Old and Sick in America: the Journey through the Health Care System
I begin where most patients begin their health care journey, with a visit to the doctor. For the majority of older individuals, this means seeing a primary care physician, usually an internist or a family practitioner, in an office setting, so Part I is concerned with care in the office. Chapter 1 focuses on the specific experience of a particular patient—my father-in-law, Saul. What it was like for him, sometimes positive, sometimes not so positive, highlights some of the crucial aspects of being a patient as it is in the office that the doctor-patient relationship grows and develops. And that relationship is key to most of the patient’s other encounters with the health care system, since the primary care physician is typically the gatekeeper to other health care services such as physical therapy and home nursing care, specialty care, and hospital treatment.
Recognizing that one person’s experience may not be representative—though I have chosen the vignette to embody what I take to be the most important features of ambulatory care—Chapter 2 asks whether other practice arrangements make a difference. Ownership, reimbursement, and organization vary, with arrangements varying from solo practice at one extreme to large, multi-specialty group practices at the other, from physician-owned to hospital-owned, and from exclusive, cash-only concierge practices to models in which all forms of insurance are accepted. Chapter 3 examines how various powerful actors within the health care system—physicians, hospitals, device manufacturers, the pharmaceutical industry, and Medicare—shape what happens to patients in the office. Physicians, for example, are interested in maximizing their autonomy and maintain a good quality of life for themselves, over and beyond their concern for the welfare of their patients. Hospitals are interested in filling their beds and rely on office-based physicians to refer patients; drug and device companies want to maximize profit by selling their most expensive products; and Medicare is concerned with both the quality and the efficiency of the health care services for which it pays.
Chapter 4 contrasts the small, intimate, low tech practice of outpatient medicine fifty years ago with the multi-physician, rule-drive, computerized practice of today and asks what factors are responsible for the change. I look for the answer in three distinct domains: scientific advances in medicine, social trends, and legislative developments. As prototypical examples of scientific progress, I discuss the new understanding of high blood pressure and diabetes that arose over the last several decades, knowledge that shapes whether, when, and how these conditions are treated. The social trends that I identify as playing a particularly potent role in changing the face of medical practice are feminism, on the one hand, which led to an enormous increase in the number of women physicians and a concomitant shift to greater interest in work-life balance, and the ascendancy of market ideology, on the other hand, which led to the commodification of medicine. Finally, I discuss the role of legislation, particularly the introduction of Medicare, the shift in the way Medicare pays physicians, and Medicare’s scrutiny of office practice as playing a dominant role in reshaping the visit to the doctor.
The next encounter with the health care system for many older patients, and the subject of Part II of Journey, is with the hospital. The modern hospital offers an unprecedented array of diagnostic procedures and treatments, from biopsies to surgery—to attempted cardiopulmonary resuscitation (CPR), as I observed early on in my medical training. For an older patient, hospitalization can be life-saving, but it can also be alienating, frightening, and even dangerous. Hospitals are complicated institutions, run by physicians, nurses, social workers, technicians, therapists, and pharmacists as well as executives, accountants, and janitors. For the patient, they can deliver cures—or cause life-threatening infections. They can provide relief from intolerable symptoms—or cause intense suffering. Chapter 5 again begins with a sample patient’s experience, the story of Barbara Ellis, who was admitted to an academic teaching hospital for treatment of congestive heart failure. Her acute medical problem was successfully treated, but not until after she had developed acute confusion, or delirium, as well as a hospital-associated infection. Chapter 6 broadens our view of the prototypical hospitalization by putting Barbara’s experience in perspective. I compare the world of the teaching hospital to that of the small community hospital, the for-profit hospital to the not-for-profit hospital, the free-standing hospital to the hospital that is part of an entire health system. Chapter 7 shows how the medical profession, the hospital CEO, and the drug and device manufacturers influence what happens to patients in the hospital. I then look at the profound effects that government, principally the Medicare program, has on the hospital through its concerns with keeping the length of stay short, avoiding readmissions, and with promoting quality and transparency. Chapter 8 contrasts the modest-sized, non-profit hospital of the early 1960s with the streamlined, high tech, business-oriented hospital of today and asks what produced the change. Once again, I identify scientific advances, social trends, and health policy as all playing a role. Developments in the treatment of heart attacks, ranging from invention of the Coronary Care Unit to cardiac catheterization and stent placement, altered what happened to cardiac patients. Progress in medical imaging, principally the invention of the CT scan and the MRI, affected just about every hospitalized patient. In the social arena, demographic factors led to a marked increase in the number of older people. Consolidation and growth of corporate America led to the rise of networks and systems of hospitals. Legislation also changed the face of the American hospital, first with the creation of the Medicare and Medicaid programs, then with modifications to those programs, including the introduction of prospective payment for hospitals, the addition of hospice care, and the creation of new home care opportunities. Finally, the Affordable Care Act ushered in value-based purchasing, which is pushing hospitals to address outcomes and not just the processes of care.
Part III takes us to the next stop on the health care journey, the skilled nursing facility (SNF). Each year, 20 percent of all Medicare fee-for-service beneficiaries (and probably an equal number of Medicare Advantage patients) are transferred to a SNF for “post-acute” or “rehabilitative” care upon discharge from the hospital. Chapter 9 tells the story of Taylor Bryan, one of the 1.7 million Medicare patients each year who spend time in a SNF. Admitted for recuperation and rehabilitation after a long and complex hospital stay for heart disease and its complications, Taylor suffered a setback on the road to recovery and was readmitted to the hospital when he developed an infection. And then, also like many other frail older people, he was too weak and too ill to make much progress in regaining his strength and independence. Ultimately, his family agreed to a palliative approach to care and he died in the SNF.[i] Chapter 10 moves beyond Taylor’s experience in a free-standing, not-for-profit nursing facility to explore how for-profit nursing homes, chains, and teaching nursing homes affect patient care. Following the now familiar pattern, Chapter 11 examines the role of nursing home administrators, hospitals, drug and device companies, the medical profession, and government in shaping the SNF experience. Administrators are concerned principally with the bottom line and with the state inspections and staff turnover that influence the financials. Hospitals see SNFs as a safety net, a place to which they can discharge patients to keep length of stay down, but increasingly have to worry about those patients being readmitted. Drug companies have a potentially lucrative market in the SNF and use their sales representatives to steer prescribing. For device manufacturers, the SNF is of interest because of its use of relatively low tech medical supplies such as wound care products and assistive devices. Physicians exert an influence on the patient’s experience primarily through their relative absence, increasing the likelihood of readmission to the hospital when patients develop a new medical problem or an exacerbation of a chronic problem.
Chapter 12 contrasts the nursing home of the early 1960s, which was a residential facility housing those who could not care for themselves, with the medical institution focused on post-acute care that it has become today. I review the advances in medicine, the social trends, and the legislation that are responsible for the changes. Scientific developments include the development of joint replacement surgery and advances in anesthesiology and the organization of care that have lead to more and more older people spending time in the ICU—patients who then need a period of rehab before they can return home. In the social sphere, changing attitudes to nursing homes led to the rise of assisted living, freeing nursing home beds for use in post-acute care. Most important of all is Medicare, which led to the creation of the short-term SNF after the introduction of prospective payment to hospitals, and which determines the SNF focus on health and safety through its system of inspections and evaluations.