3 ways Medicare can reduce overtreatment

If we in the U.S. ever hope to get a grip on Medicare costs, our society will first have to navigate a steep learning curve. That’s the lesson to take from three recent publications.

Despite the fact that Medicare is expected to represent 18% of the federal budget in 2020 (up from 15% in 2010), and that the Medicare Part A trust fund is projected to have insufficient funds to cover all hospital bills starting in 2024, polling guru Robert Blendon reported that 47% of the public do not see Medicare as a large budget item, and only 31% see it as a major contributor to the federal deficit.

Here are some of the key findings from Blendon’s study:

  • Respondents believe that Medicare recipients receive benefits worth about the same (27%) or less (41%) than what they’ve paid in. In reality, beneficiaries on average pay 1$ for every 3$ of benefits.
  • By a 3-to-1 ratio, the public believes the bigger problem under Medicare is people not getting the care they need, as opposed to receiving unnecessary care. This is despite a recent report from ICU physicians discussed by Muriel Gillick in a recent post that among their Medicare patients 15% received care that was “futile” and 12% received care that was “probably futile.”
  • Although administrative costs for Medicare are substantially lower than for private insurance, only 15% believe that Medicare is better run.
  • Every age group prefers physicians to be paid on a fee-for-service basis. The 18-to-29-year-olds are the most open to capitation payment (42%).
  • With increasing age, opinions about Medicare become progressively more favorable: 18-to-29-year-olds (61%); 30-to-49 year olds (71%); 50-to-64 year olds (75%); and, for those over 65 (88%).

Finally, a survey done by The Conversation Project – an admirable organization “dedicated to helping people talk about their wishes for end-of-life-care” — found that while 90% of us believe we should have these conversations with those we’re close to, only 30% of us have actually done it.

Taken together, the three publications define a three-pronged learning task that must be accomplished for Medicare to reduce over treatment and help contain costs. We seniors need to spread the word that 1) contrary to the views of almost half of our population, Medicare is indeed a major contributor to the financial problems of the working public, 2) seniors receive a substantial amount of ICU care that medical experts believe is “futile,” and 3) most of us probably don’t want that “futile” care, but our families and friends won’t speak up for us if we haven’t had the discussions of our values for end-of-life-case that The Conversation Project encourages.

Jim Sabin is a psychiatrist and director, ethics program, Harvard Pilgrim Health Care.  He blogs at Health Care Organizational Ethics.

3 ways Medicare can reduce overtreatment

This post originally appeared on the Costs of Care Blog and the Over 65 blog. Costs of Care is a 501c3 nonprofit that is transforming American health care delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

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  • Saurabh Jha

    “We seniors need to spread the word that 1) contrary to the views of almost half of our population, Medicare is indeed a major contributor to the financial problems of the working public..”
    I believe the challenger and his running mate tried to do that in the last election. They lost Florida. Truth doesn’t win votes anymore

  • Steven Reznick

    My eighty year old patient called with recurrent benign positional vertigo which had been diagnosed and evaluated by myself and a board certified neurologist extensively and thoroughly recentl. I advised rest, slow position changes, ambulating with assistance only and the appropriate Epley manuevers. Forty minutes later her ” friends” called 911 because she was dizzy. An ER directed workup including CT scan with views of her internal auditory canal. labs, EkGs , carotid studies and $10K later she was home. How can you control costs and utilization when the patient has no skin in the game?

    • SarahJ89

      Really? The overtreatment by the ER docs is somehow the patient’s fault?

      • Steven Reznick

        The patient had previously and within a few months been evaluated for the problem. She spoke to her doctor and was offered advice and a visit and declined. Her friends called 911. At the point 911 was called she could have called the office to say she was being taken to the ER so that we could alert the ER staff and physicians and get them the medical information and records they needed to do a thorough evaluation. As part of our welcome to the practice material and in our newsletter and on our website we review and educate our patients about how to communicate during an emergency . Upon arrival in the ER and evaluation by the triage staff in the ER she could have alerted our office or could have informed the ER staff that she had just had this problem evaluated by her primary care doctor, cardiologist, consulting and staff neurologist and neruo opthalmologist but she did not.
        When the ER staff suggested she have a CT of the brain with views of her internal auditory canal to look for a rare acoustic neuroma she could have told them that she had the test at the hospital imaging facility within the last four weeks. She did not. She is a bright articulate woman who travels to Asia six times a year on business and still plays eighteen holes of golf four days a week with aerobics classes in between.
        At the same time the ER staff could have called my office before working her up or taken the time to review their own records on file to see that they had enough evidence and information to limit their evaluation to a history and exam. If they had called me, I would have gladly gone to the ER and performed the evaluation myself. I believe the ER staff ” rounded up the usual suspects” while ordering their testing and that includes a great deal of buffing the chart for defensive medical malpractice reasons.
        The paramedics upon arrival at the scene and after their initial evaluation which demonstrated her cardiovascular and neurological stability could have called the office and discussed her case prior to transporting. Instead they treated it as a non life threatening situation and called the private ambulance firm they are contracted with for these situations. Its a win win for them both. The paramedics and fire department record another run and can justify going to the city council for funding based on volume. The private ambulance company gets its $370 for schlepping her 3 miles to the ER.
        It is multifaceted blame but basically since neither the patient nor the ER pay out of their pockets ( except for that portion that comes from their tax payments) it is easier and more profitable to do what they did. Yes the patients need to take responsibliity as do all in the health care system who continue these costly and unnecessary actions.!

  • Thomas D Guastavino

    Nothing will change until the gun is taken out of the hand of the trial bar.

  • May Wright

    “Respondents believe that Medicare recipients receive benefits worth
    about the same (27%) or less (41%) than what they’ve paid in. In reality, beneficiaries on average pay 1$ for every 3$ of benefits.”

    The “I’ve paid into it all my life, I’m going to get every dollar of my money’s worth out of it now” attitude can be a problem. I’ve heard more than one Medicare recipient get tetchy when Medicare is described as an entitlement, or put into the basket of “entitlement spending”, because they really don’t understand that most of the money being spent on them is not their own money that they put in, but money docked from their children’s and grandchildren’s paychecks.

    An uncomfortable number of people who are otherwise unhappy with the growth of entitlement spending in this country do not want anyone touching “their” Medicare, and as Saurabh Jha touches on, it’s electoral poison for any politician to tackle reform of the system.

    • SarahJ89

      When I had a CT scan I foolishly trusted my PCP that it was the right thing to do. And I wasn’t inclined to do a whole lot of research–I was a bit preoccupied with being ill. No mention was ever made of alternatives, excessive radiation–or price. I know if I called the hospital they would not have told me the price because I’ve tried that in the past.

      I was horrified when I got the bill. Thousands of dollars. It doesn’t matter who pays for it, it’s still thousands of dollars for a test that was probably unnecessary and exposed me to a lot of unwanted radiation.

      So please, when parceling out blame, do know there are a lot of us out here who would LOVE to have the information we really need to give informed and prudent consent. But that information is never volunteered and can be found, if at all, only with great diligence–a quality in scant supply when one is ill. Stop blaming the patients for systemic problems. The only behaviour you can change is your own.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Medicare is not an entitlement. It is an obligation. Medicare is short on cash because life expectancy has increased, while working wages for most people have stagnated, making most income ineligible for taxation.
    The fact that people live longer than what was expected in 1965 should be good news, not a subterfuge for finding ways to extract a few more pennies from our elderly citizens, who financed the care for the elders before them and the education for those who are paying taxes today.. That’s how social insurance works. The working generations pay for educating the next generations and for caring for the generations that came before them. In the end everybody gets their fair share, if we continue to honor our obligations.
    The fiscal problems experienced by Medicare can be easily fixed by
    removing the upper limit on FICA and including “unearned income” in the
    taxed amount to make it a more progressive tax.
    The best way to help Medicare would be to increase the size and diversify of the pool. 317 million or so should do it :-)

    • SarahJ89

      Thank you for pointing out the need to remove that cap.
      Nice dog. Is s/he yours?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Thanks. He is mine :-)

    • Cleo1117

      Medicare has changed drastically since 1965 if you look at the patients. No longer is Medicare a program for the elderly and working who become disabled. It now covered the disabled children of anyone on Medicare. Those children move right on Medicare when they become adults because their father or mother is covered. Medicare was never intended to cover anybody but the elderly so the tax was not set to include the millions who are below the age of 65.

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