Curing Medicare

Book Review.This might seem like a curious title for a blog post but it reflects a very serious national need. Medicare is the central method for financing medical care for those over 65. It brings major value but it has serious deficiencies. We are frequently reminded that the Medicare Trust Fund will shortly run low of money. Enter Dr Andy Lazris a gerontologist with over 25 years of experience caring for the elderly. In his book – Curing Medicare – he lays out the issues that truly need to be addressed if America’s seniors are to “Age Gracefully.”

Dr Lazris and I live in the same community but had never met nor knew of each other. A retirement community executive, knowing I was writing a book about primary care, urged me to meet him. Before our meeting the next week, I ran into an acupuncturist I have known for some time. He also spontaneously suggested I meet Dr Lazris and so did the CEO of a major nursing home chain. Each said Lazris was a terrific doctor, a humanist, a real “gem” and an all-around nice guy. With such a buildup it would have been easy to be disappointed. But I certainly was not.

Although he sees any adult patient, his practice is largely composed of elderly individuals living in retirement communities, assisted living or nursing facilities. He limits his practice to about 600 patients so each can get the time needed and deserved. He is at once humorous and wise, light hearted and dead serious. He clearly understands the needs of the elderly and likewise understands how Medicare works – including how it impedes care and encourages aggressive care when a more benign or palliative approach would be better medicine and certainly more humane. As he puts it, “sometimes less is more.”

Curing Medicare should be a must read by anyone who is over 65 and anyone who has loved ones that are growing older, in other words it is important for most of us to understand what he teaches us. Medicare has been a major medical and financial boon to most elderly individuals but it has some serious deficiencies and it behooves us to understand them. Dr Lazris writes from his personal experience and gives many patient vignettes to back up his observations. A major point is that it is often best to not diagnose and treat aggressively (or “thoroughly” as he puts it) but to use a more palliative approach. But Medicare in both its payment systems and its regulatory approach essentially dictates aggressive medicine, indicated or not. Whether in the home, an assisted living facility, a nursing home or the hospital, the pressures are for being “thorough”, often to the patients’ detriment if not outright harm. And such aggressive diagnosis and therapy are what make costs go sky-high. These and other problems are fully presented and discussed in a way that we can all understand and appreciate along with his commonsense recommendations for reforming Medicare.

Recently, Health and Human Services secretary Silvia Burwell announced that Medicare will shift from the current fee for service reimbursement methodology to one that rewards value, i.e., reduced costs yet improved quality. On the surface that appears like a responsible direction. But is it? In an Op-Ed in the Baltimore Sun, Dr Lazris lays out some critical issues that lead one to question the HHS rationale. He uses points and concepts discussed in detail in his book so a quick read at this link will be of interest to many potential book readers.

Overall, Dr Lazris presents us with an elegant approach to the care of the elderly, one that he personally uses as best he can despite the restrictions imposed by Medicare’s payment and regulatory dictums. He offers us commonsense suggestions on how Medicare could be vastly improved, offering patients much better quality of care yet at the same time offering Medicare (and our tax dollars) enormous savings. I recommend his book highly.

Next Time - Another book review - I Am Your Doctor by Jordan Grummet

Aging Gracefully Part 4 Comprehensive Primary Care For The Elderly

Comprehensive primary care is essential to good health, wellness and needed medical care during our elder years. It is critical to Aging Gracefully.

In the last few posts I wrote that Aging Gracefully physically requires attention to lifestyle/behaviors to assure good nutrition, plenty of exercise, reduced stress, no tobacco and – for preserving cognitive function – intellectual challenge and social engagement. That is what each of us needs to attend to but we also need a good primary care physician (PCP) to assist us on our journey. That PCP needs to have adequate time to listen and listen fully.

The Erickson Living retirement communities have developed an approach that appears to work well for its residents. Let me use it as an example. The fundamental concept is to assure that everyone has comprehensive primary care. The Erickson leadership learned that healthcare was of paramount importance to their residents. A strong program would be good unto itself but also a strong marketing attraction. After substantial study and trial and error they set the resident/patient number per doctor at a remarkably low 400 for their in-house salaried PCPs. They found that this 400:1 ratio was the ideal number of elderly geriatric residents per doctor in order to assure the quality, humanistic and integrative approach to care desired. (For comparison, the usual patient to PCP ratio is about 3000:1.) They have clearly demonstrated that this approach to primary care with a low number of patients per doctor (and a team that functions akin to a medical home) not only gives superior care but that it results in much reduced total costs of health care overall. 

According to the medical director, Matthew Narrett, MD, residents can have same or next day appointments for as long as needed, they are offered extensive preventive care (“It is never too late to prevent,”)    the PCPs are well versed in gerontology issues  and there is a strong commitment to listening. Some of the results of this approach: Chronic illnesses can be managed usually quite successfully without the need for referral to specialists but, when needed, specialists are readily available (many conduct office hours on site on a rotating basis eliminating the need to travel to a distant office). Hospital admissions are down absolutely and markedly so in comparison to equivalent groups of elderly individuals. The length of stay in the hospital for those who must be admitted is lower and the 30 day unanticipated readmission rate has consistently been below 11% (the national rate is about 20%plus) despite the average age of their residents being about 82, i.e., one would expect their average rate to be higher than the national rate for Medicare-covered individuals overall. Dr Narrett reported that resident satisfaction was very high. I confirmed that when I was at the Charlestown community to give a talk organized by residents. With no staff present, I asked the 90 or so attendees their impression of the healthcare program. I received only positive accolades.

At the Charlestown and Riderwood communities where I have toured (and other locations) the onsite clinic includes not only the PCPs, but one or more nurse practitioners, a podiatrist, and a suite for a visiting dentist, for an optometrist and for an audiologist. The podiatrist is full time (at the larger communities) but the others are there commensurate with the need. Various outside medical and surgical specialists (e.g., cardiology, gastroenterology, dermatology, orthopedics, etc.) offer office hours on site on a scheduled basis. The clinic has an on-site nurse to coordinate special needs such as preparing for surgery, returning to the community from the hospital, transferring to assisted living, arranging in-home special needs care, etc.

A Medicare Advantage Plan is also offered by Erickson Living to residents of their group of 18 continuing care retirement communities. In the Erickson plans (administered through United Healthcare) one can choose the on-site PCPs or continue with one’s own PCP, can access a wide range of specialists when necessary, can use most any hospital, can be driven to most off-site doctors’ offices at no cost, etc. Unlike Traditional Medicare where one must spend three days in the hospital in order to be eligible for Medicare to pay for the first 100 days of residential skilled nursing care,  this Advantage plan waives the required three day stay. In other words, if the resident would benefit, the doctor can make the decision and can arrange immediate referral to their on campus site. This of course eliminates a very costly and potentially hazardous hospitalization. There is also an on-site benefits specialist to assist residents with their questions. The most common plan costs substantially less than one might pay for both Medigap and Part D policies yet it includes greater benefits (e.g., basic dental) with few co-pays and no deductibles. 

Older individuals perhaps even more than others need comprehensive primary care. It is a critical aspect of Aging Gracefully. Unfortunately, most older people do not have the benefit of a PCP who can spend the time they need.

My takeaway from the Erickson model is that when the PCPs are allotted the needed time and can listen and think, the care is excellent, satisfaction is strong and the total costs come down substantially. It also means that the PCP can get back to relationship medicine where trust builds and healing is possible.

I am not advocating for Erickson Living or that you move to a retirement community but my recommendation is definitely that you seek out a PCP who can and will offer the time you need to assure good healthcare so that you can Age Gracefully.

Disclaimer – I have no financial relationship with Erickson Living. It is used solely as an example to demonstrate the utility and value of a PCP (along with a well-functioning team) who can offer each patient the time necessary for comprehensive primary care.

Aging Gracefully – Part 3 The Importance of Comprehensive Primary Care

Most people misunderstand what constitutes really good primary care.  We can slow the aging process with appropriate life style and behaviors as discussed in my last post. That is good but it is not enough. As we age it’s also important to have comprehensive primary care.  The usual expectation is that primary care is just for the “simple stuff” or for episodic care when we have a problem but that is a gross misunderstanding. 

Comprehensive primary care is actually much different. It means a close relationship between you and your PCP which is of course required to build trust and to heal. It means dealing with the episodic medical problems which occur from day to day and month to month throughout life. It also means actively managing serious chronic illnesses (a specialist in fact is rarely needed). It means coordinating that care however when specialists are needed. It means helping you to maintain your wellness and your health and working with you at chronic illness risk factor detection and reduction. And it means preventing acute illnesses through vaccines and other approaches.  This is comprehensive primary care and when it is comprehensive it can deal with perhaps 90+% of all of our health care needs.  Specialists are rarely needed, prescription use goes down and hospitalization rates fall substantially.  

 

The key requirements of comprehensive primary care include some basics – a well-educated, well-trained, up-to-date PCP who is committed to relationship-based care and uses a proactive team-based approach.  But the second key ingredient is time – time to listen, to think, to diagnose and to treat and to prevent.  Unfortunately most primary care physicians just do not have enough time today and the result is a tendency to refer to specialists. But with that time, they could have dealt with the problem themselves. 

Overcoming this time limitation is perhaps best done through some form of direct primary care -sometimes called membership, sometimes called retainer and sometimes called concierge medicine.  But whatever the name, the fundamental ingredient is to reduce the practice size from today’s standard of 2,500-3,000 down to about 500 individuals.  This allows the primary care physician to offer you same or next day appointments which last as long as necessary; the time necessary to listen and listen intensively; the time to give a truly extensive annual evaluation; the time to offer expanded preventive and wellness care.  Direct primary care physicians usually give out their cell phone number for the patient to use any time day or night and they respond to emails. 

 

Comprehensive primary care certainly costs more, but it offers better health and wellness. It offers better quality of care. Patient and doctor are more satisfied and in the end it substantially reduces the total cost of care because of the reduced necessity for specialists, testing, prescriptions and hospitalizations.  

To summarize this series of posts on aging, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this average of 1% annual decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. It is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases via nutrition, exercise, less stress and by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  And we will definitely benefit when we make good use of comprehensive primary care.