Is Medicare Entering the 21st Century?

       The do-nothing Congress may be doing something. In the immediate aftermath of the Senate’s third and hopefully final failure to “repeal and replace” the Affordable Care Act, the Senate actually passed a health care bill unanimously. With little public fanfare, it approved CHRONIC (the Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017). This bill, if it is not eviscerated or rejected by the House, takes a few important steps in the right direction.

         As a useful summary in the Health Affairs blog explains, the bill supports changes in four domains: home based care, managed care, telehealth, and accountability. In the arena of home based care, the law extends the successful “independence at home” demonstration project for two years, increasing the number of participants from 10,000 to 15,000. This is a relatively small modest program that does something critically important for some of our sickest and most complex patients—it moves the nexus of care from the hospital and the office into the home.

         In the area of managed care, the law does something quite remarkable. It incentivizes further use of Medicare Advantage programs, a long-standing Republican objective since they see Medicare Advantage as a way of privatizing Medicare. But one of the ways it does this is to allow programs to expand benefits to include social supports and help with activities of daily living. It’s a tiny wedge that could signal the beginning of a recognition that social factors contribute to health. This is the message of the book, The American Health Care Paradox by Elizabeth Bradley and Lauren Taylor  in which they argue that the reason Americans spend so much more per capita on health care than any other developed nation—and achieve poorer results—is that we substitute medical benefits for social benefits, to the detriment of well-being. We are a long way from allowing federal money to be used to pay for gardening supplies, say, so that a person with dementia would be happy puttering around at home and not become agitated and restless, perhaps triggering pharmacological treatment or even nursing home care, as has happened in the UK. But it’s a start.

         The telehealth expansion is another one of those strategies, such as electronic medical records, that on the surface is very appealing, but for which the evidence of effectiveness is mixed. It feeds nicely into the conviction that there are technical fixes to the American health care system, rather than major structural problems that must be addressed. Probably not the best use of scarce resources, but not a terrible idea.

         Finally, the Act mandates that the GAO carry out three investigations to assess the consequences of various strategies that have been piloted or proposed. One of these is a special reimbursement code for physicians to formulate a comprehensive care plan for patients with certain serious conditions. Another is whether Medicare Part D should lift its ban on drugs that help patients lose weight. The GAO is usually thorough and unbiased in its evaluations. All sound efforts at systematic evaluation—as opposed to wholesale, uncritical adoption of policies and programs—should be supported.

          Will the House pass the bill? Will it discover the most interesting parts of the legislation, ie the provision that lets Medicare Advantage programs offer benefits that are not “medical” in the conventional sense? We shall see. Tell your representative that if s/he wants to take credit for something, this would be a good place to start.

Parachuting through Life

Last week I saw the play “Ripcord” at the Huntington Theater in Boston, a hilarious comedy by David Lindsay-Abaire, and one of the rare plays that features life among the older set. Ignore the unrealistic depiction of assisted living—the playwright does not seem to distinguish between assisted living facilities and nursing homes—or the mischaracterization of who live in assisted living—the play features two women who are entirely too vigorous to require assisted living, let alone the nursing-home-like facility in Ripcord. It’s nonetheless a vivid, if exaggerated portrait of some of the poignant struggles of older life. Ripcord introduces us to two of the zaniest and most memorable elderly fictional characters in recent memory, Abby and Marilyn, forced by circumstance to become roommates.

Both Abby and Marilyn, in their own very different ways, need to come to terms with troubled relationships. Marilyn was married to an alcoholic and perhaps abusive man; Abby’s only son is a drug addict from whom she has long been estranged. Both women find themselves in a new phase of life and have to adapt to straitened circumstances, a task that Marilyn performs with grace and Abby with vitriol. But redemption comes for both of them, as Marilyn’s ability to see the good in everyone, from the aide at the facility to her lugubrious roommate finally rubs off on Abby, and Abby’s insistence on telling-it-like-it-is allows Marilyn to acknowledge and accept the flaws in her marriage.

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In its eccentric and sometimes over-the-top fashion—the “ripcord” of the title refers to the cord the two older women must pull to open their parachute while skydiving—this play brings to life one of the major insights of contemporary geriatrics: at least as important as pills and procedures for a good quality of life in old age is a robust social network. In the end, it is not fame or fortune that mark a life as having been worth living, but the relationships we forge with others.

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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!

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It's the Social Stuff, Stupid

Health care policy mavens are finally recognizing that we need to do a better job taking care of the sickest and costliest patients in American society. These are people on whom we spend a large percentage of our health care dollars without much to show for it, either in terms of standard health care outcomes or quality of life. Many of them have advanced illness. Many have multiple chronic diseases plus functional impairment plus extensive social needs. They’ve gotten the attention of people like David Blumenthal, who published an article called “Caring for High-Need, High-Cost Patients—An Urgent Priority” in the New England Journal in September and another article in JAMA sounding a similar call to action a few weeks later. They are the focus of the Coalition to Transform Advanced Illness, which produced a white paper mapping out a strategy for care and which just held a National Summit on Advanced Illness Care. Everyone defines the relevant population slightly differently and everyone makes somewhat different proposals for moving forward. One of the most creative is an idea that has been tried in England with good results.

This model gives high need patients a personal health care budget. The budget is determined by negotiation between the patient and the health care team. It “relies on a goal-setting and care-planning process in which patients and health care teams consider medical and social needs.” The budget allows payment for home supports and for technology that facilitates their remaining at home. It includes coverage for unusual and somewhat controversial non-medical needs such as a garden shed for someone with dementia so he could stay home because he had something to keep him occupied—the alternative was for him to become agitated and restless and quite likely require sedation and/or institutionalization. Interestingly, the budgets exclude access to primary care and hospital care, which are uncapped. Studies to date have found the system cost effective and associated with enhanced quality of life for the participants.

The result is not entirely surprising in light of the pioneering work done by Elizabeth Bradley and Lauren Taylor, popularized in a NY Times article in 2011 (and recently the subject of a book, The American Health Care Paradox.) What these researchers found was that though the US spends as much as 50% more than other developed countries on acute hospital care, imaging studies, lab tests, and other standard medical care, it spends much less than most other OECD countries on social services including old age pensions, disability, family support, and housing. If you combine the expenditures on both health and social services to give the true per capita spending in each country (with the amounts adjusted for GDP), it becomes clear why American health outcomes are so often inferior to those achieved in other countries: our total per capita spending is actually less than that of similar countries. The US over-invests in medical care and under-invests in social services.

A personal health budget that allows individuals to buy social services and other not strictly medical items that have the potential to enhance the coordination of care—a smart phone or a laptop, for example—is a way to compensate for America’s weakness. It fits into the prevailing ethos of individual control and of having “skin in the game.” 

If dressed up in sufficiently capitalistic sounding language, the proposal might even pass muster in a Republican-controlled federal government. It could finally transform care for the sickest, most vulnerable patients in the US health care system--and save money, too.

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Beyond Doctoring

I’ve long been amazed by the legerdemain that went into deciding what Medicare will cover and what it won’t. I’m not talking about decisions made in the past decade about what procedures to pay for, by and large rational decisions that have been based on a careful analysis of the evidence supporting their efficacy. I’m talking about some of the most basic aspects of Medicare, such as its exclusion of long term care. Now I recognize that the main concern of those who crafted the 1965 legislation was to provide some kind of health insurance for older people without busting the budget. To achieve this end, they decided to distinguish between things that are medical (which Medicare would ostensibly cover) and things that are not (which it wouldn’t). What that distinction has meant is that housing, transportation, diet, and all kinds of other nominally social goods are off limits for Medicare coverage. A new study by Elizabeth Bradley and her colleagues at Yale shows just how arbitrary—and often counterproductive—such a conceptual divide actually is.

Following up on their groundbreaking work in which they showed that countries with higher social service spending relative to health care spending had better health outcomes, the study team compared the performance of the 50 states (and the District of Columbia) over a 10-year period, from 2000-2009. They defined the extent of each state’s investment in social services by calculating the ratio of social service plus public health spending (on education, income support, nutritional assistance, housing, transportation, and the environment) to the state’s total government health care spending (Medicare plus Medicaid). Then they examined the relationship between this ratio and eight health outcomes (including the percent of the population that is obese, has asthma, or has functional limitations, and mortality rates for heart attack, lung cancer, and diabetes). What they found is that states with higher ratios of social to health spending had significantly better health outcomes (in 7 of the 8 domains).

It's striking that the variability in spending on health care (as a percentage of GDP) across the states is considerable, ranging from less than 4 percent in Colorado, Utah, and Wyoming to nearly 10 percent in Maine, West Virginia, and Missouri. Likewise, the variability in spending on social services and public health is dramatic, going from about 12 percent to over 20 percent. The net effect is that the allocation of resources between social services and health care differs substantially from one part of the country to the next.

It’s a complicated study and I’m sure that methodology mavens will have a field day with it. But the attempt to assess the contribution of social supports to outcomes is so reasonable and the results are so striking that we have to take very seriously the idea that social factors are a major determinant of health and well-being. I’m convinced this is particularly true in older people, whose quality of life is at least as affected by where they live and their ability to find meaning in life as it is by their physical ailments. I suspect that this study is as important as work by Michael Marmot showing that health worsens as people descend the social ladder—not just because of income inequality, but also because of discrepancies in social status. If we want to foster good health, which the World Health Organization defines as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” we need to focus on relationships and housing as well as on drugs and devices. And for older people, that may mean user-friendly computers and better assisted living facilities rather than a left ventricular assist device or a new monoclonal antibody.