Medicare spending is increasing at a rate the will bankrupt the system in very few years. Yet many are intent on expanding Medicare (or something like it) to cover an increasing percentage of the population as well as an increasing number of treatments. This trend is unsustainable.

Where do all those Medicare dollars get spent? Siri Carpenter reports, “Seniors with five or more chronic health problems account for two-thirds of Medicare spending….” Nearly all doctors (outside of pediatricians) treat patients in this category, but no clear guidelines exist for treating them.

Part of the reason for this is that patients with multiple conditions are excluded from medical treatment studies. Studies work well when variables are limited. Introducing multiple conditions complicates studies and can produce ambiguous results. With so many variables, how can you accurately derive the cause(s) of a given outcome?

So we are spending the vast majority of our Medicare dollars on cases for which doctors have no training or proven treatment strategies. Does this strike anyone as odd?

To make matters worse, Carpenter suggests that some of the conditions this group of people are experiencing result from the medications they are taking. Carpenter tells a horrific tale of how her once sharp mother slowly became mentally clouded and physically less able by age 61. She was taking 21 medications prescribed by five different physicians for a number of conditions.

I saw something similar with my Dad during the last two years of his life. I built a spreadsheet to help my Mom keep track of all of Dad’s meds following his stroke, but meds and dosages changed so frequently that it was a nightmare. Every doctor wanted a detailed list of everything Dad was taking. We did our homework and listed all possible side effects and drug interactions.

Every specialist insisted that Dad take the drugs they prescribed. When we pointed out potential drug interactions, our concerns were usually pooh-poohed. If you asked about anything another specialist was prescribing, the doctor would get this deer-in-the-headlights look and would clam up, out of professional courtesy. Each of these highly skilled and highly paid physicians knew about the drugs they dealt with every day, but didn’t know much about the multitudes of other drugs they were licensed to prescribe.

When we brought up specific questions about drugs, almost every specialist Dad saw told us to consult with Dad’s primary care physician. I liked Dad’s primary care doctor. He’s smart and dedicated. But he also rarely provided satisfactory answers about the horrendous drug cocktail Dad was consuming.

A couple of weeks after Dad was released from intensive care following a drug interaction that nearly killed him, he started getting seriously goofy. It was bizarre to see this man that had prized his sharp analytical mind acting in mindless ways. We were referred to a psychologist that specialized in treatment of seniors. After a very thorough examination, the doctor said that Dad was getting senile and that we simply needed to adjust to that fact. He strongly downplayed any possibility of drug induced mental problems.

A few weeks later, Dad went on strike. He simply refused to take any more drugs. Mom was beside herself. She argued that he simply had to take the drugs. He said he didn’t care if he died or had another stroke. If Mom gave the meds to him, he would just wash them down the sink.

Life was pretty harsh for Dad and Mom for about three weeks. Then Dad’s mental fog cleared and he became a rational person once again. I realized that he had been going through withdrawal symptoms during those weeks. Once it was clear that the drugs had caused Dad’s mental issues, I was pretty upset with the psychologist.

It turns out that this kind of thing is quite common. Like Siri Carptenter’s mother and my Dad, many seniors are seriously overmedicated. There is no competent coordination of all of the different prescriptions these people are taking. Each doctor knows little of the drugs prescribed by other doctors and each is afraid of saying anything for fear of offending another doctor. They’d rather see patients suffer than embarrass a colleague.

As Carpenter notes, doctors also tend to misdiagnose the problem of overmedication, assuming that the patients are naturally getting sicker. This leads to prescription of even more meds, causing a nasty spiral of diminishing life quality.

In our medical system, the patients are generally not the customers. In most cases, the actual customers are the government and/or the insurance companies. The patients are the products and system engenders extremely shoddy quality control. Cost control is pretty poor as well, although, the main role played by the actual customers is supposedly to contain costs.

What is lacking in this system is a concerned advocate for the patient. For most other products and services in our society the customers act as advocates for themselves. But in medicine, when the patient is not the customer, nobody adequately plays the role of the patient advocate, especially when a patient’s judgment becomes clouded.

Players in the system act to satisfy their own goals according to the incentives in the system. This is not to say that they are bad or uncaring people. In fact, most of them mean quite well and want to help people the best they can. But the system provides inadequate incentives and information for accomplishing that. And no matter how concerned a player might be, he/she simply cannot adequately replace the quality of concern that comes from proper customership.

We have screwed up incentives in our medical system today. More Medicare is not going to solve this problem.
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