Medicare Matters: What Geriatric Medicine Can Teach American Health Care
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《新英格兰医药杂志》
As the nation's only model of universal health care, the Medicare program is viewed by some people as a beacon of hope and by others as a doomed dinosaur. Wisely reformed, it might be part of the country's movement toward an effective, efficient, and equitable system of health care. Manipulated by special interests, it may disintegrate into insolvency as the huge baby-boomer generation becomes older and sicker during the next few decades.
Medicare Matters is a synthesis of wide-ranging observations from clinical medicine, research, and education into a set of policy recommendations for transforming the Medicare program and thereby improving the well-being of American society and elderly people in America. The book's author, Christine Cassel, is a geriatrician, researcher, and policy adviser. She is also an educator and a leader in internal medicine (she is the president and chief executive officer of the American Board of Internal Medicine).
For many stakeholders in American health care, this book provides a concise, readable primer on the Medicare program: its history, cultural symbolism, politics, vulnerabilities, and organizational structure, as well as how it operates, what it has accomplished, where it has failed, and what challenges and opportunities remain for it in the years ahead. Cassel asserts that, despite its many flaws, Medicare could be transformed into a model for sustaining one of the nation's fundamental social contracts. She emphasizes a social commitment to protecting older Americans (and their families) from impoverishment because of medical expenses.
Urging the nation's leaders to set aside their ideological agendas in the interest of health, she proposes an ambitious (and expensive) set of reforms to address Medicare's deficiencies. These reforms include eligibility at 55 years of age, expansion of managed care (with high-quality standards and low profit margins), federal mass purchasing of cost-effective products and services, coverage of care (including long-term care) according to beneficiaries' needs rather than insurers' constraints, a new specialty in palliative medicine, and increased payment for counseling, coordination of care, and other cognitive services. In chapter 9, the author says, "Medicare's entire benefit package should be restructured according to the principles of modern geriatric medicine." Cassel contends that some of the costs of these enhancements should be offset by increases in Medicare payroll taxes, competitive bidding for federal contracts, and the preventive benefits of modern geriatric medicine.
Whereas Cassel's case that "Medicare matters" is powerful, her examples of what geriatric medicine can teach to those involved in American health care are less compelling. Although models of interdisciplinary geriatric care have generated high satisfaction ratings and modest short-term functional gains, few have lived up to the promise of offsetting their costs by rendering expenditures for other health services unnecessary. Furthermore, the educational workforce in geriatric medicine will continue to lack power to teach the principles of geriatrics to others who are involved in American health care. Most of the nation's diminishing cohorts of fellows in geriatric medicine (334 fellows in 2004, 59 percent of whom were international medical school graduates) receive no training in educational methods, research, or organizational leadership.
The book's preface implores "thoughtful people from all walks of life and of all ages" to "be looking ahead at what Medicare can provide us as we get older and what it means to our children and grandchildren — and indeed, what it means to our communities and our nation." If many voters and consumers were to heed this advice and commit large numbers of votes and dollars to this mission, perhaps some leaders would come to believe, finally, that it would be beneficial — not only for the health of the nation, but also for their political careers — to undertake the daunting challenges of modernizing Medicare before it is too late.
Chad Boult, M.D., M.P.H.
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205((California/Milbank Books)
Medicare Matters is a synthesis of wide-ranging observations from clinical medicine, research, and education into a set of policy recommendations for transforming the Medicare program and thereby improving the well-being of American society and elderly people in America. The book's author, Christine Cassel, is a geriatrician, researcher, and policy adviser. She is also an educator and a leader in internal medicine (she is the president and chief executive officer of the American Board of Internal Medicine).
For many stakeholders in American health care, this book provides a concise, readable primer on the Medicare program: its history, cultural symbolism, politics, vulnerabilities, and organizational structure, as well as how it operates, what it has accomplished, where it has failed, and what challenges and opportunities remain for it in the years ahead. Cassel asserts that, despite its many flaws, Medicare could be transformed into a model for sustaining one of the nation's fundamental social contracts. She emphasizes a social commitment to protecting older Americans (and their families) from impoverishment because of medical expenses.
Urging the nation's leaders to set aside their ideological agendas in the interest of health, she proposes an ambitious (and expensive) set of reforms to address Medicare's deficiencies. These reforms include eligibility at 55 years of age, expansion of managed care (with high-quality standards and low profit margins), federal mass purchasing of cost-effective products and services, coverage of care (including long-term care) according to beneficiaries' needs rather than insurers' constraints, a new specialty in palliative medicine, and increased payment for counseling, coordination of care, and other cognitive services. In chapter 9, the author says, "Medicare's entire benefit package should be restructured according to the principles of modern geriatric medicine." Cassel contends that some of the costs of these enhancements should be offset by increases in Medicare payroll taxes, competitive bidding for federal contracts, and the preventive benefits of modern geriatric medicine.
Whereas Cassel's case that "Medicare matters" is powerful, her examples of what geriatric medicine can teach to those involved in American health care are less compelling. Although models of interdisciplinary geriatric care have generated high satisfaction ratings and modest short-term functional gains, few have lived up to the promise of offsetting their costs by rendering expenditures for other health services unnecessary. Furthermore, the educational workforce in geriatric medicine will continue to lack power to teach the principles of geriatrics to others who are involved in American health care. Most of the nation's diminishing cohorts of fellows in geriatric medicine (334 fellows in 2004, 59 percent of whom were international medical school graduates) receive no training in educational methods, research, or organizational leadership.
The book's preface implores "thoughtful people from all walks of life and of all ages" to "be looking ahead at what Medicare can provide us as we get older and what it means to our children and grandchildren — and indeed, what it means to our communities and our nation." If many voters and consumers were to heed this advice and commit large numbers of votes and dollars to this mission, perhaps some leaders would come to believe, finally, that it would be beneficial — not only for the health of the nation, but also for their political careers — to undertake the daunting challenges of modernizing Medicare before it is too late.
Chad Boult, M.D., M.P.H.
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205((California/Milbank Books)