A Doctor’s Vision for Medicare

Everybody knows what the federal budget’s long-term problem is. The president knows. The Republicans in Congress know. The Democrats in Congress know. The policy community knows. You know.

It’s Medicare.

I am a physician who has been studying Medicare data throughout my professional life. But now that I’m closing in on becoming a beneficiary, I am thinking more about what I’d like my Medicare program to look like.

My Medicare would be guided by three basic principles:

It should not bankrupt our children. Let’s be clear: Medicare is rightly the central source of concern in the deficit debate. Its expenditures are totally out of control, and represent a huge income transfer to the elderly from their children. It’s a program crying out for a budget.

So let’s pick a number — more specifically, a proportion of total economic output — to cap Medicare. Now the number is 3% to 4% of GDP. We can live with that. Distribute it to geographic regions based simply on how many beneficiaries live there. Expect howls of protest: Urban areas will complain their labor costs are higher; rural areas will complain they cannot achieve the same economies of scale. And everybody will argue that their patients are sicker.

Ignore them all: Make it a block-grant program. Sure, this raises other issues, but you get the principle.

For those who view this as a tea party solution, consider this: I drive a 1999 Volvo and live in Vermont — that should tell you something.

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.

It should recognize the value of having time to talk with your doctor. The current system rewards physicians for doing things to patients, not for talking with them. Not surprisingly, we do too much. Too many clinic visits lead to another medication being started, another test being ordered and a referral to another physician. The end result is totally predictable: too many medicines, too much testing and too many cooks in the kitchen.

But there is another problem: Subsequent clinic visits are increasingly devoted to going over medicines, reviewing test results and figuring out what the other physicians had to say. No wonder patients are increasingly dissatisfied with the process.

My Medicare would reward doctors for taking time to have a conversation. It would recognize the value of acknowledging suffering, providing reassurance, discussing options and learning how different patients want to approach care.

What would I want to talk about with my doctor? Maybe it’s a topic, however mundane, that means something to me, like whether the Jets will knock off the Patriots again this year. This serves a purpose: I want to know (and like) my doctor.

I want to talk about important things too, things that are bothering me right now. I want my doctor to care, provide insight as to what is going on, and to consider carefully whether or not medicine can help. I don’t want a knee-jerk response to some perceived need to “do something” on my behalf. I value the physician who can candidly discuss what medicine can and cannot to.

By the way, that takes time. It requires a system that rewards doctors as much for thinking about (and talking with) patients as doing things to them.

I want to talk about aging gracefully. My Medicare would be really good at this. It would help patients understand the trade-offs between the length of life and the quality of life. It would help patients understand why the side effects of early detection — overdiagnosis and overtreatment — are even more pronounced as they age (simply because there is less time for abnormalities to become important problems). And it would help patients understand the futility and the suffering caused by aggressive interventions at the end of life.

If you were hoping to play the “death panel” card, now’s your chance. But don’t play it and then pretend you care about the budget.

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. He is the co-author of Overdiagnosed: Making People Sick in the Pursuit of Health. This post originally appeared in the L.A. Times.

22 replies »

  1. Dr. Welch,

    I too am a doctor. The answer to some of your concerns is agonizingly simple. Pay the doctor for his time. Period. My accountant charges $350/hour. My attorney $400/hour. Surely, we are worth anywhere from 250-500 dollars/hour. The AMA needs to press CMS on these billings. This, of course, will never be permitted by the government. We must opt out to take back our own self-worth. Our patients will absolutely steam rolled by the upcoming disaster that is Obama-care. It is our moral duty to opt out of a corrupt system. It must be done. By the way, you first.

  2. “The current system rewards physicians for doing things to patients, not for talking with them.” So true! I am not on Medicare yet, but having retired from the military and now using civilian doctors. I have noticed this exact difference. I feel processed through. But that being said the quality of medical care is much better with civilian doctors. Because doctors are in it to make money they way out perform in speed and quality compared to the socialized military medical care. We must keep competition in the system!

  3. The problem is doctors are leaving primary care or don’t want to stay in it, which puts more pressure and less time for the doctors who are still in it to manage all the patients. This results in less time per patient, so in the end patients wait 2 hours for a 10 minute review which just isn’t enough to make an informed decision. In the end, its easy to prescribe an medication or a procedure because at least you feel you get something out of the meeting.
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  4. Interesting that you disparage drug companies, which have decreased in percent of total health care dollars for years now. Drugs used to be about 12-14 percent of health care dollars and now represent approximately 8 percent of all health care costs. And pharmaceuticals are responsible, at least in part, for people living longer and having a better quality of life than years past.

  5. Right on target, as Jim Sabin commented. I would only add one thing: Medicare is not transferring wealth to seniors. The money goes past them, but the real wealth transfer is to drug and health technology manufacturers. The ACA reforms do NOTHING to stop this; in fact, they add additional mandates that further limit payers’ ability (including CMS) to push back against exorbitant prices. I’m not an anticapitalist. We should also remember that publicly traded companies pass on much of the profit to stockholders, compared to which executive salaries are a minimal amount in a highly profitable business. But it’s unfair to say that seniors receive the financial benefit. in most cases, they either pay too much or, as you pointed out, receive too many medical interventions that produce minimal benefit.

  6. Wrong question.

    Which would you pay for and which would you not pay for is the question.

    Everyone should be able to legally buy whatever they want to pay for themselves.

    It is still a “free” country. Is it not?

  7. @ Bob Hertz: I’ll go one better. Let’s take politics out of healthcare. Indigent and destitute seniors already qualify for Medicaid as a dual benefit. This is, as you have stated, a great help to those who need the financial help. However, due to the method of payment – federal and then federal/state benefit, it creates some confusion. I can tell you in the area I live in, and with aged parents with private supplemental insurance, there is confusion among some local pharmaceutical providers regarding payment issues. If the issue is money savings, as with most budgets, isn’t it best to stream line the process? Make it an inclusive Medicare for all? Or follow Vermont’s lead? Your proposal isn’t new. And is it more shocking to propose to pay physicians for end of life counseling that was politicized as death paneling, even though they have been doing so for years for free. Everyone who can afford to pay for health services already has a choice in how they would like to proceed with their own health care. Those who cannot afford them unfortunately do not. But denying people care because they happen to have aged is not the answer either. In fact, considering these people have probably paid more into the system than any of us means they are more “entitled” to receive the services they have already paid for.

  8. Dr. Welch does a great job of articulating a view of medicine that has been championed by an economist named Arnold Kling.

    Kling believes that we will have to abandon perfectionist medical care —
    i.e. testing for every potential ailment, medicating for every potential illness, and treating every condition at any age.

    This style of medicine is a wonderful thing if we are willing to spend at least $5000 a year on healthy persons, and $20,000 a year on persons with chronic illnesses.

    Wealthy executives do receive such care at places like the Mayo Clinic.
    But the money is simply not there to give this level to almost 70 million senior citizens by 2020.

    To paraphrase Joe Biden, what Dr Welch and Kling propose is a “big f–king deal.”

    Let’s leave aside for a moment the enormous political challenge of cutting back Medicare. No politician has ever won office by proposing Medicare cutbacks, and plenty have lost office by doing so. (or even hinting they might do so).

    Instead let us ask how Medicare might reflect a non-perfectionist view of medicine, and then what is the way to control costs?

    Dr. Welch suggests a block grant. I am skeptical and here is an alternative:

    — Cancel Plan B.

    Let seniors pay for their own office visits, diagnostic tests, and outpatient procedures.

    Establish very strong consumer protection laws to prevent price-gouging.

    Seniors who have no money would receive Medicaid.

    There could also be a massive expansion of community clinics that charge sliding-scale fees.

    This would initially be shocking to an American public which expects 90 year olds to receive bypass surgery, and looks on almost any death under age 80 as premature.

    But fiscal reality may dictate nothing less.

    Bob Hertz – The Health Care Crusade

  9. Medicare amounts to late in life care. People who come into the program come from a group who may or may not have had ongoing primary care during their adult life. Those who did not will be higher risk because any chronic illness they may have will not have been maintained. Their health status will be poor, probably will remain poor, and will cost the system more due to repeated hospitalizations and ongoing expensive medical treatment. Expensive testing? Perhaps. How are you going to treat someone when you don’t know the extent of their illness. Now think about how much less this group would have cost if they had the benefit of ongoing health services throughout their adult lives.

  10. “Most of time the diagnosis isn’t made by any of the specialties you mentioned. It is made by the pathologist.”

    Cryptic statement. Do you mean patients have to die before getting the right dx (sarcasm)?
    Or do you mean that in fact, many but far from all diagnoses are based on biopsies? That does not prove much. First, someone has to decide what to look for, and what to biopsy. And then, based on the dx, cognitive services are crucial for planning the further management.

    The problem with your understanding of PC is that you may be right thinking of sproained ankles and colds, but the problem is that a lot of conditions begin innocous and then, with persisting spts, reveal themselves as serious and complicated. PCPs should be better trained then nowadays, not less. Most internist PCPs develop complex care to elderly and/or multimorbid. Good luck managing these patients with scores of specialists or NPs/PACs only.

  11. @rbar
    I am sorry–i should of defined what I meant by cognitive servies–I meant primary care. Not primary care plus three more years of fellowship.
    Most of time the diagnosis isn’t made by any of the specialties you mentioned. It is made by the pathologist.
    I wonder if the nurses and surgical techs can afford the malpractice? I suppose we would have to pay them more so they could.

  12. Oh … no. Let me set that straight. Cognitive services are not only the centerpiece of all nonprocedural specialties (hematology, rheumatology, neurology etc.), but also integral part of surgical specialties. Surgical skills are only one, often minor, part of surgical care. It’s not (or very rarely) about the cutting and probing which are technical skills that could be learned by surgical techs or nurses – it’s about the correct diagnosis, appraoch and indication of a procedure.

    Entrepreneurial MDs – please read the medical literature (e.g. rate of complex back fusions skyrocketing due to better payment, similar with cataract surgery and other procedures), or use common sense (it’s a cookie jar situation).

  13. Would love to see some real world example. IE 78 year old man with diabetes, high blood pressure both under control with medication needs a new hip – should he just sit in the chair for the next few years or get the surgery? His 77 y/o wife breast cancer survivor (mets to liver) – should she stop having annual MRI followups at Mayo? Both had parents who lived into 90’s

    Medicaid overtreatment – Adolescent girls required to have $900 HPV vaccine shots to attend school No evidence that we are inoculating those at the highest risk cervical cancer patients (those who rarely see a GYN and recent immigrants) and we won’t know if it works for 30 years..

    Private sector over treatment – 50 year old female – decides to only have mammograms every other year based on recent research ie . False positive 5% a year or 50% over 10. 3 new cancers caused by x-ray for each 1 found. Her provider told patient she will hurt doc and clinic’s quality scores if she didn’t and is pressured into it.

    Which of these patients would you treat and which wouldn’t you?

  14. Most large corporations have outsourced labor so perhaps the solution is to import docs from those countries that are more cost effective in mass (we already steal them from 3rd world countries)

    Or simply hire docs and put them on salary for Medicare.. Use the Mayo / Kaiser/VA model – systems with the highest quality and the lowest costs.. Clearly the private sector has failed in this case.

    Finally have CMS (medicare and medicaid) stop paying to train specialists and double the salary during residency and internship for primary care. Most people don’t realize that 95% of all docs in this country are paid by CMS during their residency and internship (that is why they are expected to treat them for less – they are paying back the equivalent of a 400,000 to 1.1000,000 lan for their training costs.

    The “debt” that docs complain about are their private medical school costs NOT their residency and internships. So If market forces drive behavior then use this power of the purse to increase the number of primary care docs.

  15. @rbar—why are you mystifoed? It is rather simple. Cognitive services can be done by a nurse. Look at all that could be saved.
    Number 2–what is wrong with entrrprenurial physicians? They can be both and are not mutually exclusive. What is wrong with a physician making all the money he or she can using their training and expertise?

  16. I think this author is asking that we save physicians from themselves. The policy literature strongly supports the idea that fee-for-service medicine, combined with easy access for relatively unproven new technologies is a “witches brew” that leads to our current difficulties.

    It helps to remember that one of the big reasons the Medicare program isn’t tougher on the health care delivery system was the hue and cry about “socialized medicine” when it first became law back in the 1960s. As a sop to the AMA, physicians were pretty much allowed to define what “appropriate practice” was, and the residue of that persists today.

    Its also important to recall the Medicare’s problems don’t exist in a vacuum. Rather, they reflect issues facing the entire US health care system. We can’t (and shouldn’t) try to fix the one without fixing the other as well or the cure is likely to be worse than the disease (e.g. more unsustainable cost shifting to commercial plans).

    As the September “Health Affairs” so vividly pointed out, the problem in the US is really the prices charged for everything (including physician services). George Halvorson has famously pointed out that the US spends nearly 18% of GDP on health care while the rest of the OECD runs at about 12%. The difference between the two is entirely pricing for goods and services.

    The quick fix for the US health care system is probably to follow the lead of the rest of the world and cap prices paid for everything at the average of the developed world. That results in about $1 trillion in pretty immediate savings. It’s far from an ideal solution and just resets the existing growth curve at a lower base point, but it does represent a start.

    The long term fix lies in doing a much better job of measuring and rewarding value across all of health care, including both public and private sector programs. That requires a lot of moving parts to come together and it won’t happen rapidly. However, it’s probably the only really sustainable solution available.

  17. Margalit, regarding point 2: GDP almost never goes down in nominal terms.

    In any case, having a budget would tend to make one more flexible about fees. they are not set in stone but modified if necessary to make the budget work (either fees change or rules on what is paid for change in those rare times when GDP goes down in nominal terms). Also, capital investments can be postponed, just like in the rest of the economy, which could allow one to preserve benefits during a downturn. The point is to stop acting without fiscal discipline.

  18. Two questions:

    1) Is the article stating that physicians are knowingly over-testing, over-diagnosing and over-treating, thus knowingly harming patients, and the only way to stop a doctor from doing this is to “balance his financial incentives”?

    2) Regarding the following: “So let’s pick a number — more specifically, a proportion of total economic output — to cap Medicare. Now the number is 3% to 4% of GDP. We can live with that.”
    So when the GDP is not doing well, like now for example, should Medicare cut covered services while keeping doctors’ fees constant, effectively raising seniors out of pocket expenditures, or should doctors’ fees fluctuate with GDP to keep coverage constant over time?

  19. The problem is doctors are leaving primary care or dont want to stay in it, which puts more pressure and less time for the doctors who are still in it to manage all the patients. This results in less time per patient, so in the end patients wait 2 hours for a 10 minute review which just isnt enough to make an informed decision. In the end, its easy to prescribe an medication or a procedure because at least you feel you get something out of the meeting.

  20. What Welch says makes sense to anyone giving critical thought to the high cost and overuse of medicine. Ivan Illich wrote in 1975 about this overuse of medicine in Medical Nemesis, while we were spending and inflating health care in annual double-digits. His critique of over-medicalization of life holds true today.

  21. Agree with most of the above, but the biggest issue remains fee for service and overpaying for procedures. All that unnecessary back surgery, stenting. injecting – just pay all these services similar to cognitive services (maybe a tad more for risk and expertise adjustment), and it will slowly reach reasonable utilization levels, with enormous savings and no negative consequences for anyone’s health. I am mystified why only fractions of the nonentrepreneurial (i.e. not greedy) physicians recognize this obvious point.