Stiff Upper Lip?

The British, I’ve argued previously, are ahead of us in health care for older people. They have more robust geriatric and palliative care programs than we do. They screen for frailty in older people and have a strategy for addressing the needs of those found to be frail. They devote a larger fraction of their resources to primary care (as opposed to specialty care) than we do, which benefits the aging. And data from the Commonwealth Fund consistently show that even though the UK spends a smaller percentage of its GDP and much less per capita on health care than does the US, health outcomes are typically at least as good and often better. In the fund’s most recent report, for example, the US does well in cancer care but has higher mortality from ischemic heart disease and higher rates of diabetic complications than the UK: death rate from IHD was 128/100,000 in the US compared to 98/100,000 in the UK and amputations in diabetics occurred in 17.1/100,000 in the US compared to 5.1/1000 in the UK. So the report published this month called “Health and Care of Older People in England 2017” was of great interest.

The basic demographic reality in England is the same as in the United States: the population is aging and the oldest old, those over age 85, are the fastest growing subset of the older cohort. And the economic reality in England may well foreshadow its American counterpart: over the last several years, the UK has been in the grip of belt-tightening fever, as government spending on both medical care and social services has been cut or its rate of growth slowed. The net effect is that gains in life expectancy leveled off by 2011, but more alarming, disability-free life expectancy at age 65 has been falling since 2011. Between 2005 and 2011, older women gained a full half year of good health and men gained 0.3 years. Since then, most of those gains have been lost.

Another result is that over a single year, there has been an 18 percent increase in the number of people who do not get the basic help with their activities of daily life that they need.

The authors of the study conclude that the “massive reduction in publicly funded social care has had a severe impact on older people, families, and carers.” Five years of cutbacks have led to a 26 percent increase in the number of older people with unmet needs for care and support. And this is in a country where there is a lower rate of obesity and fewer chronic diseases per person than in the US.

What’s particularly interesting is that the UK has for years devoted far more resources to social support for older people than has the US. The possibility that the mediocre or downright poor health outcomes for Americans (despite a per capital medical expenditure of more than double that of other developed countries) is attributable to lack of spending on social services was first raised by Elizabeth Bradley at Yale. She found intriguing evidence that the added dollars lavished on physician care, hospital care, and diagnostic tests, among other outlays, were not nearly as valuable as the money spent on supporting caregivers and home care. And a recent RAND study, “Are Better Health Outcomes Related to Social Expenditures?” which was commissioned to challenge Bradley’s findings, instead confirmed them. Moreover, this analysis concluded that public social expenditures (as opposed to the private ones that are favored in the US) have a particularly strong relationship with health outcomes. It also found that certain social expenditures such as spending on old age care, translate into better health outcomes throughout the life cycle (ie support middle aged caregivers and they and their children are healthier). Finally, the study concluded that the role of social expenditures is magnified in countries with a high degree of income inequality—such as the US.

The US is on the brink of rolling back government programs. Presumably, what little support is currently provided to older people and their families is a candidate for the chopping block. The British experience shows us what sort of improvements in health and well-being are achievable for older people--and also what happens when social programs are cut. Caveat emptor!

-->

An Ounce of Prevention

Kaiser Health News, one of the best sources of reporting about issues affecting older people, ran a story last week about the re-emergence of “death panel” agitation. Most of us thought this non-issue was dead, but apparently Representative Steve King of Iowa has decided that the decision by CMS to reimburse physicians for advance care planning discussions should be euthanized by Congress. Accordingly, he has introduced a bill called “Protecting Life Until Natural Death” with the explicit goal of instructing CMS to stop paying for conversations about the end of life. Which is too bad, since CMS just reported than in the first six months of 2016 alone, close to 14,000 clinicians billed for such discussions for 223,000 patients.

The irony is that the very idea of discussions by patients and their families about how they wish the end of life to unfold was spurred by a concern that patients aren’t being allowed to die a “natural death.” Instead, they have been forced to endure a technological death, death on a ventilator, in an ICU, while iatrogenesis-inducing medication is pumped in. In fact, as Representative King may or may not be aware, some physicians and ethicists advocate substituting the phrase “allow natural death” for the still oft-misinterpreted “do not resuscitate.”

There’s another reason that the proposed legislation is misguided. While advance care planning conversations are often advocated as a means of avoiding unwanted medical intervention near the end of life, they are better characterized as preventive medicine. Enabling people to talk about what matters to them and how they wish to be treated if they are very ill, approaching the end of life, and unable to speak for themselves, has the potential to ensure that patients are neither over-treated nor under-treated. It gives them the opportunity to state clearly and unambiguously that they would want to be put on a ventilator if they develop respiratory failure in the setting of advanced emphysema, however small the likelihood that they will be able to be weaned from the machine. It gives them the chance to say explicitly that they would want to be maintained with a feeding tube if they are in a persistent vegetative state, even if there is no chance of ever emerging from that condition.

What advance care planning does is to enhance patient choice. It doesn’t give government –or physicians, or health care surrogates, or families—the right to decide what treatment a patient will receive when he or she is dying. It assures that patients will make their own decisions about what kind and how much medical treatment they want. Surely that’s what Representative King wants for himself.

The Price of Tom Price

The Senate confirmed Tom Price (R-Georgia) by a 52-47 vote as the new Chief of the Department of Health and Human Services this week. Much of the debate focused on Price’s ethically and legally dubious stock purchases. He bought stock in a medical device company--and then promptly authored a bill to increase Medicare reimbursements for that company’s products. Attention to Price’s many apparent conflicts of interest are important but should be taken up by the SEC as part of an investigation of insider trading. Unfortunately, with all the attention paid to financial shenanigans, there was correspondingly less attention paid to what Tom Price would try to do to Medicare and Medicaid.

In fact, there’s a great deal of speculation about what Tom Price believes or would do, and less reliable information about what he wants to do. What we do know is that he is an orthopedic surgeon (one of the medical device companies he invested in, and which stands to benefit from legislation he favors, is Zimmer, a leading manufacturer of artificial hips and knees) who strenuously dislikes the recently introduced “bundling” of payments for joint replacement surgery under Medicare. According to this plan, which so far seems to be lowering costs without adversely affecting quality, Medicare pays a single amount for all care involved in replacing a hip or knee: hospital care, the surgery itself, and post-surgical care for 90 days. Providers whose care costs less than the target amount stand to be paid a bonus and those whose care care exceeds the target amount are hit with a penalty. Programs such as this one are piloted by the Center for Medicare and Medicaid Improvement, an agency authorized by the Affordable Care Act--and Price has specifically tried to de-fund the CMMI.

What we know is that Price was one of the authors of “A Better Way,” the House Republican outline for replacing the ACA. This document strongly favors “premium support,”  a voucher program that would give patients a fixed amount of money with which to purchase a (private) health insurance plan. While this might simply be what Medicare already does with respect to Medicare Advantage programs, the current alternative to fee-for-service Medicare, it raises the question both of whether the vouchers could be used to buy a conventional Medicare plan and also how much control CMS would have over what must be included in eligible plans. 

We know that Price favors repeal of the ACA, which provides for free coverage of preventive services such as colon and breast cancer screening, and which has reined in Medicare costs by reducing payments to hospitals, skilled nursing facilities, and Medicare Advantage plans. Undoing the ACA has the potential to reverse all these trends. 

Finally, we know that Price is in favor of converting Medicaid to a block grant program—essentially turning it over to the states. Medicaid already demonstrates enormous state to state variation, with the contribution and standards of the federal government standing between a robust insurance plan and a total farce in states such as Alabama and Mississippi. Right now, 9 million of the 46 million Medicare enrollees are dually eligible—they receive both Medicaid and Medicare.

A far larger proportion of older, eligible voters go to the polls on election day than any other group. In 2016, voter turnout among the 65+ set was close to 60 percent; among those 18-29, it was under 20 percent. 

Older people count in the eyes of our elected officials, if for no other reason than that they vote. Maybe those enrolled in Medicare didn’t realize that a Trump administration would mean for them. But with the appointment of Tom Price, we know a little more. It's time for older people to speak up for Medicare.

The Last Stop

The United Kingdom is, in many respects, ahead of the United States in its approach to both geriatrics and palliative care. Cicely Saunders established the first modern hospice in London in 1967; the US did not open its first hospice until 1974, after Florence Wald spent a year at the St. Christopher’s Hospice in England to study under Saunders. 

While the US boasts that Dr. Ignatz Nascher—himself an immigrant from Austria—coined the term “geriatrics in 1911, Nascher is not exactly a stellar role model. He wrote in his textbook, “Geriatrics: Diseases of Old Age and their Treatment,” that “We realize that for all practical purposes the lives of the aged are useless, that they are often a burden to themselves, their family and the community at large. Their appearance is generally unesthetic, their actions objectionable, their very existence often an incubus to those who in a spirit of humanity or duty take upon themselves the care of the aged.” Far more attractive a founding figure is Britain’s Marjory Warren, who created the first geriatric units in English hospitals in the 1940 and whose work led the National Health Service to recognize geriatrics as a specialty in 1947. The US medical establishment only came to see geriatrics as worthy of recognition four decades later—and instead of awarding the field specialty status, chose starting in 1988 to allow physicians to receive a “Certificate of Added Qualifications in Geriatrics,” something less than full-fledged accreditation. The gap between the UK and the US remains to this day. So when the British report a study of the factors associated with whether people die in hospital or at home, it’s worth heeding their findings.

In both England and the US, most people who are asked where they would prefer to die say they want to be at home. Where people actually die is quite different. In England, 58 percent of people die in hospital and 18 percent at home. In the US in 2007, 24 percent of people over 65 died at home, up from 15 percent in 1989. The main change in the last decade, however, has been an increase in deaths in the nursing home: hospital deaths went from 38 percent to 35 percent, but nursing home deaths from 5 to 28 percent.

But England tried to do something about the discrepancy. England adopted the “End of Life Care Strategy” in 2008 to improve care in the final year of life and to prioritize home over hospital care. The new study examines what happened to patients dying of respiratory disease between 2001 and 2014.  What they found was that among the 334,520 people who died of chronic obstructive pulmonary disease and the 45,712 who died of interstitial lung disease, hospital death fell by 6 and 3 percent, respectively, after the introduction of the End of Life Strategy. In the several years before the strategy was initiated, the proportion of pulmonary deaths occurring in the hospital had remained constant.  But the improvements were wiped out for people who had multiple co-morbid conditions. And living in a city, especially London, lower socioeconomic status, and being married, also increased the likelihood of dying in the hospital.

Another study, this one from Belgium, may shed some light on why it was so hard to enable people with chronic respiratory conditions, assorted co-morbidities, and limited resources out of the hospital. This study of family physicians, nurses, and family caregivers used focus groups and semi-structured interviews to figure out the pluses and minuses of hospital care. They identified the usual weaknesses of the hospital: inadequate expertise in symptom management, an excessive focus on curative care or on life-prolongation, and poor communication. But they also revealed that for many people, the acute hospital is a safe haven. It is a place that offers hope even to people who acknowledge that they are terminally ill. It provides continuous support and peace of mind. And it is a place of last resort for people whose families are having difficulty caring for them at home.

As my colleague Jim Sabin and I argued a few years ago in our paper “No Place Like the Hospital,” what people say they want (ie to die at home) when they are perfectly healthy may be quite different from what they actually want when they are seriously ill and imminently dying. It’s not surprising that the more complicated their medical problems and the more constrained their financial and familial resources, the more attractive the hospital seems. But with the growth of inpatient palliative care consultative services—67 per cent of American hospitals now boast such a program —in-hospital care is improving. The findings of the Belgian study, with inadequate pain management, poor communication, and excessive attention to life-prolonging therapy, are no longer universally applicable.

To improve care at the very end of life, we need to do a better job in both the home and the hospital setting. In both cases, what is needed is a potent injection of palliative care expertise. If care is in the hospital, the family physicians, specialists, and nurses providing treatment should be advised by palliative care specialists. If care is in the home, family caregivers should have the support and resources of a sophisticated palliative care team. The issue is not so much moving care from one site to another as optimizing care in each location.