Senior Medicine: When More Isn't Better
by Arthur Allen is the eHealth editor for POLITICO Pro. Joanne Kenen contributed to this report.
Published on Oct 04, 2017
America is grayer than it used to be, with the baby boom generation now retiring in droves, and the U.S. fertility rate hitting a record low. In 2014, according to the Census Bureau, 15 percent of Americans were 65 or older, already a record. By 2030, that number will rise to 21 percent and it is projected to reach 24 percent by 2060, a result of Americans living longer and having fewer kids.
Dr. George Taler still makes house calls, driving his scuffed green Toyota sedan from one apartment to another, carrying a blue satchel with a laptop, hand sanitizer and a few medical tools. Inside each apartment, he practices medicine with old-fashioned care, spending half an hour with each patient. He takes out a stethoscope, a blood pressure cuff, a pulse oximeter. And if all goes well, when the visit ends, the patient ends up getting less—not more—medical care than if she'd shown up at a medical office.
Visit No. 4 on a recent morning was Maggie Barnes, an 82-year-old stroke patient with diabetes, high blood pressure and high cholesterol. She sat in a wheelchair and shared some easy banter with a doctor she’d been seeing for more than a decade. “I feel good!” Barnes said.
“She’s got James Brown Syndrome,” Taler said, grinning. Barnes’ main worry is the wheelchair. It was six or seven years old and getting creaky—a piece had come off—and she was worried she’d fall out in the street. As for medications, Taler noted approvingly that she was down to one pill each for her diabetes, cholesterol, stroke and blood pressure, and not in pain.
For four decades, Taler, a senior physician at the MedStar Washington Hospital Center, has been trying to practice what he calls “slow medicine.” His clients are elderly people with chronic disease, individuals who typically cost the health care system around 10 times more than the average patient. And at the center of his philosophy is the idea—radical in today’s medical environment—that less can be much more.
Taler is an adherent of the guidelines of Choosing Wisely, a 5-year-old medical initiative based on the premise that the best outcomes often result from saying “no” to tempting procedures, tests and prescriptions. “Medications can be toxic as well as therapeutic,” he says. “It’s as important to cull the list on a monthly basis as it is to try new medications.”
According to some estimates, as much as a fifth of U.S. medical care is unnecessary. This represents $250 billion annually—and perhaps more important, it means patients are undergoing hundreds of thousands of procedures and prescriptions that have no benefit, and quite possibly cause them some harm. A third of medical care goes to the elderly, though they make up just 14 percent of the population. Older people with chronic illnesses stemming from obesity and age tend to get a lot of pills and procedures that aren’t helpful. Since they are more frail, they are most likely to suffer severe harm from things like drug side effects and surgeries that go wrong.
Choosing Wisely is one of the tendrils of reform that have been creeping into the U.S. health care system over the past several years as government and private-sector leaders try to find the points where cost control and better care can actually go hand in hand. The American Board of Internal Medicine Foundation started the Choosing Wisely initiative in earnest in 2012; the board’s members, largely general practitioners, had started to worry about the expanding costs and contradictions of medicine, and thought they could reduce waste by encouraging physicians and patients to talk about what care was needed, debunking the notion that more is automatically better.
So far, 80 U.S. clinical and pharmaceutical specialty societies have joined their campaign, each creating lists of five to 10 things that their members shouldn’t do—at least without thoughtful discussion with the patient. The American Gastroenterology Society recommends against colonoscopies more often than once every 10 years; the allergy and immunology society agreed that doctors should avoid prescribing antihistamines as first-order treatment of severe allergic reactions. The American Academy of Ophthalmology recommends its members not to require preoperative tests like electrocardiograms before eye surgery unless the patient has a known heart condition. The program, which publishes resources on a website and provides patient information through Consumer Reports, amounts to a broad-based effort to figure out what patients don’t really need, and then ensure they don’t get it.
But for doctors like Taler, who try to integrate those ideas into their practice, it’s clear that much of U.S. medicine is not embracing the principles of Choosing Wisely, which is colliding with a whole host of issues in medicine, from payment systems to the scattered way many patients receive their medical care, to a prevailing culture in which both doctors and patients have trouble saying “no” to more medicine.
It’s important that this change succeed, Taler said. With health care accounting for a swelling chunk of the U.S. economy—about 18 percent at last count – something has to give. If doctors and health systems can’t better shepherd our resources, bean counters may do it for them—in a way that no one likes.
ITS PROPONENTS SEE Choosing Wisely as an attempt to bridge the divide between two driving philosophies in U.S. medicine—the idea of physician autonomy built upon an almost mystical “physician-patient dyad,” as a recent writer described it, and a century’s worth of momentum toward evidence-based improvement and standardization of medicine.
In theory, doctors’ goals and patient health should be perfectly aligned. But in practice, for a variety of reasons including patient demands, lack of clarity or scarcity of evidence, in practice, doctors often employ procedures and medications that haven’t been shown to help much—and they don’t like being told how to practice in their fields.
Earlier efforts to tamp down on excessive care ran aground on those rocks—and on the American medical system’s aversion to making decisions based on cost. Physicians and patients alike bridled at the Health Management Organizations, or HMOs, where, in the pre-Obamacare days, cost-conscious reviewers meddled intensely in medicine, deciding when insurance would pay for a drug or procedure. More recent efforts to trim spending have been merged with care improvement schemes called Accountable Care Organizations, where physicians are more in the driver’s seat, and get bonuses or penalties depending on how efficient their care is—and how well their patients do overall.
The Affordable Care Act and the 2015 Medicare payment reform measure known as MACRA both push in this direction, with the government trying to encourage better medicine by increasingly paying for value—as best it can define this elusive quality—instead-of-individual services. Choosing Wisely takes a different, purely voluntary tack: A “bottom up” approach led by physician organizations rather than being foisted on doctors by the government.
“It’s a movement of clinicians taking responsibility for an issue that’s about overuse, but also better quality and safety and doing no harm,” said Daniel Wolfson, executive vice president of the American Board of Internal Medicine Foundation. “The byproduct is that it reduces cost. So we think we have solved the quality-safety-cost issue in a unique way that begins with cultural change.”
Individual hospitals have incorporated specific guidelines with success. Doctors at the Dartmouth-Hitchcock Medical Center in New Hampshire reduced unnecessary preoperative tests from 23 percent to 4 percent over a three-month period by incorporating Choosing Wisely guidelines into the electronic records their doctors use, according to a recent study. Certain behaviors targeted for cessation by the campaign—such as threading tubes through the nose and throats of patients suffering from advanced Alzheimer’s disease in order to feed them—have declined dramatically, said Joan Teno, a University of Washington physician who works with the elderly. She attributes that change largely to the Choosing Wisely campaign.
It has also attracted skeptics, including physicians who feel it’s another threat to their autonomy—this time coming from professional societies, rather than the government as practitioners of the art of medicine. Others have pointed out that some of the Choosing Wisely recommendations have been withdrawn—including an American College of Cardiology recommendation for a heart attack treatment procedure—and say it is foolhardy to issue a blanket “no” against procedures that the next wave of research may bring back into favor.
Neither the government nor insurers were able to provide data on the extent to which Choosing Wisely has cut unnecessary medicine across the country. In part, this is because it simply hasn’t penetrated the system thoroughly: A survey last year at a Massachusetts health system—presumably among the more well-versed communities in medical research found about only half of primary care physicians and a third of specialists had even heard of Choosing Wisely.
If Choosing Wisely has a cheering section, it’s the geriatricians, doctors like Taler and Teno who specialize in elderly care. Geriatrics first became a major specialty in Britain, where today its practitioners constitute the largest single group of primary care physicians. In the United States, the specialty is far smaller and has more of a consulting role. In many instances, the geriatrician acts as a firefighter called in when an elderly patient’s medical care has spun out of control.
Geriatricians like Taler come in, talk to the patient, examine their pills and make recommendations that ideally are aimed at the whole patient, not just his or her heart or lungs or pancreas. With a frail elderly patient who may not have many years to live, some of the established drugs and procedures don’t make sense anymore.
Are a diabetic patient’s other doctors pushing too hard to lower his blood sugar, raising the risk of a faint, which could result in a broken hip? Is an orthopedist recommending arthroscopic surgery—a procedure, research shows, that doesn’t cure arthritis? All those expensive Mohs procedures to remove precancerous growths—given how slow-growing they are, is it always worth the time, expense and strain on the patient to remove them so carefully?
“A lot of what we do is try to prevent harm by other providers,” said Sei Lee, associate medical director at the University of California Center for Geriatric Care in San Francisco. “The cultural norm in geriatrics is that we are trying to do more with less. We try to protect our patients from some of the iatrogenic harms. We were the choir when Choosing Wisely came out.”
“Often I’m arguing with a cardiologist who says, ‘This person’s blood pressure target is X, we should get him there.’ And my argument is, ‘He’s already on three medicines and we’ve gotten him from terrible to almost there. What’s the marginal benefit of adding a fourth medicine to get him to an optimal reading?’”
For doctors like Taler and Lee, a program aimed at voluntary moderation is a godsend: It bolsters their belief that it’s a good idea to keep patients out of the hospital and off multiple pills, and offers guidelines to other specialists that can prevent conflicts. It still isn’t easy, though: Patients and physicians often resist the recommendations for entirely practical reasons. Tranquilizers may lead to brain fog and falls, but “anyone who has taken a benzodiazepine and slept better at night and not fallen or had a car accident will say ‘I didn’t see the harm,’” says Paul Mulhausen, an Iowa geriatrician. Anti-psychotic drugs have often been abused to exert control over elderly dementia patients, but they sure come in handy when an older spouse is trying to care for an angry Alzheimer’s patient at home rather than commit him to an institution.
Some elderly patients don’t understand why they’re being told they no longer need mammographies or colonoscopies—or they do understand, and don’t like the implications. The regular procedures, like their frequent visits to the doctor, offer the psychological sense of normalcy and imply a kind of optimism that there’s life in them yet. “My 95-year-old mother is always saying, ‘When you get old they just throw you away,’” says geriatrician Joanne Lynn. “They just throw you away.’”
AND THEN THERE'S the entirely predictable obstacle to Choosing Wisely that arises in the medical specialties themselves. “The answer is money,” says Taler. “What was the question?”
Certain medical groups have been hesitant to declare as “wasteful” procedures that can be quite profitable. For example, the Choosing Wisely list for orthopedic surgeons includes somewhat ancillary issues: “Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee” is one item; “Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief” is another.
Left off the list is arthroscopic knee surgery, the most commonly performed orthopedic procedure in the United States, yet one that helps only a slim percentage of patients—and is of almost no value to the frail elderly patients who suffer most from arthritis.
In recent years, physicians have had another reason not to follow Choosing Wisely recommendations—they come into conflict with other “quality improvement” measures sponsored by the government or private insurers. Some doctors shun wise choices because making them risks penalization by Medicare.
An example is pushing for low blood sugar levels in diabetic patients. The Centers for Medicare & Medicaid Services’ new payment schema punishes physicians treating patients under Medicare if they fail to achieve a 9 percent HbA1c level, a measure of blood sugar. Other programs push for 7.5 percent. This goal, enshrined in quality improvement programs run by Medicare and many insurers, is based on a landmark 1993 study showing that the lower thresholds protected patients with juvenile diabetes from suffering kidney, eye or nerve damage, said Victor Montori, an endocrinologist at the Mayo Clinic. Subsequent research on adult-onset diabetes patients without symptoms did not duplicate that result, however—and yet the standard remains for all diabetes patients. Doctors who ignore it risk payment cuts or poor “star ratings” in published reports.
Aggressive blood sugar control is especially questionable in frail older patients whose diabetes is not going to be the thing that kills them. If blood sugar gets too low, it can lead to fainting, dizziness and falls that cause broken arms or hips. And when multiple drugs are needed to reach the low threshold, as is often the case, the regimens can become cumbersome and the likelihood of bad side effects rises.
When the American Geriatric Society tried to include easing of blood sugar control in its Choosing Wisely campaign, however, some endocrinologists became concerned and managed to water down the recommendations after a lengthy email back-and-forth, according to a geriatrician who was involved in making the list. The final list includes only a soft recommendation against the use of multiple anti-diabetes drugs.
“Quality and performance measures often lead to overtreatment,” said Kenneth Covinsky, Lee’s colleague in the UC-San Francisco geriatrics program. “They say, ‘We’re going to penalize you if your blood sugar levels are too high.’ Well, they are actually not too high. The guidelines were developed for people in their 50s and they are influenced by the drug companies.”
“If the patient’s going to be angry, insurance is going to pay and the doctor doesn’t want to get dinged, it’s a perfect storm to make sure you get extra mammograms, cancer screenings and aggressive control of asymptomatic conditions like hypertension and diabetes,” said Lynn.
THE CHOOSING WISELY campaign has its contradictions and challenges, but it seems to be helping to move physicians in the direction that American medicine overall is taking, if haltingly and uncertainly under the Trump administration, which has hinted that it wants to slow the reform experiments incorporated into the ACA.
As long as the government has purchased health care from physicians—and today the government is by far the largest payer—it has paid them by the specific services they render, evidenced in the thousands of so-called CPT codes that doctors use in billing. Increasingly, though, medicine has moved toward “value-based care,” in which payments are based not on the quantity of diagnoses, prescriptions and procedures, but rather on quality, based in part by measuring patient outcomes. A percentage of the federal payments to the new accountable care organizations is based on outcomes and evidence of good medical stewardship—including wise medical choices. Although Choosing Wisely per se is not enshrined in the payment schemes, they do depend more on holistic, “full-patient” views of medical care, which includes saying “no” to tempting but wasteful tests and procedures.
Though slowly, health care is moving in the direction of using less to do more. “I can’t think of a health care system that’s not interested in reducing utilization,” says Scott Halpern, a professor of epidemiology, bioethics and health policy at the University of Pennsylvania.
Taler, who started making house calls on his own initiative in the 1970s after seeing it done in England during a medical school fellowship there, has had a number of benefactors over the decades. For the last five years his practice, MedStar Total Elder Care, has been partially funded through a congressionally mandated demonstration project that also includes 13 other medical centers around the country. Funding runs out next month but Taler expects a new bill to extend the program for another two years.
“If Congress doesn’t want to support the triple aim [of better patient experience, population health and lower costs], I’ll go to an office and make money instead,” Taler said (he wasn't speaking literally).
The federal Medicare and Medicaid offices has reported that the 14 pilot sites, which see about 10,000 patients total, saved the health care system $32 million in two years.That number is open to some debate, he admits, because the analysis is based on a counterfactual—the quantity of trouble and medical expense his patients would have suffered without someone looking after them the way he does. And there are ambiguities involved.
He ordered the new wheelchair for Maggie Barnes because the old one was damaged enough to cause her to worry that she might fall out of it. Taler was not sure she needed a new wheelchair; the old one still rolled. By some calculus, his decision might be seen as a bit extravagant. As her doctor, though, Taler saw that Barnes’ wheels were vital to her, and her peace of mind an important part of her care.
WHILE SOME DOCTORS are slow to pick up the Choosing Wisely recommendations, there’s also a vanguard of health care organizations already moving on to more radical measures. An example is run by Farzad Mostashari, a former Health and Human Services official who heads Aledade, a company that sets up and oversees accountable care groups in 17 states. Its physicians get bonuses for good outcomes, rather than numerous procedures, and Aledade uses a special technique to screen out doctors who game the system by doing unnecessary procedures.
“We’ll ask a gastroenterologist, ‘If you were an unscrupulous gastoenterologist, what would you be doing?’” Mostashari said. The company uses that knowledge to look through a doctor’s billing claims. When it finds specialists who do things motivated by padding their billable procedures rather than best medicine, they are excluded from Aledade’s networks, he said.
Although his company is attempting even more aggressive waste-cutting, Mostashari said he appreciates Choosing Wisely. “It provides consensus support for the fundamental understanding that more is not better,” he said. “That sounds trivial, but it’s a hard concept.”
In the meantime, Taler waits for American medicine to catch up with him.
“What we’re doing is a bleeding edge operation,” he said as he drove from Barnes’ apartment to the next patient. “We’re losing money, but it’s where health care is going. And when the payment system changes, it will be coin of the realm.”