My Mom is age 88 and lives in an Assisted Living arrangement in Richmond because of her dementia. Other than the non-skilled care she requires, she looks healthy and takes only a baby aspirin and thyroid medication each day. Mabel (an assumed name) is 86 and lives in the same facility, requiring non-skilled care due to her disabling rheumatoid arthritis. Otherwise, Mabel is pretty healthy as well and remains so mentally alert and sharp that she has become the eyes and ears for many of the residents on their wing. Mabel and Mom eat three meals a day together and recently I had the opportunity to visit for a few days.
On my last day in Richmond, Mabel expressed frustration over spending the entire day trying to schedule a mammogram, Pap smear, and routine blood work. The tests were all to be done at different locations and her son would need to take the day off work to drive. The logistics were simply maddening. Knowing much of Mabel’s medical history from talks we’ve had over the years, I asked her why in heavens name was she still getting such routine testing done. And the questioning made her even testier after spending an entire day on the task and furthermore, “I have the best doctor in the world who would not order these things if I didn’t need them.” She then reminded me the woman at the other table was 99 and still seeing her doctor regularly for tests, and there is another lady on the next floor up who is 104.
After letting the dust settle for a few minutes and to validate Mabel would still talk with me, I asked her if she thought Medicare would continue to cover these routine tests in the future as is done currently. To this question she declared her faith in AARP and said that today’s Medicare members had “paid their dues in full.” I guess this means Mabel expects no changes in Medicare’s benefit design and I think, for the most part, I agree.
Our government health payers have a difficult time reducing benefits. They reduce the allowed payments and let the free market system figure out the rest. Evidence based medicine is all well and good except for the fact that many well meaning groups don’t agree on the evidence, even when conducted under very expensive and extensive research protocols. There are always holes found in the data, allowing for sometimes great variances in interpretation. And for most medical practices, the evidence is truly weak or lacking all together. Regarding preventive health screening like what Mabel and I were discussing, I’m not aware of any study evidence on patients over age 75.
On a separate front, I read this week that Walgreens, in Illinois, was no longer going to service new Medicaid patients. The Medicaid reimbursement was simply too low and was below the cost of delivering the service. Plus, payments were months behind. Oh well, I’m sure someone will service these new Medicaid enrollees. When I was working in Chicago, we would see lines of patients out the door at the Stroger hospital pharmacy, in line for free medications courtesy of the Cook County Board of Health.
If the government and all health providers got together and agreed on how to spend the scarce resource dollar, maybe we could eventually brainwash the Nation and eliminate that large amount of wasted resources we keep hearing about…some estimate to be 70 percent of the medical spend. The problem is we rarely agree on anything, even when we’ve done the best we can do to study the question. Just look at the differences in recommendations from the USPSTF and the ACS, for example. So, is economic rationing really all that bad? We may find more people being served in a manner they believe is valuable, even if it includes a routing pap smear at age 88. By having the consumer pay out-of-pocket rather than simply squeezing the price to the level providers refuse to deliver, more people are likely to benefit. Having the ability for providers to balance bill a beneficiary for service not fully reimbursed by the insurer seems to me the logical solution. Is Walgreens giving us an early sign as to where we’re heading with Medicaid? Thoughts?
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2 comments:
Bob,
It had been some time since I had checked your blog, so when I saw your latest update posted this morning on Facebook I clicked on the link to read your thoughts. As I encountered Mabel with you, my mind drifted to the concluding remarks of the executive summary of a 1997 GAO report on federal health care expenditures during the first 5 years of the 1990s. As I have mentioned this study to you before I will not go into detail except to say they reflected what you encountered in Richmond – too many unnecessary services or services provided at an inappropriate level. Clearly, systemic and fundamental problems; but, how to address them - everyone's question.
As a significant portion of the country is in a heightened state of agitation concerning the Obama administration's political agenda they are looking to the basics, core values, what is increasingly referred to as "First Principles", for guidance as to how they should respond and what they may do to confront what they see. Scholars have identified the country's first principles to be: limited government, individual liberty, the rule of law, a free market economy, personal responsibility, and moral standards.
What if medical scholars and physicians were asked to state the core values, or "first principles" of medicine? Would a set of principles emerge that might serve as a basis for guiding the development of policy and an action plan? After "first do no harm" what would such a list of principles include?
Very well said as usual, and I appreciate your gentle push back to the fundamental tenents of human accountability toward one another. There is a lot to be said for the commandment to "Love thy neighbor as thyself". Following this command would truely change the world. With self-interest out of control, for sure less is more in moving the dial.
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