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.