https://www.theatlantic.com/magazine/archive/2013/12/the-home-remedy-for-old-age/354680/
Medical treatment for aging,
chronically ill patients is costly and often ineffective. Can they get better
care at home?
By JONATHAN RAUCH, DECEMBER 2013 ISSUE of HEALTH
It is 1976. Brad Stuart is in his third year of medical
school at Stanford, doing his first clinical rotation. He is told to look at an
elderly man with advanced lymphoma. The patient is feeble and near death, his
bone marrow eviscerated by cancer. The supervising oncologist has ordered a
course of chemotherapy using a very toxic investigational drug. Stuart knows
enough to feel certain that the treatment will kill the patient, and he does
not believe the patient understands this. Like a buck private challenging a
colonel, he appeals the decision, but a panel of doctors declines to intervene.
Well, Stuart thinks, if it must be done, I will do it myself. He mixes the drug
and administers it. The patient says, “That hurts!” A few days later, the man’s
bed is empty. What happened? He bled into his brain and died last night. Stuart
leaves the room with his fists clenched.
To this day, he believes he killed the patient. “I walked
out of that room and said, ‘There has got to be a better way than this,’ ” he
told me recently. “I was appalled by how we care for—or, more accurately, fail
to care about—people who are near the end of life. We literally treat them to
death.”
Here is a puzzling fact: From 1970 until 2009, spending on
health care in this country rose by more than 9 percent annually, creating
fiscal havoc. But in 2009, 2010, and 2011, health-care spending increased by
less than 4 percent a year. What explains the change? The recession surely had
something to do with it. But several recent studies have found that the
recession is not the whole story. One such study, by the Harvard University
economists David Cutler and Nikhil Sahni, estimates that “structural changes”
in our health-care system account for more than half of the slowdown.
In a sense, Brad Stuart is one of those changes. He is a
leader in a growing movement advocating home-based primary care, which
represents a fundamental change in the way we care for people who are
chronically very ill. The idea is simple: rather than wait until people get
sick and need hospitalization, you build a multidisciplinary team that visits
them at home, coordinates health-related services, and tries to nip problems in
the bud. For the past 15 years, at Sutter Health, a giant network of hospitals
and doctors in Northern California, Stuart has devoted himself to developing
home-based care for frail, elderly patients.
For years, many people in medicine have understood that
late-life care for the chronically sick is not only expensive but also, much
too often, ineffective and inhumane. For years, the system seemed impervious to
change. Recently, however, health-care providers have begun to realize that the
status quo is what Stuart calls a “burning platform”: a system that is too
expensive and inefficient to hold. As a result, new home-based programs are
finally reaching the market, such as one launched about five years ago at
Sutter, called Advanced Illness Management. “It’s much more feasible now to
make a program like this work than it was a few years ago,” Stuart told me.
“There are a lot of new payment schemes in the pipeline that are going to make
this kind of program much easier to support.”
This is good news. Generalizing from a small sample is
always perilous, but if what is happening at Sutter is any indication, a more
humane, effective, and affordable health-care system is closer than we think.
The problem that home-based primary care addresses has been
well understood for years. Thanks to modern treatment, people commonly live
into their 70s and 80s and even 90s, many of them with multiple chronic
ailments. A single person might be diagnosed with, say, heart failure,
arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and
more. These people aren’t on death’s doorstep, but neither will they recover.
Physically (and sometimes cognitively), they are frail. Joanne Lynn, the
director of the Altarum Institute’s Center for Elder Care and Advanced Illness,
says that this “frailty course,” a gradual and medically complicated downslide,
was once exceptional but is now the likely path for half of today’s elders.
Seniors with five or more chronic conditions account for
less than a fourth of Medicare’s beneficiaries but more than two-thirds of its
spending—and they are the fastest-growing segment of the Medicare population.
What to do with this burgeoning population of the frail elderly? Right now,
when something goes wrong, the standard response is to call 911 or go to the
emergency room. That leads to a revolving door of hospitalizations, each of
them alarmingly expensive. More than a quarter of Medicare’s budget is spent on
people in their last year of life, and much of that spending is attributable to
hospitalization. “The dramatic increase in costs in the last month of life is
largely driven by inpatient hospital stays,” Helen Adamopoulos recently
reported on MedicareNewsGroup.com. “On average, Medicare spends $20,870 per
beneficiary who dies while in the hospital.”
Hospitals are fine for people who need acute treatments like
heart surgery. But they are very often a terrible place for the frail elderly.
“Hospitals are hugely dangerous and inappropriately used,” says George Taler, a
professor of geriatric medicine at Georgetown University and the director of
long-term care at MedStar Washington Hospital Center. “They are a great place
to be if you have no choice but to risk your life to get better.” For many, the
worst place of all is the intensive-care unit, that alien planet where,
according to a recent study in the Journal of the American Medical Association,
29 percent of Medicare beneficiaries wind up in their last month of life. “The
focus appears to be on providing curative care in the acute hospital,” an
accompanying editorial said, “regardless of the likelihood of benefit or
preferences of patients.”
Taler can attest to one of the more peculiar elements of
this situation, which is that a better model—namely, providing care and support
at home—has been known and used for decades. Taler himself pioneered an
interdisciplinary house-call model in Baltimore in 1980, and in 1999 he
co-founded a home-based primary-care program at Washington Hospital Center that
has served almost 3,000 people. In the 1970s, the Veterans Administration (now
the Department of Veterans Affairs) began building a home-based primary-care
program, which now operates out of nearly every VA medical center and serves
more than 31,000 patients a day. This is not newfangled, untested stuff.