By Thomas A Kruzel, ND
Recently the Arizona Republic and several medical publications ran articles about the mounting costs of medicine in the geriatric population implying that the increasingly aging population was placing an inordinate financial burden on the health care system. The problem as I see it is not the elderly population but a medical system that is ill equipped to address the normal changes of aging as well as the effects of multiple prescription medications which has become the focus of modern medicine and managed care.
Medical care in America has largely become specialist based, having evolved from a primary care based system that had been in place since the turn of the last century. This began to change sometime in the 1960s with increasing numbers of residencies in medical specialties that largely address organ systems rather than individuals. As the number of specialties in medicine increased, there has been a concomitant decrease in family practice and geriatric medicine residencies, largely because reimbursement for the family and geriatric practices of medicine still falls far behind what a specialist earns.
Where once patients saw a primary care physician to address medical problems, with referrals to specialists when necessary, the system has essentially inverted itself with patients now primarily seeing multiple specialists for treatment of a disease, specific diagnosis or organ system problem. Because of this, doctors who are trained to treat these conditions within their specialties are increasingly prescribing patients medications for single systems disease. While this system specialty focus has contributed much to the development of and our understanding of medicine, it also has contributed to an increase in longevity. Because we are living longer, the costs of extended use of prescription medications and additional medical procedures require a disproportionate amount of resources, without necessarily increasing the quality of life for individuals. More medication does not usually add up to more health. In fact, errors due to prescription medication is considered the 4th leading cause of death in the US.
In an article in the Annals of Family Medicine titled The Changing Face of Chronic Illness Management in Primary Care – A Qualitative Study of Underlying Influences and Unintended Outcomes, (Ann Fam Med. 2012;10(5):452-460.) authors Hunt, Kreiner, and Brody looked at treatment strategies and factors influencing treatment decisions. They found that clinicians “focused on helping patients achieve test results recommended by national guidelines, and most reported combining 2 or more medications per condition to reach targets”. They concluded that these factors promoted heavy use of pharmaceuticals resulting in more and more medications per condition being prescribed. Often these prescriptions were found to be necessary to treat side effects of a previous prescription.
Prescription medications contribute to roughly 8% of health care expenditures while doing nothing more than maintaining the disease state within acceptable therapeutic parameters often based upon studies funded by pharmaceutical companies.
In contrast, elderly patients who are treated by primary care and geriatric physicians generally do not receive high levels of multiple prescription medications or medical interventions simply because their physicians treat them as an individual who has a number of medical conditions that are addressed from a more holistic view point. Being guided by the individual needs, rather than standard guidelines, allows for safer and less expensive therapies. Because of this it is easier to manage the health for each individual, which includes removing unnecessary prescriptions or substituting medications with fewer side effects.
The high cost of health care spans all generations, not just the elderly. As a medical system we need to muster the political will to reallocate resources where they are most effective in promoting both the prevention of disease and to the education of medical consumers. Preventing diabetes, for example, could save the Arizona health care system upward of $5 million per individual (Zhuo et al, “The Lifetime Cost of Diabetes and Its Implications for Diabetes Prevention” Diabetes Care Sept 2014; vol 37, no. 9, 2557-2564). We also need to make sure that primary care and geriatric medical providers are compensated adequately so that they once again become the gatekeepers to the medical system.