A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.
—Andy Lazris, MD
Title: Curing Medicare: One Doctor’s View of How Our Health Care System Is Failing the Elderly and How to Fix It
Author: Andy Lazris, MD
Publication date: September 13, 2014
Price: $13.75; paperback, 290 pages
Several years ago I decided to write a book about geriatric health-care delivery from the perspective of a practicing (author’s emphasis) primary care physician…. I am a down and dirty doctor living in the trenches; I see patients 5 days a week, often 10 hours a day; while I am on call 24/7 365 days a year, I’m answering messages continuously throughout the day, including immediately before turning off my lights and immediately after turning them on in the morning,” writes Andy Lazris, MD, in the foreword of his self-published book, Curing Medicare: One Doctor’s View of How Our Health Care System Is Failing the Elderly and How to Fix It.
Adding to that mind-boggling schedule, the author lets the readers know that he is also medical director for a few long-term care facilities; runs a busy practice; is on his computer day and night and through the weekend, whether preparing weekly talks to nurses and patients or deciphering new Medicare rules, completing notes, or putting his practice’s financial house in order. Which begs the question: How did Dr. Lazris squeeze in the time to write and self-publish this book?
Dr. Lazris’ first tried the traditional publishing route, and even though an editor at a major publishing house was interested, before biting she needed an academic reviewer to give the manuscript a read. One did, and then another; both slammed the book, calling it “crass, abrasive, unprofessional, and offensive, the very antithesis of a good academic book…. It reads primarily as a denunciation of the care of the elderly in America.”
That’s subjective criticism leveled by academics, and the problem with the critique of the academics is that Curing Medicare is not an academic book, which is one of its strengths. Here’s an example of what irked his reviewers: Dr. Lazris writes: “This is a book reflective of the brewing anger among us who actually practice geriatric care, those of us who have been trampled on and muffled…perhaps this book is a bit crass, perhaps it may offend.” Dr. Lazris should know that if you ascribe behavior or sentiment to the ubiquitous “we,” you need data to back up the claim.
Academic quibbling aside, the book’s title, Curing Medicare, lays down a very large gauntlet. Medicare is ailing, but it is here to stay—unless it goes belly-up, as some conservatives predict—and, since it is the single largest payer for cancer patients, all things that might cure Medicare are of interest to the oncology community.
Quality Measures and Guidelines
Dr. Lazris uses a confrontational style, backed by anecdotal and empirical data, and in his first chapter, “Defining Quality,” he tackles a subject much discussed in the oncology community. The author gives a well-balanced overview of how certain quality-measuring metrics are not generalizable to a heterogeneous elderly population. The ASCO Post readers will find his discussion on clinical guidelines interesting as well as his observations about the value of prostate-specific antigen tests, mammograms, and colonoscopy. And while he backs the philosophy behind quality measures and guidelines, he is quick to point out a qualm that is probably shared by doctors across all disciplines.
He writes: “Quality indicators and our fixation with number measurement and number fixing through medicines has led us down a very precarious path…. Once we believe an older person’s health status can be equated to a number, we then assume that the health problems associated with aging can be solved by a guideline, which erodes the art of practicing medicine.”
On Medicare-reimbursed screening, he cites current data, such as on colonoscopy, that find: “A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.” To his credit, Dr. Lazris acknowledges the merit of government oversight entities, such as the U.S. Preventive Services Task Force, a committee that comes under constant fire from advocacy groups as well as medical organizations for its conservative outlook on screening services.
Another subject he takes head on is overhospitalization, driven by our misuse of Medicare’s Part A. Here again is a subject that the oncology community will find interesting. He wades into a thorny political area when he connects the dots between overhospitalization and profit-driven hospitals.
“Studies have found regional variation of care within Medicare populations, in which regions of the country with increased numbers of hospital beds and higher specialist concentrations are more likely to hospitalize the elderly…. These high-spending hospitals will cost Medicare more money per patient without a commensurate benefit in health outcomes,” he writes.
Although it’s an important observation for those concerned about overspending and overutilization of Medicare services, it is not a news flash. It was pointed out more eloquently years ago by the Dartmouth Atlas Project and others.
Fiscal Problems and Solutions
Many of Dr. Lazris’ discussions in the first five chapters read like an introduction to the meat of his book, which is the closing chapter, aptly called “Curing Medicare.” The author begins the chapter with a laundry list of Medicare’s profligate spending habits on services that, many times, are unnecessary. There are no missteps in his analysis; however, he doesn’t offer any new revelations that might add deeper insight into Medicare’s fiscal problems.
When he tries to boil a very complex issue down to one culprit of overspending, it comes off a bit lame. “Currently much of Medicare’s dollars go to the sickest and oldest of our patients, without any proof that such money improves quality or length of life…. Much is spent on end-of-life care, where huge expenditures are squandered in situations with tragic outcomes. Why is not the bulk of that reform effort not aimed at reducing that number?”
Herein lies a central problem of this ambitious book. In using phrases like “without any proof,” he will be eviscerated by doctor-reviewers. Moreover, the author does not quantify “that number,” nor does he offer any alternatives to the status quo he’s railing at until chapter six, the denouement of the book.
And there, in some respects, he moves out of the box, offering innovative solutions. He describes a way to decentralize the role of hospitals and specialists, reform malpractice law, enact stricter regulatory oversight, and create strategies to increase the number of primary care doctors. He also scores high marks on his reform plan for the hugely wasteful Medicare Part D drug benefit.
These are all good strategies, but he does go off the rails a bit when he makes a threadbare case for physician-assisted suicide. His most compelling argument is his bid to unify Medicare into a single program. It is a political third rail, but it is worth considering, and Dr. Lazris makes a bold argument for a single-payer system.
Curing Medicare is a flawed book on several levels. For one, the writing needed a good edit, and the tone, at times, is histrionic. That said, Dr. Lazris is a passionate advocate for patients and the system that provides their care. Readers of The ASCO Post should skim through the first five chapters and take a hard look at chapter six. The author doesn’t cure Medicare, but he offers a lot more fixes than most. ■