Democrats and Republicans alike are balking at the Baucus proposal, the latest health care reform proposal to emerge from Congress. Not surprisingly, this enormous bill has something for everyone to hate. It attempts to legislate improvements in access and quality while simultaneously addressing cost.
But what is sometimes lost in the furor is that there are actually two kinds of costs that reform must deal with: the cost of implementing the new programs (principally the cost of requiring that most Americans have health insurance, which means subsidizing premiums for individuals with low incomes); and the rising cost of health care, principally the Medicare program, which is expected to run out of money in 2017.
The Baucus proposal has a price tag of $774 billion over 10 years (though in the last few days, various modifications have added another $28 billion), which refers to the first kind of cost. But how does the Baucus proposal address the second cost issue, containing spending?
The Congressional Budget Office predicts that total spending on health care will reach 36 percent of gross domestic product by 2035, with Medicare costs alone comprising 8 percent of GDP. The vast majority of the increase in Medicare costs will be attributable to increased spending per enrollee, not to the aging of the population. And the single most important factor accounting for the increases is the emergence, adoption, and widespread diffusion of new medical technologies.
Some of these technologies are clearly beneficial; others are beneficial to some of those who receive the new drugs or devices, but are unnecessary or even harmful to numerous others for whom they are also prescribed. And some of the beneficial technologies produce only a very small benefit but at an extremely high cost, as set by the pharmaceutical or device manufacturing industries. Effective Medicare cost control will need to go beyond appealing proposals of dubious financial benefit such as expansion of preventive services and elimination of Medicare fraud (though this could save as much as $17.2 billion per year if fraud were totally eradicated).
What else does the Baucus bill suggest? It makes three significant proposals that actually might work. Collectively, they seek to modify the culture of medicine by altering the way medical care is delivered and how it is paid for.
The beauty and the peril of its strategy is to create an infrastructure for designing a program rather than actually spelling out what the program will be. The beauty is that it does not require making politically unpalatable claims, for example that CMS may need to stop reimbursing for technologies that are not cost effective. The peril is that the various centers and institutes the plan will spawn may not in fact do what they need to in order to control costs. Just what are these centers and institutes?
The most familiar one, because it is also found in the “Affordable Health Choices Act” of both the Senate and the House, is a nonprofit patient-centered outcomes research institute. This would conduct research comparing the clinical effectiveness of medical treatments. To be effective, its work would need to translate into the CMS reimbursement policies: it would have to become an extra-government agency along the lines of the much-maligned but crucially necessary British National Institute for Health and Clinical Excellence (NICE).
The second new institution is an independent Medicare commission charged with submitting proposals for reducing excess Medicare cost growth. Strong wording would effectively require Congress to do what the commission requested or come up with a fiscally equivalent alternative. This is an example of the politically astute approach of leaving open just what the independent commission would recommend.
The third institution is an innovation center within CMS to test, evaluate, and expand different payment structures and methodologies to foster patient-centered care, improve quality, and slow Medicare cost growth. Among other endeavors, the center is mandated to pilot the development and evaluation of a system of bundled payments for a single episode of care – that is, a single payment covering care in the office, the hospital, and the skilled nursing facility. For bundling to work, doctors, nursing facilities, and hospitals will need to band together to form accountable care organizations, and Baucus promotes the establishment of these organizations by offering them a share in the cost savings they generate.
Will the research institute, the commission, and the innovation center, with it assorted pilot programs, do the job? Without knowing just what they will recommend, it is impossible to be sure. But their focus will be on the right areas: figuring out what works and what doesn’t, determining who benefits from new technologies and by how much, and developing systems of care that assure that patients get the interventions that work but not those that don’t. It’s our best shot to date.
This article appeared on the Hastings Center HealthCareCostMonitor on September 24, 2009.
Read more: http://healthcarecostmonitor.thehastingscenter.org/murielgillick/baulking-at-baucus/
October 15, 2009
End-of-Life Planning is No Conspiracy
Far from a left-wing conspiracy to deprive you of desirable care near the end of life, advance care planning - talking with one’s physician about goals and preferences for medical care in the event of incapacity - is the best way to ensure that your wishes are respected if you lose the capacity to speak for yourself. Because it is widely recognized as the ideal way to prevent both over-treatment and under-treatment, it has become the standard of care over the past 15 years.
Survey after survey indicates that most patients want to have end-of-life discussions but most do not have them. For example, a 2005 AARP survey in Massachusetts of members over age 50 found that 89 percent of those polled rated having honest answers from their doctor about end-of-life conditions as very important but only 17 percent had discussed their preferences for such care with their physicians. Study after study also shows that American patients continue to die in pain, on ventilators, and in the intensive care unit, though many of them did not want such treatment at the end of their lives. For instance, the Robert Wood Johnson study “Means to A Better End: A Report on Dying in America Today’’ found that 42 percent of all nursing home residents were persistently in pain, and the Dartmouth Atlas of Health Care found that 18 percent of deaths nationwide take place in intensive care units and 32 percent in the hospital, although the majority of Americans say they would prefer to die at home.
When physicians are asked why they do not regularly engage in advance care planning with their patients, they report that they do not have the time for such conversations. The legislation under consideration in Congress that would allow physicians to be reimbursed for an advance care planning discussion with their patients is simply an attempt to correct the imbalance between what patients want and clinical reality.
The current proposal is far from the first attempt to facilitate advance care planning. The federal Patient Self-Determination Act of 1990 mandates that all patients admitted to a healthcare facility receiving Medicare or Medicaid funding be asked if they have an advance directive (a written document specifying their wishes in the event of incapacity) and be given information about advance directives if they do not have one. Every state as well as the District of Columbia has advance directive legislation, which provides for the use of a living will (a statement about preferences in particular clinical situations) or designation of a healthcare proxy (a person to make medical decisions in the event the patient loses the capacity to do so) or both.
The only question we should be discussing is whether a federal mandate to allow physicians to bill specifically for discussions about goals and directives for care will actually succeed in stimulating advance care planning. That is why the bill calls for monitoring the use of the planning code - if it is ineffective in promoting end-of-life discussions, then we will need to find other strategies. The issue is not whether advance care planning is desirable; it is how best to encourage patients, families, and clinicians to have such conversations.
The reason it is important to have the conversations is that death is not optional. What is optional is how we will experience life’s last stage: Will we be in pain or will we be comfortable? Will we be in the hospital or at home? Will we be in an intensive care unit or enrolled in hospice? Discussions about end-of-life care have been shown to result in patients experiencing less depression, less pain, and less anxiety in their final days. Advance care planning gives us the opportunity to avoid both over- and under-treatment by allowing us to express our preferences and by discussing them with our personal physician.
This article appeared as an op-ed in the Boston Globe on August, 12, 2009.
Survey after survey indicates that most patients want to have end-of-life discussions but most do not have them. For example, a 2005 AARP survey in Massachusetts of members over age 50 found that 89 percent of those polled rated having honest answers from their doctor about end-of-life conditions as very important but only 17 percent had discussed their preferences for such care with their physicians. Study after study also shows that American patients continue to die in pain, on ventilators, and in the intensive care unit, though many of them did not want such treatment at the end of their lives. For instance, the Robert Wood Johnson study “Means to A Better End: A Report on Dying in America Today’’ found that 42 percent of all nursing home residents were persistently in pain, and the Dartmouth Atlas of Health Care found that 18 percent of deaths nationwide take place in intensive care units and 32 percent in the hospital, although the majority of Americans say they would prefer to die at home.
When physicians are asked why they do not regularly engage in advance care planning with their patients, they report that they do not have the time for such conversations. The legislation under consideration in Congress that would allow physicians to be reimbursed for an advance care planning discussion with their patients is simply an attempt to correct the imbalance between what patients want and clinical reality.
The current proposal is far from the first attempt to facilitate advance care planning. The federal Patient Self-Determination Act of 1990 mandates that all patients admitted to a healthcare facility receiving Medicare or Medicaid funding be asked if they have an advance directive (a written document specifying their wishes in the event of incapacity) and be given information about advance directives if they do not have one. Every state as well as the District of Columbia has advance directive legislation, which provides for the use of a living will (a statement about preferences in particular clinical situations) or designation of a healthcare proxy (a person to make medical decisions in the event the patient loses the capacity to do so) or both.
The only question we should be discussing is whether a federal mandate to allow physicians to bill specifically for discussions about goals and directives for care will actually succeed in stimulating advance care planning. That is why the bill calls for monitoring the use of the planning code - if it is ineffective in promoting end-of-life discussions, then we will need to find other strategies. The issue is not whether advance care planning is desirable; it is how best to encourage patients, families, and clinicians to have such conversations.
The reason it is important to have the conversations is that death is not optional. What is optional is how we will experience life’s last stage: Will we be in pain or will we be comfortable? Will we be in the hospital or at home? Will we be in an intensive care unit or enrolled in hospice? Discussions about end-of-life care have been shown to result in patients experiencing less depression, less pain, and less anxiety in their final days. Advance care planning gives us the opportunity to avoid both over- and under-treatment by allowing us to express our preferences and by discussing them with our personal physician.
This article appeared as an op-ed in the Boston Globe on August, 12, 2009.
Falling Down on the Job
It’s not often that a report appears that identifies a problem and at the same time, another report is released that offers a solution to that problem. But that may be what happened this month with the publication of an article describing the frequency of hip fractures and their complications and another article detailing an intervention that reduced the complication rate after hip fracture.
The first study presents data on hip fractures in the U.S. between 1985 and 2005. Previous data indicated that there are about 350,000 hip fractures every year in the U.S., almost all of them in people over 65 and the vast majority in people over age 75. Half of those who break their hip never return to their baseline level of mobility, 20% die within a year, and 25% of those who lived independently before the fracture require permanent nursing home care afterwards. The new report concludes that hip fracture rates and subsequent mortality among people over 65 are declining. But closer inspection of the data shows a different picture.
What the report really shows, as the authors indicate in the discussion section of their paper, is that there were two distinct time periods worthy of analysis. Between 1986 and 1995, the incidence of fractures increased in both men and women (corrected for age) but between 1995 and 2005, the incidence declined steadily. It declined a lot: among women, the incidence fell 25% and among men it fell 19%. But the mortality story is another matter. Looking at death rates at 1 month, 6 months, and at a year after hip fracture, the study found that between 1986 and 1995, mortality fell, but between 1996 and 2005, there was no improvement in mortality whatsoever.
The decline in the rate of hip fractures is good news, though it’s not entirely clear what caused it. The authors point to lifestyle factors, such as greater intake of vitamin D and calcium, along with increased exercise. They also point out that bisphosphonates, medications used to treat osteoporosis, were introduced at just about the same time that hip fracture rates began to fall, but these drugs can account for at most 40% of the reduction in risk.
The lack of improvement in mortality in the recent 10-year period, however, is troubling. Much of it reflects the fact that older people who fracture a hip are frail—and their frailty predisposes them to other medical problems in the following year. But the second article on hip fractures that appeared in a major medical journal this month offers a ray of hope. Reporting on the impact of co-management of hip fracture patients by orthopedists and geriatricians, investigators from the University of Rochester School of Medicine found enormous improvements in outcomes with their model.
Patients cared for in the “Geriatric Fracture Center” in Rochester were older than their counterparts who received standard orthopedic care (mean age 84.7 vs 81.6), they were more likely to have dementia (53% vs 21.5%), and they were much more likely to come from nursing homes and assisted living facilities (60.6% vs 12.2%). Despite all these differences, the co-managed patients fared far better. They went to the operating room much more quickly (in an average of 24.1 hours vs 37.4 hours), which has been shown to lead to better results. They stayed in the hospital less long (4.6 days on average vs 8.3 days) and they had fewer complications (30.6% vs 46.3%). In particular, they were less likely to develop delirium (acute confusion), infection, and blood clots, all of which predispose to early death.
The finding that “co-managed” patients did better than those cared for exclusively by orthopedists does not necessarily translate into improved survival rates. Some of the long-term mortality is unrelated to the hip fracture and simply reflects the reality that people who break a hip tend to be old and sick and that people who are old and sick die. But the component of the mortality from hip fractures that is amenable to intervention probably involves the post-operative management of patients. It is precisely those nasty complications of surgery that, over time, cause death. Finding a way to take care of individuals with hip fractures that decreases their risk of complications is an excellent strategy for preventing death.
Is the “Comanaged Geriatric Fracture Center” really the answer? It may be. The Rochester study was a retrospective cohort analysis, so it is possible that the findings reflect undetected differences between the patients or other differences in the institutions where care was provided. A randomized trial, in which some patients receive one form of care and others, chosen randomly, get the other type of care, would demonstrate decisively whether and how much co-management helps. But joint care by orthopedists and geriatricians is in widespread use in other countries such as Australia and New Zealand, with good results. And similar but less potent strategies have been used in the U.S., such as the use of geriatric consultation for patients on the orthopedic service. When this multidisciplinary approach was instituted at Oregon Health Sciences University and at the Johns Hopkins Bayview Medical Center, fewer complications, decreased length of stay, and earlier surgery were all observed. These systematic ways to assure improved care for older people with hip fractures can be instituted now. There’s pretty compelling evidence that they work and cost calculations suggest they save money, too. If we don’t start introducing this model into practice, we’re falling down on the job.
The first study presents data on hip fractures in the U.S. between 1985 and 2005. Previous data indicated that there are about 350,000 hip fractures every year in the U.S., almost all of them in people over 65 and the vast majority in people over age 75. Half of those who break their hip never return to their baseline level of mobility, 20% die within a year, and 25% of those who lived independently before the fracture require permanent nursing home care afterwards. The new report concludes that hip fracture rates and subsequent mortality among people over 65 are declining. But closer inspection of the data shows a different picture.
What the report really shows, as the authors indicate in the discussion section of their paper, is that there were two distinct time periods worthy of analysis. Between 1986 and 1995, the incidence of fractures increased in both men and women (corrected for age) but between 1995 and 2005, the incidence declined steadily. It declined a lot: among women, the incidence fell 25% and among men it fell 19%. But the mortality story is another matter. Looking at death rates at 1 month, 6 months, and at a year after hip fracture, the study found that between 1986 and 1995, mortality fell, but between 1996 and 2005, there was no improvement in mortality whatsoever.
The decline in the rate of hip fractures is good news, though it’s not entirely clear what caused it. The authors point to lifestyle factors, such as greater intake of vitamin D and calcium, along with increased exercise. They also point out that bisphosphonates, medications used to treat osteoporosis, were introduced at just about the same time that hip fracture rates began to fall, but these drugs can account for at most 40% of the reduction in risk.
The lack of improvement in mortality in the recent 10-year period, however, is troubling. Much of it reflects the fact that older people who fracture a hip are frail—and their frailty predisposes them to other medical problems in the following year. But the second article on hip fractures that appeared in a major medical journal this month offers a ray of hope. Reporting on the impact of co-management of hip fracture patients by orthopedists and geriatricians, investigators from the University of Rochester School of Medicine found enormous improvements in outcomes with their model.
Patients cared for in the “Geriatric Fracture Center” in Rochester were older than their counterparts who received standard orthopedic care (mean age 84.7 vs 81.6), they were more likely to have dementia (53% vs 21.5%), and they were much more likely to come from nursing homes and assisted living facilities (60.6% vs 12.2%). Despite all these differences, the co-managed patients fared far better. They went to the operating room much more quickly (in an average of 24.1 hours vs 37.4 hours), which has been shown to lead to better results. They stayed in the hospital less long (4.6 days on average vs 8.3 days) and they had fewer complications (30.6% vs 46.3%). In particular, they were less likely to develop delirium (acute confusion), infection, and blood clots, all of which predispose to early death.
The finding that “co-managed” patients did better than those cared for exclusively by orthopedists does not necessarily translate into improved survival rates. Some of the long-term mortality is unrelated to the hip fracture and simply reflects the reality that people who break a hip tend to be old and sick and that people who are old and sick die. But the component of the mortality from hip fractures that is amenable to intervention probably involves the post-operative management of patients. It is precisely those nasty complications of surgery that, over time, cause death. Finding a way to take care of individuals with hip fractures that decreases their risk of complications is an excellent strategy for preventing death.
Is the “Comanaged Geriatric Fracture Center” really the answer? It may be. The Rochester study was a retrospective cohort analysis, so it is possible that the findings reflect undetected differences between the patients or other differences in the institutions where care was provided. A randomized trial, in which some patients receive one form of care and others, chosen randomly, get the other type of care, would demonstrate decisively whether and how much co-management helps. But joint care by orthopedists and geriatricians is in widespread use in other countries such as Australia and New Zealand, with good results. And similar but less potent strategies have been used in the U.S., such as the use of geriatric consultation for patients on the orthopedic service. When this multidisciplinary approach was instituted at Oregon Health Sciences University and at the Johns Hopkins Bayview Medical Center, fewer complications, decreased length of stay, and earlier surgery were all observed. These systematic ways to assure improved care for older people with hip fractures can be instituted now. There’s pretty compelling evidence that they work and cost calculations suggest they save money, too. If we don’t start introducing this model into practice, we’re falling down on the job.
Subscribe to:
Posts (Atom)