Don't Let Medicare Undermine the Health of Future Generations!

Zeke Emanuel, who is becoming the national educator-in-chief about health care in his new role at the University of Pennsylvania, preaches an excellent sermon in today's New York Times - "What We Give Up for Health Care."

Zeke's point is obvious, but, amazingly, it's one our political process has been oblivious to: what we spend on health care we can't spend for other purposes. That creates an ethical imperative to consider opportunity costs for health care expenditures. The proper question is - "does this health care expenditure create more human benefit than other possible expenditures?" - rather than the one we typically ask - "does this health care expenditure produce any benefit for the patient, no matter how small the benefit or how high the cost?" Zeke shows how health care costs have acted as an economic cancer, invading and obliterating investments we would otherwise make in wages (which have been stagnant or declining), education, and other crucial components of our lives.

As important as medical care can be, income and education are also crucial determinants of health. When we reduce wages to pay for health insurance, and reduce educational investments at every level to pay for Medicare and Medicaid, we're reducing overall health and well-being. The real "death panel" is our reflexive investment in medical interventions that produce minimal or no benefit at the cost of investments that would do more for us!

Zeke argues that "liberals" should be as concerned about health care costs as "conservatives" are:

There is an inevitable trade-off between rising health care costs and things liberals really care about, like access to college and good wages for working Americans. We cannot have it all. The health care reform act will help us save — mainly by changing how physicians and hospitals are paid and delivering better care to our most expensive patients. But more can be done: for starters, we could speed up the implementation of payment reform, stop Medicare payments for tests and treatments that provide no benefit and endorse competitive bidding for medical goods and services.

The premise of this blog is that many of us in the Medicare age group - whether we're "liberal" or "conservative" - share a concern about the future, and don't want current Medicare expenditures to undermine the health and well-being of future generations.

Avoiding overtreatment, and the moral imperative to consider opportunity costs, should be our relentless advocacy focus!

Raising the Age of Medicare Eligibility - First Prize Dumb Idea

This week the Congressional Budget Office released a report on proposals to raise the age of eligibility for Medicare and Social Security.

The CBO concludes that raising Medicare eligibility to 67 would reduce federal spending by $148 billion between 2012 through 2021. By 2030, Medicare's net spending would be reduced by 5% - 4.7% of GDP rather than 5%. Those numbers sound good.

But reducing federal expenditures doesn't reduce the need for medical care. Some lucky folks (I'm in that category) (a) have employment that provides health insurance and (b) are happy to continue working. Some who would rather retire will continue to work, increasing health care costs for their employer (and fellow employees). Some will scramble to find alternatives which will cost them more than Medicare would. And some will become uninsured, at an age when this is progressively risky. Overall costs - to individuals, employers and other government programs would probably go up more than the $148 billion reduction in Medicare outlays.

The CBO does not comment on the fact that employers are not clamoring for ready-to-retire employees to stay on the job simply to avoid being uninsured.

Raising the Medicare eligibility age isn't meaningful cost reduction - it's simply a form of hot potato, dumping the costs into other accounts. It intensifies the fragmentation of our health system, and worsens overall quality of care.

In my view, the proposal is born out of despair about achieving constructive Medicare reform in which health professionals, patients and families collaborate on behalf of improved care (basically more compassion and less technology) and reduced costs. From 35 years of practice in a not-for-profit HMO setting I know this kind of collaboration is possible. But it requires a spirit of cooperation and trust that is not easy to find in our toxic political environment. 

How to Make Medicare Go Broke

Zeke Emanuel and Steve Pearson, colleagues I admire greatly, have an Op Ed in today's New York Times that shows how our current way of running Medicare will ultimately send the program down the tubes.

Here's the first paragraph, and the gist, of their argument:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

Proton beam is a form of radiation that uses atomic nuclei rather than other sources of energy, such as gamma rays, x-rays, or electrons. Proton beams have less scatter, theoretically making it possible to provide more narrowly focused treatment, which, again theoretically, could allow more vigorous treatment of a cancer with less injury to surrounding tissues.

The key word is "theoretically." Proton beam fulfills its promise for relatively rare radiosensitive cancers in children and some rare nervous system tumors in adults. But for its widest use - prostate cancer - there is no evidence for superior outcomes. Medicare payment policy, however, results in a fee of about $50,000, twice as much as equally effective forms of radiation.

Facilities like Loma Linda in California, M.D. Anderson in Texas, Massachusetts General Hospital, University of Pennsylvania, and now two Mayo Clinic sites, are eager to pilot new forms of treatment and to maintain their competitive position in U.S. health care. You can get a sense of how actively marketed proton beam is from the Loma Linda website.

Zeke and Steve identify three alternative Medicare payment policies:

1. Refuse to pay for proton beam except for  diseases where there is solid evidence for clinical superiority. This is what most private insurers do - as an example, see Aetna's detailed policy.
2. Use the option of providing "coverage with evidence development," an approach whereby Medicare would cover proton beam for prostate and other cancers, but only for patients enrolled in a randomized trial comparing the treatment to its alternatives.
3. "Dynamic pricing" - a system whereby Medicare would pay more for proton beam, but only for diseases for which the treatment has been shown to be more effective than the alternatives.

We seniors need to demand that Medicare follow the policies Zeke and Steve argue for. Doing so will (a) protect us from economically-driven recommendations for treatments we don't need, and (b) help to constrain Medicare costs so that (c) future generations can have the same advantages we have. What they propose isn't rationing - it's prudent spending for demonstrated value. That's something we do in our own lives all the time!

[Zeke and Steve's analysis sets in after treatment for prostate cancer has been recommended. Alas, there's lots of reason to believe that many men are treated for cancers that would not have impaired their health or longevity. Overuse of the PSA test is another story for another time, but if you're interested, there's an excellent NPR interview  with Dr. Gilbert Welch, author of Overdiagnosed: Making People Sick in Pursuit of Health.]