Older people are, like all people, a widely varied group.
Some are healthy and independent and can live on their own until very old age,
while others have diseases that make them infirm at chronologically much
younger ages. Some live with family members or have family members living with
them. Most of those are well cared for, but some are exploited or even abused.
Some elders live in assisted living facilities or nursing homes. A lot more of
them are women than men, a reflection of differences in life expectancy. And
most of them will, sooner or later, have an adverse event occur that leads them
to be hospitalized. Sometimes it is almost routine, getting admitted for a
complication of an existing condition such as chronic lung disease or heart
disease; sometimes it a surprise, as when a 90-year old who has lived alone and
been healthy falls and breaks her hip. The first time something happens, I find
myself often repeating to these people and their families, is always the first
time, whether at 20 or 90.
Whenever I am the attending physician on our inpatient
service, we have a number of such people admitted, but in the last two weeks
the number of people admitted who were what my residents call “little old
ladies” seemed especially high. They ranged in age from their late 60s to 104;
some lived in nursing homes, some with family, and some lived alone (including
the 104 year old!). Some were admitted to the hospital for the first time,
while others were “frequent fliers”; some had families hover around and others seemed
to be left alone even when their family lived in town. A lot of them had falls,
sometimes with broken bones (most commonly hip fractures, but others as well),
sometimes, fortunately without. Some had moderate to very severe dementia, from
Alzheimer’s or other causes, and may know only who they are (or not even that);
others are “sharp as a tack” – at least when we can fix the dehydration or
whatever else has brought them in.
One characteristic shared by many of these people is that
they are unlikely to be safe returning to their homes. If they have fallen,
they are likely to fall again. If they avoided a hip fracture this time, they
may not next time. We do tests to see if there is an “explanation” for why they
fell that might be treatable. Did they have a stroke? Should they be on blood
thinners that make another stroke less likely but make the possibility of a
bleed into their brain much higher if they do fall and hit their head? Heart
rhythm problems? Maybe a pacemaker. Low blood sugar? Are they taking too much
insulin? Maybe they “just” tripped: on the cat, on the rug, on the hem of their
pants (which might be because those pants are hanging low from the 40 lbs they
have lost since they were last seen a year ago -- really? I have been eating. I
never noticed I was losing weight!) But, while anyone can trip, if it happens
more than a couple of times, they are at risk of something bad. Sometimes it is
possible for a health worker or family member to the home and help get rid of
clutter, area rugs, and such, but sometimes that isn’t enough.
No one wants to go to a nursing home, especially compared to
some idealized vision of being better and functional at home. Few families want
to send their parents or grandparents to a nursing home, feeling that it is
abandonment, or undignified, or irresponsible. Occasionally, there are
complicating social issues, as nursing homes will take the Social Security
check that family members are living on or Medicaid will require the sale of
the house that family members are living in. And nursing homes are not a panacea;
some are better than others, and folks get sick enough to require admission
back to the hospital even from the best. But often they are a safer option,
even when the family is committed to care. A person may be hospitalized by the
family for a minor change that makes the Alzheimer’s victim even harder to care
for; the primary care doctors may have already discussed admission to a nursing
home, and, as one put it, “their voices said ‘no’, but their eyes and body
language said ‘yes’.”
Medicare will pay for a period of time in a “skilled nursing
facility” (SNF), where a person who was hospitalized but no longer needs to be
in an acute-care hospital can get time to recover, get physical therapy, get to
the point where they in fact, often with home health and a supportive family,
go home. It works for someone who just had surgery, or someone who broke a bone
and either had it surgically repaired or not. But to get this “benefit” the
person needs to spend 3 midnights in the acute care hospital. Whether they need
acute care or not. Indeed, if they don’t “meet Medicare criteria” for an
inpatient hospitalization, they are not even officially “admitted” but are in a
fantasy world of “observation status” where they are in the hospital, but are officially outpatients. And those
nights don’t count toward “qualifying” for a SNF. So if you (or your father, or
grandmother), “just” tripped and hurt themselves, and didn’t break a hip this time (sometimes they have already
had both hips repaired), and is “just” bruised, and may have a “little” disorientation but no new stroke, and a little difficulty caring for themselves,
and could really benefit from a month of skilled nursing, you better be able to
pay for it, because Medicare won’t because they didn’t have 3 nights of “qualifying”.
This is crazy. I am a huge fan of “Medicare for All” rather
than the nonsense patchwork of often-inadequate private insurance plans (and
people who are uninsured) that we currently have. But that Medicare for all –
and right now, for those who are on it – needs to have a rational payment and
benefit structure. I understand the financial challenges facing Medicare (and
the whole health insurance system – it is not a “Medicare” problem, it is a
medical care problem) and believe that we need to save money by spending it
rationally. This means, perhaps, not paying
for every drug that the FDA approves even when it is not better than an
existing, cheaper drug. This means not doing fantastically expensive
interventions on people whose quality and duration of life will be marginally
affected. It does mean placing people
in the settings in which they can get the most appropriate, cost-effective
care, whether at home with or without home health, in a skilled nursing
facility, in a long-term care facility or in an acute care hospital. It does not mean requiring that someone who
would benefit from a stay in an SNF first have to “qualify” by being in an
acute care hospital overnight.
My local paper recently had a big front-page article about
the fantastic new technology being employed at our hospital using GPS to map
the location on the heart where an abnormal rhythm is being generated, so that
it might be able to be fixed.
Congratulations to the cardiologists and engineers who have developed this, and
to the PR department that got it in the paper. It might be a big help for a few
people, and will almost certainly be very costly (and profitable for the
hospital). But as we develop all these expensive new technologies that might
help a few people a lot and might help a few more a little, it is insane if we
save money by not providing what we already know is the right thing in
prevention and intervention for the conditions that affect the many. Right now,
Medicare is trying to save money by identifying “fraud”; they do this (this is
absolutely true!) by contracting with bounty-hunter companies called “RAC”s to
discover when a patient has been “admitted” when their condition didn’t
technically qualify and they should have been on “observation” status. They should be saving money by not paying for
expensive high-tech procedures which offer little benefit.
A rational health care system, as we have discussed before,
means that people are getting the right care in the right setting; this is the
ostensible promise of health-care integrated systems. But, just as we will
never have enough primary care doctors doing prevention and early treatment as
long as we pay them a fraction of what we pay those doing heroic (and often
ineffective) intervention for far-advanced disease, we will not have a rational
health care system if we pay for huge high-ticket items but not for people to
be in the right setting for them to receive the care that they need.
Medicare can, and should take the lead. For seniors, it is
our national health program. Others will follow.
