“WISDOM LIES NEITHER IN FIXITY NOR IN CHANGE BUT IN THE DIALECTIC BETWEEN THE TWO”—OCTAVIA PAZ

Abstract

To the Editor: Dr. Reuben's editorial on the CareMore Model is an enthusiastic endorsement of the insurance plan's Medicare Advantage chronic disease management program.1 The outcome statistics presented are impressive, but the skeptic would want to know the case-mix details to understand whether the positive outcomes are truly a reflection of the disease management processes rather than an advantageous population bias. Medicare Advantage programs have repeatedly been accused of “cherry picking” their enrollee populations. The fact that the program disproportionately serves the younger Medicare population suggests this may be the case. As Dr. Reuben points out, the relevance of corporate chronic disease management programs to frail older adults is uncertain, although others would go further and state that the relevance is dubious. American geriatric medicine, now more than 50 years old, is still struggling to solidify its identity within the brave new world of corporate and industrialized medicine. Will geriatricians be “nifty after fifty mezzanine physicians” or “extensivists” or “corporate physicians choosing protocols” or “primary care physicians whose role is to refer into the system and take care of the issues that are not of interest to the model”? These are the supporting roles outlined to further the goals of the corporate enterprise. Or will we be irrelevant to it and it to us? If aging is an uneasy truce between the individual and the environment, then the mission of geriatric medicine is to help frail older adults maintain the uneasy truce but also to know when the truce is no longer tenable. If corporate medicine can perform this mission better than the geriatrician, so be it, but the words of a patient came to mind while reading of the CareMore Model. “When I am sick, I really don't want to be cared for by a businessman. In fact, I really don't want to be cared for by a businessman even when I am well.” Will the role of the geriatrician be defined by the corporate paradigm or by the needs of the frail older adults in our communities? Let us find wisdom in the robust dialectic! Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: RDE is responsible for the entire content of this paper. Sponsor's Role: None.