If this was a pill, you’d do anything to get it

[n2doc]

Posted by Ezra Klein on April 28, 2013 at 5:07 am

When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It’s not his graph, he’s quick to say. Coburn is not the sort to take credit for other’s work. But it’s a graph that explains why he’s doing what he’s doing. It’s a graph he particularly wishes the folks who run Medicare would see, because if they did, then there’s no way they’d be threatening to shut down his program.

The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it’s below 100. When’s the last time you heard of an American dying from diarrhea?



“For all the millennia before this in human history,” Coburn says, “it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases.”

With chronic illnesses like diabetes and heart disease you don’t get better, or at least not quickly. They don’t require cures so much as management. Their existence is often proof of medicine’s successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today’s medical system: Its successes have changed the problems, but the health-care system hasn’t kept up.

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http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/28/if-this-was-a-pill-youd-do-anything-to-get-it/

[Drale]

1. "Average life expectancy was 45 years old at the turn of the century."

That is just not true. Those numbers are horribly skewed by the extremely high death rate before the age of 5. If you made it past the age of 5 you had a pretty good chance of living to 70 or 80 years old with a proper diet and avoiding accidents. This is one of the biggest misnomers about the base that we historians have been rallying against for a long time, but no one seems to want to listen.

[denverbill]

2. You know, this just sucks.

A program that actually improves results and saves money, so THAT'S what gets eliminated.

[frazzled]

3. I read this long piece and have mixed feelings about it

Yes, I see that having a nurse visit regularly is necessary and good for a portion of seniors with chronic conditions. But it's not something that all seniors need or want.

Two problems stuck out for me in reading this. One was the quote, "Despite the years-long relationships, she’s not turned her patients into highly effective self-caregivers. Everyone we see admits to missing their medicine or making bad diet decisions or slacking on exercise routines. Graefe just laboriously pushes them to make slightly better decisions on the margins." Well, slightly better is good, but is it good enough? One wonders if scaling up this project system-wide before larger-scale trials are implemented is going to be worth it.

The related problem is the one the article hints at from the trial period: this kind of home nursing care is ripe for big money-making. The implementation of a program like this must be seriously considered.

My experience is with my own elderly parents (96 and 87). They may be unique in that they both have all their mental faculties, which is the most important thing in keeping people both out of hospitals and out of nursing homes and relatively healthy: they understand and adhere pretty well to their medication and exercise regimens. But there's only so much you can do for your health at a certain age. My mother had breast cancer five years ago, my father landed in the hospital with flu and pneumonia this winter (despite having had both the flu and pneumonia shots). They're both type 2 diabetics.

When my father was released from the hospital in February, I made sure to arrange for a nurse to come visit 2-3 times per week: this is 100% covered by Medicare. I was there for the initial visit, and I was extremely impressed with the nurse and her advice and listening skills. It made my father determined to do his breathing-machine exercises and daily walks more rigorously--but only because he wanted to be done with the visits and get rid of the nurses. Within two weeks they agreed they didn't need to come any more. We had also arranged for a senior assistant to come three times a week for errands, housecleaning, etc. They fired the agency after two visits, because they felt they didn't need this, and they value their privacy. So much for help.

What if you're a lousy self-care giver with a chronic condition and your doctor orders home nursing visits ... but you don't want them? How much of this is going to be foisted onto seniors or ordered without sufficient cause?

I'm on the fence here about how this should be done. I was immensely grateful to Medicare for paying for a nurse to come visit my father when I could no longer stay in town. But even though he's very elderly and diabetic, he really doesn't need someone to come check up on him now that he is over his major illness. Who gets to determine that?

[1-Old-Man]

4. My sister and I put together a family tree back to the 1600s, nearly everyone lived into their 80s

I was very much suprised to see that at least within our family nearly everyone lived into their 80s all the way back. We got as far as 1607 in our family search. Now that is not to say that the average age of death was in the 80s, that didn't happen because of all the infant deaths. So the average may have been 45, but that doesn't mean that many people didn't live to older ages.