Our dysfunctional payment system is incapable of adequately providing for patients with multiple health conditions:

Where all the money goes:

Two-thirds of people over age 65, and almost three-quarters of people over 80, have multiple chronic health conditions, and 68 percent of Medicare spending goes to people who have five or more chronic diseases.

Who we don't know how to treat:

Yet people with multiple health problems – a condition known as multimorbidity – are largely overlooked both in medical research and in the nation's clinics and hospitals. The default position is to treat complicated patients as collections of malfunctioning body parts rather than as whole human beings.

Ignored in medical research:

A 2007 study found that 81 percent of the randomized trials published in the most prestigious medical journals excluded patients because of coexisting medical problems.

Paying physicians by task is a double whammy:

Time pressures intensify the doctors' predicament. A typical 15-minute appointment leaves too little time to weigh the risks and benefits of a complex treatment plan, much less to fully consider the patient's preferences and priorities.

Paying for performance is a triple whammy:

Quality-improvement measures, which tie doctors' compensation to how closely they follow evidence-based practice guidelines, further complicate matters, and some worry that they provide a financial incentive for physicians to sacrifice individualized decision-making.

"Doctors know that it's not right for someone to be on 15, 18, 20 medications," said Dr. Tinetti, a Yale geriatrician. "But they're being told that that's what's necessary in order to treat each of the diseases that the patients in front of them have."