It is well documented that health services in the United States, representing 17.9% of GDP, are the costliest in the world. Medicare alone accounted for $672 billion (20% of national health expenditures) in 2016, of which a significant percentage financed the treatment of frail older people near the end of life. It is equally acknowledged that we do not receive optimum care for our money. There are scores of powerful vested economic interests with their hands in the government till, each attempting to maximize their health care dollars from the system.
Old and Sick in America: The Journey through the Health Care System analyzes how institutional structures and practices affect the elderly patients' functioning and recovery from acute illness. The author, Dr. Muriel R. Gillick, has been a practicing physician for 30 years. She deftly takes us on a tour of the health care system through an investigation of outpatient physician offices, hospitals, nursing homes, pharmaceutical companies, and the medical device industry, and the complex ways they influence one another in the practice of medicine.
The book is divided into three parts, corresponding to the main sites of medical services for the aged: physician offices, hospitals, and nursing homes. In each section, Gillick addresses their various organizational structures, size, types of ownership, and ways of reimbursement and how these factors influence patient care. Most important, she argues that the Medicare program, along with its amendments and changing rules and regulations over the decades, plays a huge and continuing role in shaping the way the several interested parties deliver services.
A main strength of Old and Sick in America is the inclusion of vignettes that are based on real-life encounters with the particular medical institution under study. These stories, threaded throughout the book, engage the reader far more in the problems faced by chronically ill elders than would the presentation of mere facts and charts. Gillick, for example, illustrates the issues associated with an office visit through the experience of her father-in-law, Saul. She demonstrates, among other issues, how the shortage of available doctors, the location of physician practices, the rise of nurse practitioners and physician assistants as stand-ins for MDs, and growing out-of-pocket costs affect older patients.
In part 2, the case of Barbara Ellis shows how aged patients fare during a typical hospitalization, beginning with the emergency department. Gillick examines the rise of hospitalists and their impact on patients, commonplace adverse complications of a hospital stay (delirium, infections, incontinence), and the ongoing problem of readmissions. She also perceptively explores the effect of hospital structure, size, geographic location, and ownership on clinical outcomes, patient satisfaction, and actual care. Finally, Gillick observes how the often conflicting needs of various types of physicians (hospitalists, residents, internists, and outpatient doctors), Big Pharma, device manufacturers, and hospital CEOs and other administrators can be at odds with the well-being of patients.
Another valuable contribution of Old and Sick in America is Gillick's assessment of the social trends, scientific advances, and policy enactments that have transformed medical care over the last five decades. For example, she notes the escalating commercialization of medicine since the 1980s. According to Gillick, for physicians this has entailed less autonomy and vastly reduced time on hands-on care; patients, on the other hand, “feel like widgets on a production line” (72).
Likewise, she demonstrates how hospitals have steadily become technologized, corporatized, and bureaucratized. As with other sectors of medical services, they have consolidated through mergers and acquisitions into larger and larger chains that include both vertical and horizontal integration. Gillick points out that, “for patients, this near monopoly growth has meant higher prices and lower quality of care” (144).
Nevertheless, she insists that Medicare, too, has played a key role in the transformation of the modern hospital, in both its detrimental and beneficial qualities. Gillick views the program as the driving force in such aspects as shorter lengths of stay, “quicker and sicker” discharges, growth in home health care, expansion of ambulatory surgical centers, ascension of hospitalists, emergence of value-based reimbursement, and considerable expansion of postacute, short-stay skilled nursing homes (SNFs). Indeed, as Gillick argues, “a SNF stay after hospitalization is becoming the norm for older people” (167).
The latter institutions are the focus of part 3 and are evaluated through the experiences of Taylor Brian. Gillick points out a number of issues endemic to SNFs that Brian faced: delays in receiving medication; low-quality services; significant and preventable adverse harm to residents; limited rehabilitation, which stops when the patient is no longer “improving”; and avoidable hospital readmissions. However, she fails to capture the full extent of the problems, mainly because Taylor Brian had both an adult son with expertise in the field (he was a physician) and adequate financial resources. And this points to one of the limitations of the book more generally: Gillick chooses individuals for her vignettes who do not confront serious educational or financial constraints.
On the other hand, she does an excellent job in capturing certain facets of the nursing home industry and government regulations. For instance, Gillick provides a thought-provoking description of the Centers for Medicare and Medicaid Services website Nursing Home Compare and its inadequacies. As she puts it, “Government inspections and rankings can detect the most egregiously bad care, but the regulator's view of what constitutes good care is merely the absence of bad care” (183). She disparagingly adds: Centers for Medicare and Medicaid Services employs a “Michelin approach to evaluating quality” (156) through its 5-star rating system.
Similarly, Gillick skillfully compares types of nursing home ownership, indicating how the 70% of for-profit institutions differ from the not-for-profit facilities. She depicts the growth of nursing home chains and their complicated organizational histories, including publicly traded companies, those held by private equity firms, and their horizontal and vertical integrations. She argues that the convoluted ownership structure allows the for-profit facilities to maximize profits, hide assets, and protect themselves from patient lawsuits. Critically, she describes how these practices foster poor-quality care and even neglect and abuse of residents.
In the next section on SNFs, the author gives us the differing perspectives and goals of administrators, hospitals, Big Pharma, physicians, and medical supply companies. She contends that the agenda of the vested interests are often antithetical to meeting the needs of older residents, who are mainly concerned with achieving the best quality of life possible. And, these formidable stakeholders doggedly preserve the status quo, thereby making it difficult to initiate fundamental alterations to the health care system. Ultimately, Gillick is relying on Medicare, which she calls “the only participant in this drama that is single-mindedly concerned with access to and quality of health care for its members” (238). I strongly suspect, especially in the age of Trump, that she is being overly optimistic; it is questionable whether the program will be used as a lever for significant (and much needed) change.
Old and Sick in America is a highly readable and insightful book that carefully explains key aspects of how the elderly experience the US health care system. In my view, it would be beneficial for health care experts (and their students) seeking a concise overview of issues related to care of the elderly.