To the Editor:
I applaud and concur with Dr. Stefanacci’s article on the survival of Medicare.1 Clearly, reallocation and prioritizing will be needed, and the sooner the better. Missing from the article was address of the astronomical dollars spent on the last three months of life; this must be rethought and hospice offered for the frail elderly if basic care does not work. Secondly, I believe there should be real choice offered in senior plans such as a Palliative Care Plan that offers “basic” medical care with care coordination, therapy, etc., but also some home help for elderly individuals who are dependent upon others for aid with activities of daily living or in need of durable medical equipment supplies versus access to aggressive hospital intervention.
Just some thoughts based on my 20-year experience with the VA Home-Based Primary Care program.
Kay Schroer, CNS
1. Stefanacci RG. What is Medicare going to do to survive? Clinical Geriatrics 2008;16(12):25-27.
Dr. Stefanacci responds:
I’m in complete agreement to the comments regarding the need to manage care for seniors at end of life in a more appropriate manner. While I noted that improvement in utilization is critical to Medicare’s survival, I go on to state that decreasing benefits “directly by Medicare is highly unlikely given the U.S. dislike for any form of government rationing, especially in healthcare.”
Although rationing of Medicare benefits is unlikely politically, perhaps what can be accomplished is better practice of what has been termed “slow medicine.” Based on research completed at Dartmouth Medical School, “slow medicine”1 encourages physicians and other healthcare professionals to reconsider and potentially discontinue care that may have high risks and limited benefits, as is the case with some emergency room visits and some hospitalizations.
So while it will be awhile before Medicare develops separate or limited benefits for older persons at the end of life, we can and should start practicing appropriate “slow medicine” today. This process needs to begin with physicians and other healthcare professionals who, as Ms. Schroer indicates, are aware of a more enlightened and appropriate approach to utilize the finite resources within the Medicare program.
Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD
CMS Health Policy Scholar, 2003-04
The Institute for Geriatric Studies,
Mayes College of Healthcare Business & Policy,
University of the Sciences,
1. McCullough D. Slow medicine. Dartmouth Medicine website. http://dartmed.dartmouth.edu/spring08/html/grand_rounds.php. Accessed January 28, 2009.