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A Policy That Puts the Elderly at Risk

Medicare: Refusing to pay for early diagnosis screening tests, the system lets degenerative diseases gain silently.

November 29, 1998|ARTHUR D. SILK | Arthur D. Silk, an internist in Garden Grove, has been an elected representative to the California Medical Assn. and a California delegate to the American Medical Assn

Distracted by too much Monica or diverted by repeated HMO horror stories, most seniors are not aware that even fee-for-service Medicare patients are not covered for the mainstream medical care they thought they were promised. For example, even an 80-year-old is not allowed an annual physical examination unless he is willing to pay for the visit out of pocket.

Patients don't usually enter a doctor's office and announce that they have cancer or diabetes. More often, they offer vague symptoms of fatigue or weight loss or pain, and it is the skill of the doctor, aided by appropriate laboratory screening tests, that enable rapid diagnosis and treatment. Medicare fails patients by refusing to cover what it calls "screening tests." It refuses to acknowledge that most medical diagnosis is by its very nature a screening process.

Almost all of the degenerative diseases to which older people are susceptible progress silently for years before they become symptomatic. People don't feel any differently if their cholesterol is sky-high, but it is a silent menace that can lead to heart disease and stroke unless detected by a screening test and treated. Screening for early diagnosis is recommended by every professional organization from obstetricians to geriatricians. It should be the way all modern medicine is practiced. But because of Medicare regulations, it isn't covered for senior citizens who perhaps need it the most.

In the United States, diabetes is the No. 1 cause of blindness and the major reason for kidney dialysis. It was vision-dimming retinopathy found by her ophthalmologist that first alerted a 70-year-old woman that she had the disease. At that point, her blood sugar was very high and the diabetes was already beginning to destroy her kidneys. Her doctor had not previously detected the problem because to comply with Medicare regulations for a blood sugar test, she would have had to manifest some of the recognized symptoms of diabetes; until her eyes went bad, she didn't. Yet the American Diabetes Assn. advises that there are millions of completely asymptomatic Americans who are diabetic and don't know it.

Not until 69-year-old Mr. P. vomited blood did a medical work-up reveal that he had cirrhosis of the liver as a result of hepatitis C, apparently acquired from a blood transfusion years before. It was not that he avoided his doctor. Indeed, he had a capable primary care physician and saw her at least once a year. But there was never a Medicare-sanctioned symptom that would have allowed Medicare coverage for a liver panel that might have revealed his diagnosis before his near fatal hemorrhage.

A vigorous 72-year-old retired trucker who had been recently widowed complained of lack of energy, poor sleeping and general apathy, but none of the symptoms are included in Medicare's list for authorizing a simple blood count. It was more than four months before it was finally established that he had a form of leukemia, months that might have been used to treat him for leukemia instead of depression. Had he been allowed the usual "new patient screen," the diagnosis would have been made at his first visit.

It is ridiculous to require doctors to avoid ordering certain tests unless they meet cookbook criteria developed 1,000 miles away from the patient and perhaps five years ago. Since the mantra of the medical bean counters is the mercenary "cost-effective" threshold, I ask how many metabolic screening tests could be bought by avoiding one liver transplant? How many preventive examinations could be paid for by eliminating the need for one open-heart surgery? How long does one patient have to be on renal dialysis before it becomes cost-effective to screen others for diabetes?

When it becomes politically expedient, Medicare authorities do acknowledge the value of screening. For example, they have approved routine screening mammograms because it has been irrefutably shown that the tiny spicules of calcium that may indicate breast cancer, months or years before the most sensitive examination could find a lump, can be life-saving. They recognize the value of screening Pap smears for the same reason and recently have belatedly approved screening procedures for the early detection of colon cancer and osteoporosis.

It is time for Medicare to abandon the "Alice in Wonderland" medical mythology that if you can't see it or feel it, you can't possibly have it, and rejoin the world of modern medical practice.

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