woes are over—after a long period of seemingly relentlessly rising costs, costs that were rising so fast that they were clearly the major threat to the federal budget, Medicare per beneficiary expenditures actually fell last year. Economics guru and NY Times editorialist Krugman argues that the good news cannot simply be attributed to the recession because Medicare is a government program and therefore recession-proof. Now it’s dangerous to take issue with a force such as Krugman.  But I want to at least raise the possibility that Medicare expenditures are not immune to the economic downturn because of the large amount of money that Medicare beneficiaries pay out of pocket for health care. And if a patient doesn’t get a drug prescription filled, for example, because his co-pay is too high, then Medicare does not have to pay for that drug, and expenditures fall. In this vein, a report released in July by the Henry J. Kaiser Family Foundation, “How much is enough? Out-of-pocket spending among Medicare beneficiaries: a chartbook” is very sobering.

The main findings of the report (see chart in previous post) are that fee-for-service Medicare recipients spent an average of $4734 out of pocket for health care in 2010, up from $3253 in 2000--a 44% increase. Most of that spending is by those age 85 or older: they spent an average of $5962 out of pocket compared to only $1926 for those ages 65-74.  And older people with 3 or more “ADL deficits,” or difficulties carrying out basic daily activities, spent a mind-boggling $9200 on health care, mainly on services. Out of pocket spending went to items such as Medicare premiums, other supplementary insurance, and long term care. In addition, 11% went to paying for prescription drugs as Medicare Part D has evolved since its inception to include more and more cost shifting to patients.

Interestingly, my colleagues at the Harvard Pilgrim Health Care Institute, just published a study in Health Affairs in which they present data indicating that older patients are increasingly skipping pills, taking less than the prescribed doses of medicines, or failing to fill prescriptions altogether in order to save money: among patients with 4 or more chronic conditions, they found that while 14.9% experienced “cost-related medication nonadherence” in 2005, this rate fell steadily until it reached 10.2% in 2009, and then it began rising again, reaching 10.8% in 2011.

So it is entirely possible that the fall in Medicare costs reflects at least in part decisions made by patients to forgo particular pricey interventions. The result, predictably, would be savings to the entire Medicare program. Now whether such choices made by patients adversely affects their health is another matter.  The Health Affairs study assumes that non-adherence to medications is likely to lead to adverse health outcomes including worth health states and increased rates of hospitalization, especially in older individuals with multiple chronic conditions. They base their assumption on studies from the 1990s, principally conducted in the mentally ill and in Medicaid patients, that in fact showed that when patients did not take their medicines as prescribed, their clinical condition deteriorated. Whether the same would hold true for chronically ill older patients today is not so clear: there is ample evidence that older individuals with multimorbidity are at increased risk of adverse drug reactions the more medicines they take and that following the guidelines for all the diseases they have can cause falling, fainting, confusion, and other problems. Nonetheless, it would be preferable for physicians to make wiser prescribing decisions based on an understanding of physiology rather than leaving it to patients to decide which medications to forgo based on cost.

Medicare expenditures are falling and it behooves us to understand exactly why and to evaluate the consequences. Whether the cost saving strategies of the Affordable Care Act are responsible, and whether the particular decreases in costs have had any effect on patients’ health and well-being, is yet to be determined.

Out of Pocket Health Care Costs for the Frail are Over $9000

Here's an interesting graph from the Henry J. Kaiser Foundation's recent report on out of pocket health care spending by Medicare beneficiaries. More to follow on this topic in my next post.

Penny Wise, Pound Foolish

What drove me crazy about practicing medicine in a nursing home wasn’t the patients, although with their many medical problems often including cognitive impairment they were a challenge; and it wasn’t the families, though with their anxiety and attentiveness and sometimes their guilt they were an even greater challenge. What drove me crazy about nursing home medicine was Medicare billing.

When I saw patients in the nursing home, I was hemmed in by the fact that Medicare had a very clear idea of what constituted an appointment with a nursing home patient. According to Medicare, a “visit” (billing jargon) entailed a face to face “encounter” (more billing jargon) between a “clinician” (in this case, me, the physician) and the patient.

Once the patient and I were in the same room, I had a script to follow. I was first supposed to take a “history,” (medicalese for eliciting symptoms); then I was supposed to do a physical exam, which involved specified “elements” (examination of particular bodily parts). Finally, I was supposed to engage in “evaluation and management,” which might result in ordering lab tests or prescribing a medication. The problem was that in the nursing home environment, a history and physical, to be useful, looked very different from what Medicare had in mind. Many of my patients were demented and couldn’t possibly give a coherent history. Moreover, many of those who had relatively mild dementia could always be counted on to complain about something, so if it had been up to the patient, I would have made a visit every day. Many of the patients had medical conditions that required observation over a prolonged period, not just at one point in time. For example, a patient with dementia might have paranoid delusions that significantly affected his or her quality of life, but those delusions would come and go. A patient with Parkinson’s disease might have difficulty walking that fluctuated over the course of the day, depending both on random changes and on when the patient last took medication. As a result, the most meaningful history and the most useful physical observations had to be obtained secondhand—from nurses, nurses aides, and other staff members including physical therapists and social workers. I spent much of my time interviewing personnel about my patients, time that Medicare did not recognize as valuable because it was not part of an “encounter.”

Starting in January, 2015, Medicare will pay a special monthly “complex chronic management” fee on top of the usual reimbursement to primary care patients who care for patients in the office. But somehow the nursing home environment is assumed to be immune from the need for this kind of supplementary support. Calls to family members and discussions with other members of the interdisciplinary team are supposed to be part of the “evaluation and management” services that are “bundled” into the Medicare fee schedule. So it’s thought to be perfectly reasonable for a physician to be paid $92 in 2015 for a nursing home visit for an acute medical problem such as a new pneumonia (code 99309). To merit this payment, the physician must provide documentation that he or she has taken 2 out of 3 possible steps: obtained a detailed history, performed a detailed physical exam, or engaged in “moderately complex” medical decision making. Only if the physician takes a comprehensive history, performs a comprehensive exam, and engages in highly complex medical decision-making can he or she bill with the code“99310,” earning the somewhat more generous sum of $136. For comparison, note that a gastroenterologist is paid on average $220 for performing a colonoscopy, a 20-minute procedure. 

No wonder physicians often respond to a call from the nursing home about a sick patient with an order to send the patient to the hospital for evaluation. Send a frail nursing home patient to the emergency room and he has, I would guess, about a 90% chance of being admitted. So instead of paying a physician an appropriate amount for making a visit to the nursing home and instituting on-site medical care, Medicare would fork out a minimum of $5774 (the base DRG payment) for a 5-day hospitalization, exposing the patient to the risk of iatrogenesis. Does this make any sense?