October 16, 2011


A doctor's vision for Medicare: Everyone knows the program is the big long-term problem in the federal budget. Here are three basic principles for what it should look like. (H. Gilbert Welch, October 16, 2011, LA Times)

It should not waste money on low-yield medicine. I don't change my Volvo's oil every 1,500 miles, even though some mechanics might argue that it would be better for its engine. Nor do I buy new tires every 10,000 miles, even though doing so would arguably make my car safer. But in Medicare (as well as the rest of U.S. medical care) such low-yield interventions are routine.

Measurements considered normal in the past now trigger treatment for high blood pressure, high cholesterol, diabetes and osteoporosis. Tiny abnormalities that were invisible in the past now trigger follow-up scans, fiber-optic examinations, biopsies and surgery.

Increasingly, all Medicare beneficiaries are being viewed as being "at-risk" for something, particularly heart disease and cancer. We doctors joke that the well person is the one we have not examined thoroughly enough. (The last Medicare skin exam that failed to identify something that might lead to skin cancer occurred in 1970.)

But it's not funny anymore. Because once you are labeled at-risk, something must be done.

My Medicare would recognize the problems with this approach. Because almost everyone is transformed into a patient needing intervention, it's an approach that costs a huge amount of money. And no matter what we doctors do, we can't take you to zero risk.

But we can cause harm. Our medications have side effects; our surgeries and procedures have complications. And occasionally our interventions cause death.

My Medicare would focus on patients who are genuinely sick: those who have symptoms (e.g., chest pain) or are at high risk of something bad happening (e.g., really high blood pressure). These are the patients for whom the benefits of medical intervention clearly outweigh the harms. The rest of us are better off left alone.

That's right, most of us would do just as well -- or better -- with less medical care. Restoring balance to the system will first require more balanced information for patients because what they get now systematically exaggerates the benefits and downplays (or ignores) the harms of intervention.

But it will also require that someone take responsibility for deciding which treatments should be provided based on the evidence of which treatments lead to better outcomes. If you don't want the government to do this, then your doctor will need to step up to the plate. And the only way that will happen is to balance his financial incentives.

Those who believe they have a fundamental right to receive low-yield, ineffective and harmful care are sure to invoke the "R-word": rationing. But let's hope they at least have the good sense not to say it while at the same time arguing for less government spending because they don't want to bankrupt their children.
The key is just to not ban people from consuming health care provided from outside the Medicare system.  Medicare would be more of a system that provides genuine medicine to people who need it and folks who just want to consume more regardless of health effects would be free to waste their money as they are on any other consumer good.

Posted by at October 16, 2011 9:35 AM

blog comments powered by Disqus