Casi 1 de cada 7 adultos mayores muere dentro del año después de someterse a una cirugía mayor, según un nuevo estudio que arroja luz sobre los riesgos que enfrentan las personas mayores cuando tienen procedimientos invasivos.

Los pacientes mayores con probable demencia (33% mueren dentro del año) y fragilidad (28%), así como aquellos que se someten a cirugías de emergencia (22%) son los más vulnerables.

La edad avanzada también aumenta el riesgo: los pacientes de 90 años o más tienen seis veces más probabilidades de morir que los de 65 a 69.

El estudio, de investigadores de la Escuela de Medicina de Yale, publicado en JAMA Surgery, aborda una importante brecha: aunque en Estados Unidos los pacientes de 65 años y más representan casi el 40% de todas las cirugías, faltan datos nacionales detallados sobre los resultados de estos procedimientos.

“Como campo, hemos sido realmente negligentes al no comprender los resultados quirúrgicos a largo plazo para los adultos mayores”, dijo la doctora Zara Cooper, profesora de cirugía en la Escuela de Medicina de Harvard y directora del Centro de Cirugía Geriátrica en Brigham and Women’s Hospital de Boston.

La información sobre cuántas personas mayores mueren, desarrollan discapacidades, ya no pueden vivir de forma independiente o tienen una calidad de vida significativamente peor después de una cirugía mayor es crítica.

“Lo que los pacientes mayores quieren saber es: ‘¿cómo será mi vida?'”, dijo Cooper. “Pero no hemos podido responder antes con datos de calidad”.

En el nuevo estudio, el doctor Thomas Gill y sus colegas de Yale examinaron datos de reclamos de Medicare Tradicional y de encuestas del estudio Nacional de Tendencias de Salud y Envejecimiento que abarcan de 2011 a 2017.

Se contabilizaron como cirugías mayores los procedimientos invasivos que se realizan en quirófanos con pacientes bajo anestesia general. Los ejemplos incluyen cirugías para reemplazar caderas rotas, mejorar el flujo sanguíneo en el corazón, extirpar cáncer del colon, extirpar vesículas biliares, reparar válvulas cardíacas y hernias, entre muchas más.

Los adultos mayores tienden a experimentar más problemas después de la cirugía si tienen afecciones crónicas como enfermedades cardíacas o renales; si ya están débiles o tienen dificultad para moverse; si su capacidad para cuidar de sí mismos está comprometida; y si tienen problemas cognitivos, apuntó Gill, profesor de medicina, epidemiología y medicina de investigación en Yale.

Hace dos años, el equipo de Gill realizó una investigación que mostró que 1 de cada 3 adultos mayores no había vuelto a su nivel básico de funcionamiento a los seis meses de una cirugía mayor. Los más propensos a recuperarse fueron los adultos mayores que se sometieron a cirugías electivas para las que podían prepararse con anticipación.

En otro estudio, publicado el año pasado en Annals of Surgery, su equipo encontró que se realizan 1 millón de cirugías mayores en personas de 65 años o más cada año, incluido un número significativo cerca del final de la vida.

“Esto abre todo tipo de preguntas: ¿estas cirugías se hicieron por una buena razón? ¿Cómo se define la cirugía adecuada? ¿Se consideraron las metas del paciente?”, dijo el doctor Clifford Ko, profesor de cirugía en la Escuela de Medicina de UCLA y director de la División de Investigación y Atención Óptima del Paciente en el Colegio Estadounidense de Cirujanos.

Como ejemplo de este tipo de toma de decisiones, Ko describió a un paciente que, a los 93 años, se enteró que tenía cáncer de colon en etapa temprana además de una enfermedad preexistente del hígado, el corazón y los pulmones. Después de una discusión en profundidad y de que se le explicara que el riesgo de malos resultados era alto, el paciente decidió no realizar un tratamiento invasivo.

Pero la mayoría de los pacientes eligen la cirugía. La doctora Marcia Russell, cirujana del Sistema de Atención de Salud del Área de Asuntos de Veteranos de Los Ángeles, describió a un paciente de 90 años que recientemente se enteró de que tenía cáncer de colon durante una internación prolongada por una neumonía.

“Hablamos con él sobre la cirugía y su meta era vivir el mayor tiempo posible”, dijo Russell. Para prepararlo en casa para la futura cirugía, le recomendó que hiciera fisioterapia y comiera más alimentos ricos en proteínas, para fortalecerse.

“Es posible que necesite de seis a ocho semanas para prepararse para la cirugía, pero está motivado para mejorar”, dijo Russell.

Las decisiones que toman las personas mayores acerca de someterse a una cirugía mayor tienen amplias implicaciones sociales.

A medida que crece la población de más de 65 años, “cubrir la cirugía va a ser un desafío fiscal para Medicare”, señaló el doctor Robert Becher, profesor asistente de cirugía en Yale y colaborador de investigación de Gill.

Un poco más de la mitad del gasto de Medicare se deriva a la atención quirúrgica para pacientes hospitalizados y ambulatorios, según un análisis de 2020.

Además, “casi todas las subespecialidades quirúrgicas experimentarán escasez de profesionales en los próximos años”, dijo Becher. Señaló que en 2033 habrá casi 30,000 cirujanos menos de los necesarios para satisfacer la demanda esperada.

Estas tendencias hacen que los esfuerzos por mejorar los resultados quirúrgicos para los adultos mayores sean aún más críticos. Sin embargo, el progreso ha sido lento. El Colegio Estadounidense de Cirujanos lanzó un importante programa de mejora de la calidad en julio de 2019, ocho meses antes de la pandemia de covid-19.

Requiere que los hospitales cumplan con 30 estándares para lograr una experiencia reconocida en cirugía geriátrica. Hasta ahora, están participando menos de 100 de los miles de hospitales elegibles.

Uno de los sistemas más avanzados del país, el Centro de Cirugía Geriátrica del Brigham and Women’s Hospital, ilustra lo que es posible. Allí, se examina a los adultos mayores candidatos y, aquellos a los que se considera frágiles se someten a una evaluación geriátrica exhaustiva y se reúnen con una enfermera que ayudará a coordinar la atención después del alta.

También se evalúa a los seniors tres veces al día en busca de delirio (un cambio agudo en el estado mental que a menudo afecta a los pacientes mayores hospitalizados), y se usan analgésicos no narcóticos. “El objetivo es minimizar los daños de la hospitalización”, dijo Cooper, quien dirige el esfuerzo.

Cooper comentó sobre una paciente a quien describió como una “mujer sociable de poco más de 80 años que todavía usaba jeans ajustados e iba a cócteles”. Esta mujer llegó a la sala de emergencias con diverticulitis aguda y delirio. Se llamó a un geriatra antes de la cirugía para ayudarla a controlar sus medicamentos y su ciclo de sueño y vigilia, y para recomendar intervenciones no farmacéuticas.

Con la ayuda de los miembros de la familia que la atendieron, “ella está muy bien”, dijo Cooper. “Es el tipo de resultado que trabajamos muy duro para lograr”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.

The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.

Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result.

But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but put that decision off until February.

Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.

Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage. “From the outside, it seems pretty smelly,” he said.

In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”

Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.

The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the government paid the health plan to treat, or if medical reviewers judge the illness is less severe than claimed.

That happened on average for just over 20% of medical conditions examined over the three-year period; rates of unconfirmed diseases were higher in some plans.

As Medicare Advantage’s popularity among seniors has grown, CMS has fought to keep its audit procedures, and the mounting losses to the government, largely under wraps.

That approach has frustrated both the industry, which has blasted the audit process as “fatally flawed” and hopes to torpedo it, and Medicare advocates, who worry some insurers are getting away with ripping off the government.

“At the end of the day, it’s taxpayer dollars that were spent,” said David Lipschutz, a senior policy attorney with the Center for Medicare Advocacy. “The public deserves more information about that.”

At least three parties, including KHN, have sued CMS under the Freedom of Information Act to shake loose details about the overpayment audits, which CMS calls Risk Adjustment Data Validation, or RADV.

In one case, CMS charged a law firm an advance search fee of $120,000 and then provided next to nothing in return, according to court filings. The law firm filed suit last year, and the case is pending in federal court in Washington, D.C.

KHN sued CMS in September 2019 after the agency failed to respond to a FOIA request for the audits. Under the settlement, CMS agreed to hand over the audit summaries and other documents and pay $63,000 in legal fees to Davis Wright Tremaine, the law firm that represented KHN. CMS did not admit to wrongfully withholding the records.

High Coders

Most of the audited plans fell into what CMS calls a “high coding intensity group.” That means they were among the most aggressive in seeking extra payments for patients they claimed were sicker than average. The government pays the health plans using a formula called a “risk score” that is supposed to render higher rates for sicker patients and lower ones for healthier ones.

But often medical records supplied by the health plans failed to support those claims. Unsupported conditions ranged from diabetes to congestive heart failure.

Overall, average overpayments to health plans ranged from a low of $10 to a high of $5,888 per patient collected by Touchstone Health HMO, a New York health plan whose contract was terminated “by mutual consent” in 2015, according to CMS records.

Most of the audited health plans had 10,000 members or more, which sharply boosts the overpayment amount when the rates are extrapolated.

In all, the plans received $22.5 million in overpayments, though these were offset by underpayments of $10.5 million.

Auditors scrutinize 30 contracts a year, a small sample of about 1,000 Medicare Advantage contracts nationwide.

UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.

UnitedHealthcare spokesperson Heather Soule said the company welcomes “the program oversight that RADV audits provide.” But she said the audit process needs to compare Medicare Advantage to original Medicare to provide a “complete picture” of overpayments. “Three years ago we made a recommendation to CMS suggesting that they conduct RADV audits on every plan, every year,” Soule said.

Humana’s 11 audits with overpayments included plans in Florida and Puerto Rico that CMS had audited twice in three years.

The Florida Humana plan also was the target of an unrelated audit in April 2021 by the Health and Human Services inspector general. That audit, which covered billings in 2015, concluded Humana improperly collected nearly $200 million that year by overstating how sick some patients were. Officials have yet to recoup any of that money, either.

In an email, Humana spokesperson Jahna Lindsay-Jones called the CMS audit findings “preliminary” and noted they were based on a sampling of years-old claims.

“While we continue to have substantive concerns with how CMS audits are conducted, Humana remains committed to working closely with regulators to improve the Medicare Advantage program in ways that increase seniors’ access to high-quality, lower cost care,” she wrote.

Billing Showdown

Results of the 90 audits, though years old, mirror more recent findings of a slew of other government reports and whistleblower lawsuits alleging that Medicare Advantage plans routinely have inflated patient risk scores to overcharge the government by billions of dollars.

Brian Murphy, an expert in medical record documentation, said collectively the reviews show that the problem is “absolutely endemic” in the industry.

Auditors are finding the same inflated charges “over and over again,” he said, adding: “I don’t think there is enough oversight.”

When it comes to getting money back from the health plans, extrapolation is the big sticking point.

Although extrapolation is routinely used as a tool in most Medicare audits, CMS officials have never applied it to Medicare Advantage audits because of fierce opposition from the insurance industry.

“While this data is more than a decade old, more recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars,” said Mary Beth Donahue, president of the Better Medicare Alliance, a group that advocates for Medicare Advantage. She said the industry “delivers better care and better outcomes” for patients.

But critics argue that CMS audits only a tiny percentage of Medicare Advantage contracts nationwide and should do more to protect tax dollars.

Doolittle, the former CMS official, said the agency needs to “start keeping up with the times and doing these audits on an annual basis and extrapolating the results.”

But Kathy Poppitt, a Texas health care attorney, questioned the fairness of demanding huge refunds from insurers so many years later. “The health plans are going to fight tooth and nail and not make this easy for CMS,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).