Medicare’s $10 Billion Secret

Author: Michael Wasserman MD

Originally published: Tuesday, December 10, 2013

I am a geriatrician, a physician who specializes in caring for older adults. I tell my patients, “If you want a doctor who will prescribe lots of medications, order lots of tests, send you to lots of specialists, and put you in the hospital at the drop of a hat, I’m not your guy.” I’ve practiced a high touch, low tech brand of medicine for the past 25 years. My patients and their families appreciate my approach to care, and there is data that shows it to be quite cost effective. So, why are there so few doctors like me and why does the Medicare program have such astronomical costs?

Since the founding of Medicare in 1965, the government has subsidized the training of physicians; these subsidies come directly out of the Medicare program. The original theory was that this ensured that there would always be enough doctors to care for the older population.

In 2012, Medicare spent close to $10 billion on Graduate Medical Education. Despite this taxpayer subsidy, very little is spent on training doctors in the nuances of caring for older people. In the end, Medicare is spending our taxpayer dollars to assure that young physicians ARE NOT trained to care for Medicare beneficiaries.

Geriatricians like me have known for years the differences in treating older adults. There are a number of good examples. In older adults, the use of expensive medications to prevent the abnormal heart rhythm of atrial fibrillation has been shown to have worse outcomes than it does for younger patients. The aggressive treatment of elderly men for prostate cancer can be more harmful than conservative treatment. The treatment of fractured vertebrate with an expensive procedure known as vertebroplasty has not been shown to be appreciably better than doing nothing! Most people are intuitively aware of the increased complications that older people face during hospitalization.

A multibillion dollar industry of antipsychotic medication has recently been called into question by the Office of Inspector General. These very powerful and dangerous medications are typically used off label as a chemical restraint in the management of demented older adults. The lack of adequate education of health care professionals in the treatment and management of dementia, and, in particular, Alzheimer’s disease, is incomprehensible for a program spending $10 billion a year to support the training of physicians.

From a socioeconomic perspective, it makes no sense to use money from Medicare to inadequately train physicians to care for Medicare beneficiaries. The situation is made worse by a reimbursement model that has primary care physicians and geriatricians amongst the lowest-paid physicians. The government gives the American Medical Association (AMA) control of the reimbursement model through a committee called the RUC. What is most astounding is that until recently not a single geriatrician was on the committee that is set up to determine Medicare reimbursement. Most of the RUC’s members are specialists. With the foxes guarding the hen house, it should not be surprising that procedures are AMA receives over $70 million a year in the form of royalties and publishing revenue for managing the national coding and reimbursement system. The AMA then turns around and spends close to $20 million a year lobbying Congress. The incentive for the AMA to want to continue with such a system is obvious; how Congress continues to allow this flow of money to stay in place is not.

Geriatricians are experts in caring for the elderly. The number of geriatricians is declining every year while the population of older adults is increasing. There is evidence that most geriatricians practice a cost effective form of medicine. It is imperative that we transform the health care work force so that we are able to provide this type of care to our growing elderly population.

The continued misuse of taxpayer supported graduate medical education funds is nothing short of negligence. Medicare’s $10 billion secret needs to come out in the open—we can no longer allow our legislators to ignore it. I propose that we change the dynamics of graduate medical education so that competency in the care of older people is an absolute requirement. Furthermore, to encourage more physicians to enter primary care with a focus on the elderly, we must dramatically change the reimbursement system. The AMA has missed their opportunity to do this, and the system that continues to reward them must be abolished.