What's Wrong with Medicare

One of my colleagues posted on twitter today that he can spend an unlimited amount of money in caring for his patients.  That's because he's a geriatrician and his patients have Medicare.  Generally, he's right! And that's not good.  When President George W. Bush, the Republicans, and the Democrats passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, I asked, rather than provide all this money for prescription drugs for older adults, shouldn't we be asking whether they need most of the drugs to begin with?  The bill was supposed to cost $400 billion, but ultimately cost nearly $549 billion over the next decade, and proved to be a huge windfall to the pharmaceutical industry.  It arguably jumpstarted the unfettered rise in Medicare prescription drug expenditures from ~10% of Medicare expenditures to nearly 20%.  The saddest part of this is that we still haven't addressed the issue of appropriate prescribing for older adults.  That's just the beginning.

The Medicare program spends over $10 billion a year training young physicians how NOT to care for older adults.  They build on this by providing the highest reimbursement to specialists who perform unnecessary procedures on older adults.  Very few physicians have any interest in geriatrics.  Many physicians are incompetent when it comes to the geriatrics approach to care.  This has led to a bunch of programs that try to work around the problem.  Care transition programs that have non-physician coaches encouraging patients to get appropriate care, readmission reduction programs that try to force physicians to reduce hospital admissions, are just some of the many programs that try to make up for a poorly trained workforce.

We MUST reform the way we train doctors, starting in medical school and continuing on through residency.  Geriatrics is just one part of this training that MUST be better incorporated into the educational process.  Palliative care, already an integral part of Geriatrics, is woefully lacking in medical education.  We spend a lot of money, time and resources training physicians the wrong way, and then we spend an inordinate amount of money on unnecessary care.  Adding on to that, we spend even more money on programs that try to make up for all of this!

So, what's wrong with Medicare?  It's an expensive program that provides a lot of unnecessary care at a high cost to taxpayers.  Most Americans like the program, because they can have what they want, even if they don't need it.  Medicare for All?  Are we really ready for it?  Shouldn't we fix what's wrong with the program first, before assuring that the entire healthcare market follows suit?