One way or another, the costs of the Medicare program must be cut. That likelihood can of course be averted in part by raising taxes, means testing, increasing copayments and deductibles, and raising the age of eligibility for benefits.

Given the political climate, a significant tax increase is not likely, and even the other possibilities are not likely going to be sufficient. That most dreaded option, by Democrats and Republicans alike, a direct cut in benefits, will be necessary. Can it be done equitably, with everyone sharing the burden in a fair way?

My straight answer is: probably not. The best that might be achieved will be to keep the inequity at a low, tolerable level – that is, insofar as one can speak of what sounds like an oxymoron, a fair inequity. The reasons for that outcome are not hard to find. All major actors in health care have good reasons – in their own eyes – why cuts should not be visited on them, and many of them are engaging in a form of hostage-taking to show the dangers of tampering with their reimbursements or benefits.

Doctors don’t want their Medicare or Medicaid reimbursements cut and threaten that they will stop taking patients in those programs if that happens. That threat has been successful every year for many years in persuading Congress to set aside its long-standing mandate for annual reductions in reimbursements.

Hospitals are no less receptive. Their threat is more indirect: we will not be able to handle the costs of caring for patients, already a problem for many hospitals on the margins of financial solvency.

The elderly and the public by a large majority, as shown consistently by public opinion surveys over a long period of time, do not want benefit cuts (and aren’t enthusiastic about higher taxes either). The implicit threat message to politicians is that they will not be reelected if they go after Medicare. And the elderly of course do not want cuts because they have paid their taxes over the years for it and feel entitled to Medicare benefits.

Even now what they get is often not enough. The elderly spend an average of between $3000 and $10,000 out of pocket a year, many being forced into bankruptcy. The theoretical, even high probability, danger that Medicare itself may eventually be destroyed if costs are not controlled does not have the nasty bite of benefit cuts, which will hurt current Medicare beneficiaries immediately and personally.

Equity would require that each of the affected groups, patients and providers alike, be burdened more or less simultaneously and in ways that, if not perfect, at least does not lead to outrage and a gross sense of unfairness. Why are they picking on us and not everyone else? That would be a reasonable question to ask if some were obviously hit harder than others. Even so, a kind of putative equality – everyone gets cut equally – does not obviate the possibility, even likelihood, that some groups will have greater problems than others in bearing the burden.

If the supercommittee of 12 cannot come to a consensus on balancing tax increases and benefit cuts, that will automatically trigger an across-the-board 2% reduction a year in Medicare payments. That kind of flat cutting, however the cuts will be calculated, is hardly likely to have the nuance necessary to get an equitable balance.

My solution: a parallel private committee, put together at once and bringing representatives of the major groups together, should be organized by one of the health care foundations or the Institute of Medicine. The supercommittee has to make its recommendations, or failure to agree, known by November 23. The parallel committee should have its work done by mid-to-late October to get its findings before the supercommittee while the latter still has time to act on its findings. The charge to the parallel committee should be straightforward: see if you can work out a fair plan to achieve some reasonable agreement on the equitable sharing of the cost burden.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

It is time to recognize a new fallacy, maybe not a logical fallacy up there with the ad hominem argument but surely, I believe, a political one. It might be termed “the real problem” fallacy. I first thought of it years ago when I told people I was interested in working on ethical and policy problems of medicine, even starting a research center on that topic. “But how can you justify focusing on that,” one person responded almost indignantly, “when the real problem is the proliferation of nuclear weapons?” Another said with identical language that “the real problem” is “the Israeli-Arab conflict.” Well, maybe so, but we just ignored them.

Then, many years later, closer to my own field, Christine Cassel wrote in her 2005 book, Medicare Matters, that “rationing appears unjustifiable when there are abundant opportunities to economize by improving efficiency and effectiveness in the health care system.” Just this year, Judith Feder, a professor at the Georgetown Public Policy Institute, said that it was wrong to focus on entitlement reform when “the problem is overall health care spending.” And so on: the real problem, a chorus of discordant cost control voices cry out, with Medicare is fee-for-service medicine, or background costs, or great regional variations in cost, or commercialized American medicine; or excessive use of technology.  

Actually, one of them may indeed be the real problem (and my vote would go to the underlying costs of the system), but then why do I call it a fallacy? Its implication is that we have to solve a long-term underlying problem before we take on another one here and now before our eyes. Medicare has a critical cost problem right in front of us. We cannot wait until the almost intractable 50-year-year-old problem of waste and inefficiency has been vanquished. And we can hardly put off entitlement reform until we have done away with “excessive overall spending,” which could take generation or more to achieve, if at all.

Our health care system can be likened to a large and ailing schooner at sea in a storm. The wooden hull is rotting, dangerously taking on water, the weight of which is making the sails ineffective. The sails, as it turns out, are in shreds and must be repaired if the ship is to make it to port where the hull can be repaired. But patching the hull requires that men who should be working on the sails must have the boat stopped so they can swim under the hull to do the necessary work. Meanwhile, it is rumored that the nearest port may not be able to fix hulls or provide new sails – but that a much farther port, dangerously far, is well– equipped to do so. The consensus of the crew is that the real problem is the company that made such a boat, with a poor hull and bad sails; it should be sued.

The captain responds that the crew may well be right, but that is beside the point: the boat is sinking. Medicare is no less sinking. Whatever the underlying real problems, its reform must be begin at once, and by the most direct means possible (no falling back on bending the curve): cutting benefits and raising taxes.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

This post is about policy dysfunction, not erectile dysfunction.

Medicare reform is so complicated that it’s easy to get lost in arcane minutia. But if we take a big picture view of the two main approaches to containing Medicare costs — the Sustainable Growth Rate (SGR) formula and Paul Ryan’s voucher proposal — we see the cost problem for what it is — a symptom of policy dysfunction.

Both approaches embody a basic truth. The U.S. must get a grip on Medicare costs, and accomplishing that won’t happen without setting limits. The SGR does that by pinning the tail on physician fees. If per capita Medicare costs rise too much, fees have to come down correspondingly. The Ryan plan pins the tail on Medicare recipients — if costs rise faster than the vouchers they receive, it’s their problem to solve.

Both approaches deserve respect for not indulging in the delusion that “waste, fraud and abuse” will do the job. But both are profoundly wrong.

It’s not primarily physicians’ fees that drive Medicare costs. It’s the services we physicians order. Lowering fees across the board puts prudent and profligate physicians in the same boat. The SGR is a make-believe “solution” that Congress repeals every time the formula prescribes a massive fee reduction.

The Ryan plan is similarly misguided. Medicare recipients aren’t “consumers” of health care. When shopping for clothes we (I’m Medicare eligible) can choose between Walmart and Nieman Marcus. That’s consumerism. But when cancer or heart disease occur we don’t “shop” at a cancer or cardiac mall — we seek doctors and nurses we trust and put ourselves in their hands. The negative reaction to Ryan’s proposal shows that U.S. society won’t accept putting the risk of cost overruns onto Medicare recipients alone any more than Congress accepts putting that risk uniquely onto physicians.

The SGR and the Ryan plan both try to solve a cultural and ethical problem with a simple technical fix. In part because of our reluctance to accept the inevitability of aging, decline, and death, and in part because the medical-industrial complex has sold us on the idea that ever more medical intervention will make us younger, healthier and happier, we haven’t yet accepted the fact that we (“we” = physicians, patients and the wider public) must collaboratively manage Medicare (and the entire health system) in a more parsimonious, evidence-based manner.

The fact that a wise and compassionate proposal to pay doctors for visits in which they discuss their patients’ goals triggered an eruption about “death panels” demonstrates the depth of the cultural and ethical challenge. Sarah Palin and Newt Gingrich almost certainly knew they were lying in crying “death panel,” but the fact that the public responded as strongly as it did shows that the very idea of discussing values about the goals of health care is seen, by many, as an assault on life itself.

The result of Medicare policy dysfunction is a program that too often harms seniors by overtreatment, creates ever-increasing out-of-pocket costs for Medicare recipients, and robs the next generation of opportunities they would otherwise have.

Medicare reforms that are guided by clinical evidence ethical reflection will better serve seniors and society. I continue to believe that advocacy for this approach from within the community of Medicare recipients will embolden political leaders to be more courageous. That kind of advocacy may serve as Viagra for policy dysfunction!

Jim Sabin, M.D., is a clinical professor in the departments of population medicine and psychiatry at Harvard Medical School. He is coauthor of Setting Limits Fairly: Learning to Share Resources for Health. This post originally appeared on his blog, Health Care Organizational Ethics.

The surprise victory of a Democrat in a House race in upstate New York a few weeks ago was widely taken to be a rebuff to the Paul Ryan plan to reform the Medicare program. For Democrats the take-away message seemed to be that opposition to Medicare reform is now a political winner, just as support for it is a loser. But the Democrats may have trapped themselves in a corner that sooner or later they will have to get out of, and made all the worse by short-term delaying tactics.

The current debate on raising the national debt ceiling will offer some insight into the future Medicare struggle. The strategy of the Democrats, led by Vice President Biden, appears to be that of finding ways to cut Medicare expenses, but not by cutting benefits. Representative Nancy Pelosi has said that she will “never support any arrangement that reduced benefits for Medicare – absolutely not,” and other Democrats are joining her on this stand. But let us assume that, save for minor Medicare cuts, Biden’s negotiations are successful, the debt ceiling is raised, and benefits are not seriously targeted. Where will that leave the Democrats in the future?

Here’s the fix they will find themselves in. They know Medicare’s annual cost increase must be seriously curbed for the program’s own survival, and they know there is also the added pressure of curbing the rise of the national deficit/debt. They surely know as well that every reputable policy analysts has for years judged that the cost of Medicare can only be dealt with by a significant rise in taxes or a cut in benefits or some combination of both.

They also know, as do the Republicans, that there is little public support for benefit cuts, with hardly more than 20% to 25% in favor of them. As for raising taxes the only kind with any support is higher taxes for the rich. Nor is there any likelihood of a shift in those figures in the next few years. The economic crisis will make it hard to raise taxes and the popularity of Medicare – as well as the sense of permanent entitlement it has encouraged over the years – will make it hard to cut benefits.

Drew Altman, president of the Kaiser Family Foundation, recently underscored a highly relevant reason why Medicare is so sacrosanct, what he calls its “multiplier effect.” By that term he means the vast number of people who are both directly and indirectly affected by the program, by direct benefits and the indirect impact on families of those benefits. Medicare, he notes, touched the “lives of more than 125 million Americans” in 2008: 75 million children of beneficiaries, 4 million spouses, 8 million disabled under the age of 65 (and their supportive families), and some 38 million beneficiaries over 65. That is a huge constituency, most of whom would be terrorized by any sharp benefit cuts.

And that’s not all. There is also a disturbing recent development, that of some weakening of support among Democrats for the Independent Payment Advisory Board, one of the few features of the Affordable Care Act that would directly and powerfully hold down Medicare cost escalation. Another obstacle is the pre-ACA legislation calling for a steady reduction in physician reimbursements, known as the “doc fix.” But many physicians have made clear that, should such a thing happen, they simply would not take on Medicare patients. They are, in effect, holding the present Medicare program hostage to the status quo.

Both parties, it is said, are now looking forward to the 2012 elections, hoping their present tactics put them in a commanding position. Republicans have already been burned by supporting the Ryan plan, which has gained weak voter support. Democrats have gloated about that victory, but Nancy Pelosi’s adamant stand against a cut in benefits surely showed that Democrats got the deeper message, not lost on their adversaries either: don’t mess with Medicare. The tactic of choice now for both sides is to stall for time and make gestures toward changing Medicare, but in a way that does not alienate seniors and the public.

Unless the economy greatly improves, President Obama will go into the election in a weak position, one hardly conducive to campaigning on a platform that includes Medicare cuts. The Democrat resistance to such cuts will make it all the harder to do so later. He should be taking the first steps now to avoid the appearance of weakness and vacillation in 2012, should he decide on a strong stand on Medicare reform as a candidate for reelection. If he does not, then the Medicare program will be in even worse danger than at present.

Obama can, however, have one advantage if he decides on a course of boldness. The Republicans have bet on the Ryan plan, a bet that is not paying off. They have nothing better to offer at the moment, and no signs that they will.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

A.B. Shaw, a British physician, once noted, “Aortic valve operations on the elderly are very cost-effective if the result is death or cure instead of prolonged illness.” While this may be a bitter observation, we know that the cost of treating chronic disease quickly surpasses acute lifesaving therapies because of the duration of treatment. Seventy-six percent of Medicare spending is on patients with five or more chronic diseases.

This post, as a follow-up to Polo Black-Golde’s post last May, analyzes the projected cost of seven common diseases affecting the elderly, and thus the Medicare program. Unless otherwise noted, all Medicare figures come from the most recent spending report from the Center for Medicare and Medicaid Studies (CMS).

Alzheimer’s disease

The number of new patients diagnosed with Alzheimer’s disease is increasing, but Alzheimer’s-related mortality is decreasing. Together, these trends account for the predicted increase in the number of people living with Alzheimer’s from 5 million today to 16 million by 2050. This growth will profoundly impact Medicare costs, given that the average annual cost of a Medicare patient with Alzheimer’s is triple that of a patient without: $13,207 and $4,454, respectively.

In 2005, Medicare spent $91 billion on patients diagnosed with Alzheimer’s disease, and this amount is expected to more than double to $189 billion in 2015, and increase to over $1 trillion by 2050.

Stroke

The cost of care in the first 30 days following a stroke is only $13,019 in mild cases and $20,346 in severe cases, and yet the lifetime cost of a stroke is approximately $140,048. The bulk of those costs comes in the form of chronic care and rehabilitation.

The mortality of strokes decreased 20.7% between 1995 and 2005. Over a similar period (1995–2006) the incidence has decreased 12.8%, but this trend is expected to soon reverse itself as the population ages – particularly ethnic minority groups who are at especially high risk of stroke. The result will be an increase in spending on stroke care, from $65.6 billion in 2008 to $2.2 trillion by the year 2050 if there are no changes in treatment, preventative care, or trends of risk factors (i.e. incidence of obesity).

Diabetes

Whereas the mortality of the previous two diseases is declining, the mortality of diabetes in the general population is increasing by 1.2% annually. Coupled with an exponential growth in the diabetic population (11 million in 2000, 23.6 million in 2009), and a predicted 52.9% increase in incidence rate between 2003 and 2023, the human and economic burden of diabetes in the future is certain to be overwhelming.

Currently 10% of health care dollars are spent on overall direct costs related to diabetes, amounting to $92 billion a year (1.5 times the amount spent on stroke or heart disease). The Centers for Disease Control and Prevention predicts that spending on diabetes care will reach $192 billion in 2020.

Medicare reported spending only $1.4 billion ($7,383 per discharge) on diabetes in 2007, but this number is limited to in-patient services, which excludes most diabetic care, such as insulin therapy.

End-Stage Renal Disease

Treatment for end-stage renal disease (ESRD), often caused by diabetes or hypertension, includes hemodialysis and kidney transplantation. Overall spending on ESRD treatment increased from $8.01 billion in 1996 to $33.61 billion in 2006. Recent data predicts a 150% increase in the number of patients undergoing hemodialysis and kidney transplantation in the next decade, which will continue the upward trend in treatment costs.

Medicare alone spent $23 billion on ESRD related hospitalizations in 2006, an average 9.2% annual increase from 1992.

Chronic Lung Disease

The Centers for Disease Control and Prevention lists fourth leading cause of death in the adult population as chronic lower respiratory disease, which includes bronchitis, emphysema, COPD, and asthma. The mortality of chronic lung disease is predicted to decrease at a rate of 1.5% a year until 2030, and yet the cost of treating it is predicted to more than double from $176.8 billion in 2006 to $389.2 billion in 2011 and to reach $832.9 billion in 2021. The reason for this skyrocketing increase is a 31.1% increase in the number of diagnoses predicted by the Milken Institute.

Medicare spent over $8 billion on respiratory disease, excluding pneumonia, in 2006, a figure that is bound to increase tremendously in the next decade.

Heart Disease

Heart disease has long been the leading cause of death in the United States. However, for the last 60 years, the age-adjusted mortality rate heart disease has been in decline. From 1950 to the mid-1980s, heart disease accounted for roughly 40% of all mortality; since 1986 this has slowly decreased. The most recent data from the CDC show that in 2005 heart disease accounted for 27.1 percent of overall mortality in the U.S, at an age-adjusted rate of 222 deaths per 100,000.

In contrast to the decreasing mortality rate from heart disease, expenditures are on the rise. In 2007, the overall cost of direct care for heart disease was $164.9 billion and is estimated to have been $183 billion in 2009. As the use of expensive treatments for heart disease such as pacemakers and internal defibrillators, continues to increase, so too will the cost of care. According to the Milken institute, overall cost of heart disease is predicted to reach $186 billion in 2023. In 2006, Medicare spent $24 billion on heart disease.

Cancer

The CDC reports that overall spending on direct care for cancer totaled $74 billion in 2004. While there are not any reliable cost projections for cancer, there has recently been an exponential increase in the cost of cancer drugs. Cancer treatment is especially prone to spending an exorbitant amount of money on a marginal benefit, with some treatments, such as Avastin – used for metastatic breast, colon, and non-small cell lung cancer – costing over $90,000 for a 1.5-month increase in predicted survival time, or $2,000 per day.

Medicare spent $7.3 billion dollars on inpatient cancer care, but this does not include most chemotherapy, which is administered as an outpatient service and is covered under Part B. Medicare spending on Part B drugs in 2004 totaled $10.87 billion, representing a steady 25% annual increase from the $2.76 billion spent in 1997. Given that the incidence of cancer in people above age 65 is nearly 10 times that of people under 65, as the population ages Medicare is bound to pay a large and growing portion of the nation’s over all spending on cancer treatments.

Considering that chronic diseases account for such a great proportion of Medicare’s overall spending, any increases in chronic care spending will directly affect Medicare. Ideally, Medicare spending will not increase annually more than the rate of inflation, 2 to 3%. However, each of these seven diseases explicitly underscores the fact that current trends make that goal almost impossible.

Kimberly Swartz is an intern at The Hastings Center.

Democrats and Republicans alike are balking at the Baucus proposal, the latest health care reform proposal to emerge from Congress. Not surprisingly, this enormous bill has something for everyone to hate. It attempts to legislate improvements in access and quality while simultaneously addressing cost.

But what is sometimes lost in the furor is that there are actually two kinds of costs that reform must deal with: the cost of implementing the new programs (principally the cost of requiring that most Americans have health insurance, which means subsidizing premiums for individuals with low incomes); and the rising cost of health care, principally the Medicare program, which is expected to run out of money in 2017.

The Baucus proposal has a price tag of $774 billion over 10 years (though in the last few days, various modifications have added another $28 billion), which refers to the first kind of cost. But how does the Baucus proposal address the second cost issue, containing spending?

The Congressional Budget Office predicts that total spending on health care will reach 36 percent of gross domestic product by 2035, with Medicare costs alone comprising 8 percent of GDP.  The vast majority of the increase in Medicare costs will be attributable to increased spending per enrollee, not to the aging of the population. And the single most important factor accounting for the increases is the emergence, adoption, and widespread diffusion of new medical technologies.

Some of these technologies are clearly beneficial; others are beneficial to some of those who receive the new drugs or devices, but are unnecessary or even harmful to numerous others for whom they are also prescribed. And some of the beneficial technologies produce only a very small benefit but at an extremely high cost, as set by the pharmaceutical or device manufacturing industries. Effective Medicare cost control will need to go beyond appealing proposals of dubious financial benefit such as expansion of preventive services and elimination of Medicare fraud (though this could save as much as $17.2 billion per year if fraud were totally eradicated).

What else does the Baucus bill suggest? It makes three significant proposals that actually might work. Collectively, they seek to modify the culture of medicine by altering the way medical care is delivered and how it is paid for.

The beauty and the peril of its strategy is to create an infrastructure for designing a program rather than actually spelling out what the program will be. The beauty is that it does not require making politically unpalatable claims, for example that CMS may need to stop reimbursing for technologies that are not cost effective. The peril is that the various centers and institutes the plan will spawn may not in fact do what they need to in order to control costs. Just what are these centers and institutes?

The most familiar one, because it is also found in the “Affordable Health Choices Act” of both the Senate and the House, is a nonprofit patient-centered outcomes research institute. This would conduct research comparing the clinical effectiveness of medical treatments. To be effective, its work would need to translate into the CMS reimbursement policies: it would have to become an extra-government agency along the lines of the much-maligned but crucially necessary British National Institute for Health and Clinical Excellence (NICE).

The second new institution is an independent Medicare commission charged with submitting proposals for reducing excess Medicare cost growth. Strong wording would effectively require Congress to do what the commission requested or come up with a fiscally equivalent alternative. This is an example of the politically astute approach of leaving open just what the independent commission would recommend.

The third institution is an innovation center within CMS to test, evaluate, and expand different payment structures and methodologies to foster patient-centered care, improve quality, and slow Medicare cost growth. Among other endeavors, the center is mandated to pilot the development and evaluation of a system of bundled payments for a single episode of care – that is, a single payment covering care in the office, the hospital, and the skilled nursing facility. For bundling to work, doctors, nursing facilities, and hospitals will need to band together to form accountable care organizations, and Baucus promotes the establishment of these organizations by offering them a share in the cost savings they generate.

Will the research institute, the commission, and the innovation center, with it assorted pilot programs, do the job? Without knowing just what they will recommend, it is impossible to be sure. But their focus will be on the right areas: figuring out what works and what doesn’t, determining who benefits from new technologies and by how much, and developing systems of care that assure that patients get the interventions that work but not those that don’t. It’s our best shot to date.

Muriel Gillick, M.D., is a Clinical Professor of Population Medicine at Harvard Medical School and a physician specializing in geriatrics and palliative medicine at Harvard Vanguard Medical Associates. mgillick@partners.org; 617–509-9977.

Regional variations in healthcare spending have been described for decades. The Dartmouth Atlas Project has spent years examining Medicare spending patterns across the country. Findings indicate that some areas spend much more than others, sometimes twice as much. Improved health outcomes do not appear to be associated with Medicare spending, after controlling for disease-severity and other factors, including age.

These studies got widespread political attention in a recent article by Atul Gawande in the New Yorker – President Obama called a meeting to discuss it in the Oval Office. The evidence Gawande presents point to the most emotionally compelling cause of variation: supply-driven demand, sometimes pushing deep into fraudulent territory.

This evidence has led to the disturbing observation that supply sometimes may be driving demand. Fixing the source of these variations could halt the subsidization of high-cost regions by lower-cost. The question remains: how much of the demonstrated regional variation can be painlessly reduced by politically feasible options?

Concrete solutions are hard to come by, but in December 2008 the Congressional Budget Office described 115 options to reduce health care spending. Some of these options were intended to address these variations, and their immediate economic impact was quantified.

One option called for the incremental reduction of physician fees in Hospital Service Areas that are in the 90^th percentile. This would have the effect of decreasing physician fees by as much as 30 percent in some areas, while leaving 90 percent of areas untouched. The total savings over the next 10 years would be $5.3 billion. A second, related option calls for reducing payments to hospitals in areas with an exceptionally high volume of elective admissions. This would save a modest $2.5 billion over 10 years.

The most dramatic option proposed would call for global reduction in payments in areas that spend greater than 10 percent more than the national average. These reductions would be scaled so that the higher spending areas receive proportionately larger reductions. For example, a region that spent twice the national average would have payments reduced by 45 percent across the board, thereby bringing total spending to the national average. These calculations assume that the volume of patients would constant, which history shows it would not.

One could anticipate a combination of effects. Experience shows that increased volume would partially make up for lost revenue. Decreases would simultaneously occur due to reduced provider participation in Medicare, and perhaps even small-scale migration of providers. The repercussions on provider availability would be enormous in the highest spending markets, leaving lower-spending areas free to continue on their current, relatively frugal tracks.

That said, if these changes were to result in real savings, the disruptions could possibly be bearable. As the CBO shows, however, the savings would be about $50.9 billion over the next 10 years, an average of only $5 billion per year. To put this into perspective, total Medicare expenditures in 2007 alone were about $420 billion. There would in all likelihood be an adverse spillover effects on the rest of our national health spending, as hospitals in heavily cut areas begin to replace revenue from other sources, namely private insurance.

As the Dartmouth Atlas researchers repeatedly state, these heavy-handed solutions are not what they envisioned. Restructuring health care delivery by emulating successful models of accountability is touted as the ideal solution. On a national scale, this would take drastic intervention that today lacks sufficient political backing. However, smaller models, such as the Mayo Clinic or Cleveland Clinic, expanding gradually as they succeed, could thrive within the frameworks currently being proposed in Congress.

Regional variations are not the disease to be cured; they are the symptoms of a health care system with some counterproductive incentives. A long-term restructuring of health care to reward quality and not quantity could organically, though perhaps not completely painlessly, reduce spending. The difficulty lies in implementing this on a large scale.

Anthony Marfeo is a fourth year medical student at Yale. Anthony.Marfeo@yale.edu.

Even though a major obstacle to agreement on the health care reform bills is their price tags, cost control is not being seriously confronted, writes Daniel Callahan, editor of the Health Care Cost Monitor, this week in The New England Journal of Medicine.

“Although everyone bewails rising costs, the constituency for doing something about them is skimpy,” he says in his essay. The essay was also the subject of a post on Forbes.com by Matthew Herper.

“What would be good enough?” Callahan writes. “A way must be found to resolve a basic dilemma: cost controls that are likely to be politically acceptable will not be very effective, and what might be effective will not be acceptable.”

Callahan recommends paying close attention to techniques used in other countries to control costs: “Some of them set limits on care that doctors consider necessary, and most require the strong hand of government: for instance, price controls on pharmaceuticals, negotiated physicians’ fees, caps on hospitals’ annual budgets, and limitations on the introduction of new technologies…They should be pushed.”

The Forbes.com post notes: “Callahan’s editorial comes the same day the chairman of the Senate Finance Committee, Sen. Max Baucus, said the group has figured out how to cover the costs of its still unfinished health care reform bill.”

—Susan Gilbert

So much of the debate over controlling health care costs at the end of life is of the either-or variety: give patients access to all available treatments or condemn them to death by rationing. As Dr. Laura Carstensen, director of the Center on Longevity at Stanford University, puts it in an excellent front page article in The New York Times, “Either we have to throw everything we’ve got at keeping people alive or leave them on the sidewalk to die.”

But the article, written by Jane Gross, who created the Times’s New Old Age blog, gives lie to that simplistic way of thinking. “Sisters Face Death With Dignity and Reverence,” looks a congregation of nuns in a Rochester, N.Y., who live out their final days in a facility that provides excellent palliative and hospice care, along with social and intellectual engagement up until the very end. It’s not that the nuns are denied aggressive life-extending treatments; but few choose them.

Sister Dorothy Quinn, for example, 87 years old and dying of heart disease, decided not to take most of the 23 medications that had been prescribed for her. She also declined to have a mammogram to determine if a lump in her remaining breast was cancerous, “understanding that she would not survive treatment,” Gross wrote.

This sort of decision-making is possible because of an environment where doctors talk to patients frankly and openly about their conditions, the likely benefit from various treatment options, and death.

The experience is in stark contrast to that of most patients dying in hospitals, which often leads to the use of expensive and futile treatments at the end of life, as described in several posts here.

One post discussed the dramatic increase in the use of life-extending treatments for people in their 80s and 90s, including kidney transplants and dialysis.

In another post, Harvard geriatrician Muriel Gillick described a man in his late 70s who had had a massive stroke and was “being kept alive in the ICU with a variety of high-tech interventions.” His wife agreed to the treatments because the doctor hadn’t explained that even if he survived the ICU, rehabilitation would be grueling and he would either die or be extremely debilitated.

“Once she understood both what treatment would entail and how unlikely meaningful recovery was, she had no further hesitation: the right course of action for her husband was to focus exclusively on his comfort,” Gillick wrote.

In the Times article, Dr. Robert McCann, the geriatrician who treats the nuns, says that “they have better deaths than any I’ve ever seen.”

He goes on to say, “It is much easier to guide people to better choices here than in a hospital, and you don’t get a lot of pushback when you suggest that more treatment is not better treatment.” In an audio slideshow, McCann says that he uses one-third the amount of narcotics for the nuns than for his patients dying in other facilities because the nuns have less need for the drugs.

The article clearly touched a nerve. It was the most frequently e-mailed New York Times article on July 9, and received dozens of comments, most full of praise for the end of life care described.

Could that kind of care take hold outside the convent, in the rest of the country? Gross is hopeful that it might. The nuns there “animate many factors that studies say contribute to successful aging and a gentle death – none of which require this special setting,” she wrote. “These include a large social network, intellectual stimulation, continued engagement in life and spiritual beliefs, as well as health care guided by the less-is-more principles of palliative and hospice care – trends that are moving from the fringes to the mainstream.”

To give that trend a push would probably require a change in Medicare proposed by Gillick in another previous post here. As it stands now, she wrote, Medicare reimbursement favors “burdensome, expensive, treatments at the end of life.” It also provides excellent hospice care, but only if patients make a “diabolical choice” – agreeing to forgo some palliative treatments that can ease their symptoms, such as oral chemotherapy.

Gillick said that a better and potentially money-saving option would be to provide hospice care along with some hospital care, but excluding the most expensive kinds of interventions, such as major surgery and ICU care.

It’s not either-or, everything or rationing. And, based on the comments on the Times article, it’s an option that many people would gladly choose for their last days.

Susan Gilbert is the associate editor of the Health Care Cost Monitor and the staff writer of The Hastings Center.

Just how far attitudes and expectations about aging have changed in the last 60 years hit home when I stumbled on an article from the New York Times Magazine written in 1950 called “Recharting Life for an Aging America.” The author, a physician, wrote, “To lead a long and happy life falls, for the average citizen, into the same category of irrational wishes as to be a millionaire or a movie star.” The reality, he said, is that most old people are “lonely, poor, ailing, crippled, ugly, [and] mentally and physically deteriorated.”

Today, by contrast, as Sharon Kaufman suggested in her post, elderly Americans today take the possibility of ever-increasing longevity for granted. The change in perspective is dramatic and it’s very new: while Americans born in 1950 could expect to live far longer than their grandfathers did, most of the improvement in life expectancy was due to decreases in infant mortality. It was only in 1970 – five years after the introduction of Medicare – that 65 year olds could look forward to a longer period of retirement than any previous generation. By 2005, white men could anticipate another 17.2 years of life, and white women 20 years.

But is the result really that Americans today fail to accept that death is inevitable? Or do patients appear to believe that death is optional because physicians seldom discuss life’s final stage and continue to offer treatments, even if they are of little or no benefit? For all the lip service paid to informed consent and joint physician-patient decision-making, older patients seldom understand their likely trajectory with and without a particular treatment.

I recently came across a dramatic example of this problem in the course of a palliative care consultation at a major teaching hospital in Boston. The patient was a man in his late 70s who had been hospitalized with a devastating stroke due to massive bleeding in his brain. He was being kept alive in the ICU with a variety of high-tech interventions.

The attending neurologist told the patient’s wife that the likelihood of recovery was very small but that the full extent of his improvement might not be known for months. The doctor held out no hope of a full recovery and expected that if the patient did survive, he would require total care and would have little if any language capacity.

The patient’s wife didn’t think her husband would have accepted such profound limitations on his functioning, but she wasn’t absolutely sure. She wondered whether she should authorize further vigorous treatment to “give him a chance.”

What quickly became clear to me was that the wife’s conception of what it would be like for her husband over the next two months if she opted for attempted rehabilitation and life-prolonging treatment bore little relationship to reality. She imagined that “going to rehab” would be as benign as taking a daily vitamin pill.

I explained to her that after transfer to a rehab facility, her husband would likely suffer multiple complications, such as pressure ulcers or pneumonia. He would probably be shuttled back and forth between the rehab facility and the hospital – and after all that, he would either die or be left extremely debilitated. Once she understood both what treatment would entail and how unlikely meaningful recovery was, she had no further hesitation: the right course of action for her husband was to focus exclusively on his comfort.

In today’s medical world, this kind of discussion is rare. If Medicare patients are to get appropriate care, and if costs are to be controlled, physicians must have such conversations. But since the focus throughout a physician’s training is on prolonging life, with little attention to maximizing quality of life or to deciding when to stop, medical education will need to change.

Right now, Medicare and Medicaid pay just under $10 billion per year to hospitals in the form of General Medical Education funds to train residents. But as the Council on Graduate Medical Education observed in a letter to the Secretary of Health and Human Services in May 2009, hospitals are not held accountable for how they spend the money. Their concern is with their own labor needs, not with training the next generation of physicians to manage chronic disease. It is time to monitor and regulate the way the federal government’s money is spent and require proficiency in end of life discussions alone with disease management and care coordination.

Kaufman thinks that telling patients about the trajectory of illness with different treatment options won’t be good enough because patients engage in magical thinking. She cites a study in which patients who think their chances of relatively long-term survival are favorable, “despite prognostic models to the contrary,” want aggressive treatment. In other words, physicians can lay out the various possible scenarios but patients will gamble that they will be the lucky ones who have the best outcomes.

My experience suggests that most patients do respond to realistic discussions about their future, but the way to deal with the minority of patients who might want to try treatments that have a vanishingly small chance of working is simply not to offer such interventions. This decision should be made at the policy level.

National Institutes of Health consensus conferences will be required to determine a new standard of care for patients with a variety of chronic conditions, such as dementia and heart failure, in the last phase of life. The Centers for Medicare & Medicaid Services (CMS) will then need to give teeth to the practice guidelines that emerge from such conferences by agreeing to reimburse only for treatment that is consistent with those guidelines.

Perhaps the greatest challenge is that policymakers, who will need to endorse the kinds of changes I am suggesting, share the same expectations of ever-increasing longevity as other Americans. A good starting point, therefore, is to limit treatments that are burdensome, unlikely to be effective, and expensive. The next step will be to dispassionately analyze interventions that offer only a slight chance of benefit and that are expensive but not burdensome to patients.

As Kaufman mentions, some devices such as pacemakers have become increasingly acceptable as they have become smaller and implanting them has become safer and less invasive. Likewise, some cancers have become chronic illnesses because of the “explosion in new, specifically targeted and less toxic treatments,” as Kaufman writes. In many instances, older cancer patients show “unprecedented willingness” to undergo treatment precisely because it isn’t “aggressive” in the sense of being burdensome.

Why shouldn’t patients want a potentially life-extending treatment if it comes in the form of a pill, without the nausea, vomiting, hair loss, and bone marrow depression associated with conventional chemotherapy? Ultimately, policymakers will have to take into consideration cost-effectiveness in deciding whether CMS will cover such treatments.

Far less politically charged are the steps that should be taken immediately: regulating spending on graduate medical education and limiting reimbursement for treatments that come at a high price to both patients and society without conferring any appreciable benefit.

Muriel R. Gillick, MD, is a geriatrician and palliative care physician at Harvard Vanguard Medical Associates in Boston and a Professor of Ambulatory Care and Prevention at Harvard Medical School. Her most recent book is The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies. mgillick@partners.org; 617–509-9977.

An explosion of life-extending interventions for older persons is changing the face of many medical specialties in the United States Routine and innovative treatments are prolonging more lives at older ages than ever before, and the average age of patients who receive surgery and other nonprimary care interventions that extend life is rising. Indeed, octogenarians comprise the most rapidly growing group of surgical patients, and there is a growing medical literature on the justification and benefits for performing many procedures on persons over age 80. These practices are reshaping medical knowledge and societal expectations about “normal” old age, longevity and the time for death.

For clinicians, there are no longer steadfast assumptions about technological or biological limits to what medicine can do for older persons. Patients, for their part, have become medical consumers responsible for questing after their own health and longevity. Desire for therapeutics into advanced age has grown along with the aging of the population.

Four and a half million people in the U.S. are 85 years old or older. By 2050, 20 million persons will be over age 85. There are enormous pressures from multiple sources – patients, their families, the “technological imperative” in medicine, the structure of health care financing, the specter of litigation, the excitement surrounding new interventions, professional training and subspecialization, and, above all, the cumulative successes of clinical medicine – to attempt to stop the course of end-stage disease late in life. Together, the availability of more options and the normalization of life-extending treatments at older ages promote the notion that aging and death are not inevitable and foster the assumption that one can and should choose to intervene. (That assumption is not as pervasive in Europe, where the limitations to health care resources are widely acknowledged.)

Examples of the expanding use of four kinds of therapies are emblematic for the rising age for interventions of all kinds. Their success in extending lives and well-being contributes to the cost challenges that accompany medical interventions in an aging society. As clinical criteria for performing these procedures expand to include older, sicker people, two accompanying social trends contribute directly to rising costs and the problem of limiting them. One trend, diminishing the risks of death by whatever clinical means available, has already become standard practice and is seen to be ethically appropriate, even necessary (for those who can access services). The other is that of ever-new biotechnological tools that create a more perceived need to intervene, in order to treat the risk of death.

Cardiac procedures

Coronary artery bypass graft surgery, angioplasty, stent procedures are now commonplace for persons in their 80s and not unusual for persons in their 90s. Cardiac valve replacement therapies are becoming more common in the ninth decade as well. Studies indicate that successful outcomes for those procedures can be obtained for select groups of patients aged 90 or older, although hospitalization may be longer and morbidity higher than for younger patients.

Advances in treatments for strokes and heart attacks have prolonged lives, although they have led also to emerging epidemics of heart failure and atrial fibrillation among the elderly. The prevalence of heart failure has been increasing over the last decade, with approximately 550,000 new cases diagnosed each year. Available interventions for severe heart failure include hospice care, the automatic implantable cardiac defibrillator (AICD), the left ventricular assist device (LVAD), and heart transplant. These dramatically distinct offerings include both ends of the intervention spectrum in contemporary medicine – from end-of-life palliation to heroic (yet only potential) life-extension. This range of treatments complicates choice because hope is always embodied in heroic interventions. A recent study shows that patients who think their chances of relatively long-term survival are favorable want aggressive therapies – despite prognostic models to the contrary.

Relatively few individuals consider and receive a LVAD or cardiac transplant, although cardiac transplant in the seventh decade is not uncommon. In contrast thousands of older Medicare recipients now qualify for the AICD device (with or without pacemakers). Use of the device is rising substantially because the Centers for Medicare and Medicaid Services in 2005 approved the expansion of the eligibility criteria to include primary prevention for patients who have never suffered a cardiac event. The device regulates a lethal cardiac rhythm, thereby reducing the risk of a fatal heart attack. In 2005 more than 100,000 individuals received an AICD, up from 48,000 in 2001.

Although a recent study shows the device to be effective in reducing mortality for older patients, opinions diverge about whether the AICD for very old individuals is appropriate. Meanwhile use of this device is on the rise because it prevents death, the treatment of risk itself has become important in medicine, and specialist and subspecialist referrals pave the way for its use. As devices become smaller, as techniques for implanting them become safer, and as less invasive procedures are used with greater frequency and success, physicians and the public have learned to view them as standard interventions. Reduced risks associated with all of these procedures produces a sense that life extension is open-ended.

Kidney dialysis

Since 1972, when Medicare benefits were extended to all persons with end-stage renal disease (ESRD), the earlier more stringent criteria for dialysis selection have fallen away. At the same time, advances in dialysis care mean that physicians are now more successful at treating ever-older patients with complicated disease. Many health professionals feel that it is morally unjustified not to offer dialysis to any patient with ESRD. Projected trends for the next decade indicate an increasing proportion of new dialysis patients older than age 75. Currently, 25 percent of all U.S. dialysis patients are over 75; 14 percent are over age 80. The goals of treatment, however, have not evolved from half a century ago to reflect this shift in demographics. With few exceptions, the medical literature has not addressed the role of palliative care and the acknowledgment of the nearness of the end of life in dialysis settings, which indicates that clinicians are disinclined to discuss death with patients.

Kidney transplant

Medical evidence shows that transplantation is the treatment of choice for suitable patients with ESRD, and there is growing demand for kidney transplantation among older persons with kidney disease – both from patients on dialysis and those who would like to avoid dialysis altogether. The number of kidneys transplanted to people over 65, from both living and cadaver donors, has increased steadily in the past two decades in the U.S. In 2008 15 percent of all kidney transplants went to persons age 65 and over. Transplants are no longer unusual in the seventh decade of life and are sometimes performed into the early 80s. As the waiting time for cadaveric kidneys increases (often beyond five years), there has been greater ethical pressure on family members and friends to become living donors.

Cancer treatments

Many cancers have become chronic illnesses today, manageable and sometimes curable because of the explosion in new, specifically targeted and less toxic treatments. Older patients who in the past did not receive treatments are now receiving them for several reasons. There is an unprecedented willingness of older cancer patients to undergo aggressive and long-term treatments. Physicians do not want to deny older patients therapies that may make them more comfortable or extend life, and clinical investigators are becoming increasingly interested in including older persons in clinical trials. As a result, potentially life-extending treatments have become routine into the eighth decade, and, in much smaller numbers, into the 90s. Yet there is controversy about how aggressively to treat cancers at older ages; doctors, patients, and families are often uncertain about how to proceed.

Without medical guidelines or explicit discussions between doctors and patients about the end of life or the toxicity of treatments, many patients and families proactively choose aggressive, toxic, and costly treatments up until the time of death, even when clinicians also offer hospice care. Recent medical studies express a concern about the growing numbers of patients who receive aggressive chemotherapy up until a few days and weeks before death.

Complicating medical success

Standard procedures are difficult to refuse. It seems against medical progress and common sense to say no, especially if interventions are immediately lifesaving or preventive, and current medical discourse emphasizes that refusing a procedure today may increase the risk later for other problems and especially for death. Success in extending older lives creates the grounds for individuals to decide whether and how to seek more time for themselves and their loved ones. These examples point to the growing difficulty of defining medical success and the “best treatment” plan in an aging society. Ethics and best practices insure that those patients who can access all that medicine has available will be offered state-of-the-art treatments. Patients, when faced with serious disease and options about what to do, often find themselves contemplating a calculus about how much more time they want to live. Because the value of life is neither age-dependent nor quantifiable, their deliberations provide one reason why debates about age-rationing remain lively and unresolved.

Sharon R. Kaufman, PhD, is professor of medical anthropology at the University of California, San Francisco. Her current primary research focus is on the impact of medical technique on individuals in an aging society. Her most recent book is …And a Time to Die: How American Hospitals Shape the End of Life; sharon.kaufman@ucsf.edu; 415–476-3005.

Everyone is well aware that Medicare is in trouble. But it is not clear that everyone realizes just how serious it is. The 2009 report by the Trustees of the Medicare program spotlighted the most visible sign of distress, projecting that it would be insolvent in a mere eight years. But it is possible, and likely, that Medicare’s troubles will persuade Congress to increase the payroll tax deduction a bit, cut some expenses here and there, and thus put off insolvency for a few years. The long-term cost projections are another story, not so easily dealt with: a rising number of elderly coming into the program accompanied by a parallel rise in the cost of treating them.

In today’s post, Muriel Gillick, a geriatrician at Harvard, sketches a clear picture of that troubling future, but offers a glimmer of hope. Our colleague, Polo Black Golde, lays out the sometimes startling cost projections for a variety of conditions afflicting the elderly.

—Daniel Callahan and Susan Gilbert, editors