What the New Year Will Bring

I’ve been searching for something upbeat to say about health care for older people in 2017. It’s been difficult to find anything newsworthy. The best I could come up with was that the direst predictions might not come to pass. Speaker of the House Paul Ryan says he wants to privatize Medicare by instituting “premium support,” which means giving people fixed amounts of money to buy health insurance on the private market instead of using government-run Medicare. But he might not get his way; after all, there are 46 million older people on Medicare and they like their program. Assurances that any changes won’t go into effect for several years may not be good enough. The nomination of Georgia Representative Tom Price to serve as head of the Centers for Medicare and Medicaid Services strongly suggests there will be a push toward substituting block grants for the federal Medicaid program, which would mean large cuts to Medicaid in many states. It might not happen; there are roughly 6 million older people who are dually eligible—they qualify for both Medicare and Medicaid, and they survive thanks to the current arrangement.  And then there’s the vaunted repeal of the Affordable Care Act, which might mean axing the Center for Medicare and Medicaid Innovation, an institute that has been testing strategies to improve quality and save money, as well as PCORI, the Patient Centered Outcomes Research Institute, a major source of grants for studies of innovative health care programs. Congress might leave those parts of the ACA intact, but CMMI was budgeted $10 billion for the period 2010-2019, of which about $3.5 billion remains. This money looks to me to be ripe for cutting by an administration that touts ideology as the basis for decision-making, not science. But surely there must be something uplifting to say about the new year. Judith Graham of Kaiser Health News suggests there is.

Beginning in January, 2017, Medicare will introduce new rules that offer incentives for physicians to change the way they care for the sickest, most vulnerable older patients, those with multiple serious chronic conditions, those with dementia, and those suffering from mental illness, especially depression. Medicare is changing its reimbursement system for “complex chronic care management.” Basically, it will pay more for coordination of care and require jumping through fewer hoops to get the extra payments. Medicare is also going to be more generous in paying for comprehensive dementia assessment—if physicians follow a number of rules. They have to assess their patient’s ability to perform activities of daily living, they have to evaluate behavioral symptoms, they need to review medications, and they need to use standardized tests for assessing cognition. Finally, they will have to elicit the patient’s goals and values and determine the caregiver’s knowledge and resources to develop a care plan for the patient—including plans for what to do when the patient becomes acutely ill. Medicare will offer an incentive for primary care doctors and behavioral health specialists to work together to deliver effective care for older patients with mental illness. Finally, Medicare will recognize that taking care of elderly patients involves more than classic “visits” consisting of a doctor sitting opposite a patient, taking a history, doing a physical exam, and prescribing tests or treatment: it entails such activities as talking to family members and reaching out to community service providers. Recognizing the value of physician work that doesn’t involve face time with patients means reimbursing physicians for their time and that’s exactly what Medicare will initiate.

These are all good developments. Physicians do need to coordinate complex chronic disease management and they ought to properly assess patients with cognitive impairment and develop an advance care plan for them. Similarly, they have to be able to spend time working with families, caregivers, and other professionals to do a good job for their oldest patients. But whether tweaking the fee-for-service system to achieve these ends will work is another question. What we know works are special programs for eligible patients, programs such as GRACE (Geriatric Resources for the Assessment and Care of Elders) or PACE (Program of All Inclusive Care for the Elderly) or Guided Care. These are comprehensive programs with a dedicated staff of physicians, social workers, nurse practitioners, and others who already provide complex care management,  who already know how to evaluate memory, and who often work with behavioral health as well as caregivers. Whether encouraging primary care doctors to adopt these approaches simply by offering to pay extra for incorporating these strategies into routine practice will be equally effective is far from clear. But it might be a step in the right direction. And if there’s money available to measure whether it works or not, we might actually find out.

They All Add Up

With so much attention rightfully devoted to big ticket items in medicine such as the new drug for hepatitis C that costs $1000 a pill or high tech devices such as the continuous flow left ventricular assist device, which costs on average about $200,000 to insert, not many people are talking about the little ticket items. But the reality is that spending a small amount per person on a huge number of people adds up to just as much—or maybe more—than spending an enormous amount  per person for just a few individuals. So I was very pleased to see a research letter in JAMA Internal Medicine about that lowly test, the urinalysis. 

I was pleased that the authors looked at the consequences of the rampant ordering of urine tests in people with no symptoms suggestive of either an infection in the bladder or kidneys or acute kidney dysfunction, the only circumstances in which urinalyses have been found to be meaningful. The reason, quite simply, that most urine tests are useless or, as the article suggests, actually harmful, is that the majority of older people have bacteria in their urine. What this means is that the injudicious ordering of a urine test will far more often produce a “false positive” result than a “true positive.”

It so happens that twice in one morning of seeing patients this week, I was asked to order a urine test for no good reason. To be fair, the well-meaning daughters of the patients who requested the test, quite insistently, I might add, thought it was with good reason. Their mothers were being diagnosed with dementia, a condition that had developed insidiously over a period of at least a year and probably several, and they were hoping I would identify a “reversible cause” of this otherwise progressive, ultimately fatal illness. Neither patient, however, had any symptoms to suggest a bladder infection: they did not have burning on urination, they did not have urinary frequency, they had no fever or flank pain. One lady was 96; the other was 91. Since the majority of elderly women have bacteria in their urine, I was concerned that if we got a sample from these two (no mean feat if we wanted a “clean catch” specimen, uncontaminated by bacteria from the surrounding skin and from stool), it would show bacteria. But if we did anything with the result—and what was the point of getting the test unless we were planning to treat the ladies in the vain hope that a course of antibiotics would cure their dementia—we would do little more than expose them to a risk of another problem such as clostridium difficile colitis, a potentially serious, occasionally lethal infection common in debilitated older people that typically results from killing off other bowel bacteria with antibiotics.

So what did the new study find? The authors looked at 403 consecutive adult patients admitted to the general medical service of a hospital in 2014 and 2015. They found that in this group, who somewhat surprisingly had a median age of 79, 62% had a screening urinalysis at the time of admission. Fully 84% of these individuals lacked any symptoms suggestive of a urinary tract infection. Of the asymptomatic patients who were screened with a urinalysis, 30% had a positive test. Of those with a positive test, 22% were treated with antibiotics.

Maybe this is actually reassuring: only 30% of asymptomatic patients had bacteria in their urine, not the 90% the authors quote from the literature. And only 22% of the asymptomatic patients with a positive test were given antibiotics, not everyone. 

The research letter in JAMA Internal Medicine leaves many questions unanswered. We don’t know why so many asymptomatic patients had a urine test ordered—perhaps the physicians believed that the fall or fainting episode that triggered the hospitalization was in fact caused by a bladder infection, which is conceivable, even if dementia (what my patients suffered from) is not. We don’t know what proportion of those who were needlessly treated developed complications because of the antibiotics they received. We can’t measure just how much the injudicious use of antibiotics in situations such as this contributes to the development of bacteria that are resistant to multiple antibiotics, bacteria that go on to cause real disease that is phenomenally difficult to treat. 

We do know that there are over half a million people age 65 and over hospitalized each year according to the National Hospital Discharge Survey. If over half of them have an unnecessary test, and if a third of those tests are positive, and a fifth of those positive tests lead to potentially risky treatment, that’s still a lot of bad decisions. All those small ticket items add up, and we need to pay attention to the little decisions we make every day, not just to the big decisions we make once in a while.