I am at the age where my family and friends all seem to be coping with agingrelatives. And I can tell you that something has gone terribly wrong with both thehealth care system and the system of nursing care.
People in their 80s and 90s, when their health starts to deteriorate, tend to have multiple thingswrong with them. From a doctors point of view, they are very time consuming to treat. Theyoften tend to be fearful and forgetful.
All of this means that either a family member, or a very conscientious doctor, needs to becarefully coordinating their care, or disastrous mishaps will occur. But middle aged sons anddaughters are nearly all in the workforce, without much time to spend with frail and agingparents.
And despite the promise of managed care, they one thing doctors are not paid to do is spend alot of time with patients or on the phone.
Indeed, managed care has become a parody of its original aspirations. Back in the days whenHMOs were nonprofit, prepaid group health plans, the idea was that paying doctors salaries totreat a fixed number of patients would reward prevention and remove any incentive either toundertreat or to overtreat.
In the 1990s, after most HMOs had become for-profit, shareholder owned corporations, theytried to make money signing up Medicare patients. The government encouraged HMOs to serveseniors, on the theory that this would cut costs. HMOs targeted relatively healthy oldsters, inthe hope of making a bundle.
But it mostly didn't work. For one thing, old people gradually become older people. Evenhealthy ones eventually get sick. For another, the Medicare payments to HMOs weren'tadequate to the need. So most elderly people, especially the sickest ones, went back toconventional Medicare.
The Medicare program, though reformed to discourage overly long hospital stays, is stillbasically a fee-for-service program. That means it rewards intensive medical interventions, suchas surgery, but doesn't reimburse enough money to compensate doctors for the careful casemanagement that older people require. The more that Congress cuts the Medicare budget, themore money comes out of hands-on care.
One member of my extended family has been shuttled from specialist to specialist, while hiscase falls between the cracks because his overworked primary care doctor fails to adequatelycoordinate the whole enterprise. After many months, nobody knows what's wrong with him.
Another, in her mid-80s, was barely spared unnecessary and dangerous open heart surgery,only because her daughter had the wit and the energy to ask impertinent questions and seek asecond opinion.
The mother has multiple conditions. The daughter is spending half her time on the phone doingwhat her mother's primary care doctor should be doing.
The managed-care system is saving money by displacing the burdens of caring back ontofamilies. Those who don't have families available to accept such burdens risk becomingcasualties of the medical system. When it comes to people in their 80s and 90s, especially thosewithout close relatives on the case, the system can simply bury its mistakes.
The story is, if anything, worse when it comes to nursing care. Most nursing home care is paidby Medicaid. The reimbursements are inadequate, so nursing homes tend to recruit help fromthe very bottom of the labor market.
Assisted living is an attractive alternative to nursing care, but is costs far more than mostelderly people typically can afford usually $2,500 a month and up. And Medicaid won't pay any of its costs.
Both parties are crowing about the huge and growing budget surplus, as if it were a costlessboon to the economy. But the fact is that a big chunk of the surplus came out of cuts in thebudget for Medicare and Medicaid.
Our society is demanding that everyone work, but ignoring the cost to the enterprise ofcaregiving. We are becoming a richer economy, while we impoverish those most dependent onthe care of others.
So the wondrous budget surplus is anything but costless. As anyone who has lately helped anelderly friend or relative navigate hospital care can tell you, the costs are coming at the expenseof our own parents.
This is a political failure, because these are mostly public dollars. But somehow, the votersaren't connecting the dots and demanding better of our elected officials. If we fail to make this apublic issue, our families will suffer the consequences.
