This is a sign in front of our local hospital, and it is a piece of wisdom that my frail elderly patients should heed. Not that it is a substandard hospital; in fact, it is excellent in many ways. But as most of us who practice geriatric medicine know well, hospitals can be very dangerous for elderly patients. In my book I talk about the data that demonstrates a very pervasive falacy in medical care: that thorough, aggressive care given to the frail elderly will help them live better and longer. Nothing could be farther from the truth; in fact, in too many cases, just the opposite is true. And hospitalization, rather than helping the very sick elderly, often causes substantial harm, especially in people with dementia. It is aggressive care at its zenith. But Medicare continues to pay for hospitalization above all else, and thus many older people have no choice but to ignore the above sign and enter its vaulted walls. And Medicare even rewards those who enter the hospital, for if they can stay for three nights, older people are able to attain substantial benefits, including 100 days of care in rehabilitation centers. Without the three night stay, they would have to pay out of pocket. And for those elderly who choose to be treated at home, Medicare turns a blind eye; they will not pay for most essential home care, or palliative care. Thus the hospital becomes a necessary evil for the elderly of our nation, a reality created and sustained by Medicare's rules and payment structure. Is Medicare reform helping to ameliorate this very deleterious and expensive glitch in the system, and helping to reduce the end-of-life aggressive care, typically occuring in the hospital, that eats up a quarter of Medicare's budget without producing any beneficial results? The answer is no. In fact, quite shockingly, Medicare has been relying on the hospital to captain many of its reform efforts. As primary care doctors, it is up to use to reverse this trend. We should be steering reform, and it should be from the bottom up. Home care and palliative care must be the norm if any reform is going to suceed.