Avoiding Futile Care and Reducing Medicare Costs

By Jim Sabin, MD

If we in the U.S. ever hope to get a grip on Medicare costs, our society will first have to navigate a steep learning curve. That’s the lesson to take from three recent publications.

Despite the fact that Medicare is expected to represent 18% of the federal budget in 2020 (up from 15% in 2010), and that the Medicare Part A Trust Fund is projected to have insufficient funds to cover all hospital bills starting in 2024, polling guru Robert Blendon reported that 47% of the public do not see Medicare as a large budget item, and only 31% see it as a major contributor to the federal deficit!

Here are some of the key findings from Blendon’s study:

  • Respondents believe that Medicare recipients receive benefits worth about the same (27%) or less (41%) than what they’ve paid in. In reality, beneficiaries on average pay 1$ for every 3$ of benefits.
  • By a 3-to-1 ratio, the public believes the bigger problem under Medicare is people not getting the care they need, as opposed to receiving unnecessary care. This is despite a recent reportfrom ICU physicians discussed by Muriel Gillick in a recent post that among their Medicare patients 15% received care that was “futile” and 12% received care that was “probably futile.”
  • Although administrative costs for Medicare are substantially lower than for private insurance, only 15% believe that Medicare is better run.
  • Every age group prefers physicians to be paid on a fee-for-service basis. The 18-to-29 year olds are the most open to capitation payment (42%).
  • With increasing age, opinions about Medicare become progressively more favorable: 18-to-29 year olds (61%); 30-to-49 year olds (71%); 50-to-64 year olds (75%); and, for those over 65 (88%).

Finally, a survey done by The Conversation Project – an admirable organization “dedicated to helping people talk about their wishes for end-of-life-care” – found that while 90% of us believe we should have these conversations with those we’re close to, only 30% of us have actually done it.

Taken together, the three publications define a three-pronged learning task that must be accomplished for Medicare to reduce over treatment and help contain costs. We seniors need to spread the word that 1) contrary to the views of almost half of our population, Medicare is indeed a major contributor to the financial problems of the working public, 2) we seniors receive a substantial amount of ICU care that medical experts believe is “futile,” and 3) most of us probably don’t want that “futile” care, but our families and friends won’t speak up for us if we haven’t had the discussions of our values for end-of-life-case that The Conversation Project encourages.


 James Sabin, M.D., 74, is an organizer of Over 65, a clinical professor of psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.  This post originally appeared on the Over 65 blog.

2 Comments on “Avoiding Futile Care and Reducing Medicare Costs

Marge Ginsburg
November 11, 2013 at 3:35 pm

In the findings you mention about Medicare is that 15% Administative Overhead implies that it is ‘better run’ than private insurance. While overhead is one metric, I don’t think by itself, this assumes an efficient organization. The paultry oversight Medicare provides to egregious physician prescribing and the high level of Medicare fraud suggests to me that Medicare should be devoting more to administrative oversight, not less. “Better run” means it uses its resources effectively and efficiently. I’m not convinced that Medicare does.

Otherwise, this is great commentary and should be widely distributed.

December 30, 2013 at 3:36 pm

I would also point out that some of the ways in which Medicare already controls costs and defines “futile” (or rather “unnecessary”) types of care are questionable. For example, their wheelchair guidelines, which many private insurance companies have adopted, are shameful – only if someone requires the chair to move from room to room within their own home will they be provided with a wheelchair or similar device. I can’t imagine that this cost-benefit analysis – that disabled people are best left being house-bound, as long as they can get from room to room inside their own house, rather than providing them the means to leave the home and be productive members of society, is a good one, and yet by taking a very narrow view of the cost / benefit equation, one could argue that providing wheelchairs for any use outside the home is “futile” or “unnecessary”. I don’t disagree with the overall premise, but would urge that definitions of “futile” care need to be carefully scrutinized, and the starting point of today being defined as not having room for improvement in covering more services is a very dangerous assumption to make.


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