With the Senate’s attempt to repeal and replace the
Affordable Care Act temporarily on hold, I turned my attention to the MedPAC
report sent to Congress earlier this month, its annual report on “Medicare and
the Health Care Delivery System.” MedPAC, I once said, is one of the
most-important-organizations-you-never-heard of. It is an independent group of
17 commissioners appointed by the US Comptroller General that advises Congress
on the Medicare program. Some of Medicare’s most influential programs in recent
years, such as the readmissions reduction program and the hospital acquired
conditions reduction program, had their origins in MedPAC recommendations.
One chapter that
I found particularly intriguing was the one on hospital and SNF (skilled
nursing facility) use by Medicare beneficiaries who reside in nursing
facilities. Much attention has been paid to patients going from the hospital to
home and back to the hospital, and a fair amount of attention accorded to
patients going from the hospital to the SNF (rehab) and back to the hospital.
But this section addressed a different population: the frailest 1.6 million
people in America, those living in long term care facilities. It asked whether
they were being appropriately transferred to the acute care hospital. As the
MedPAC report noted, these are patients who often get into trouble when they
are hospitalized: they are prone to falling, developing delirium, suffering
from hospital-associated infections, and to experiencing the adverse effects of
“polypharmacy,” the prescribing of multiple medications. These are individuals
who live in an environment that provides nursing care 24/7 along with personal
care, as well as access to physicians, prescription medications, and physical
therapists. Surely it would be better for the nursing home residents—and for
Medicare’s bottom line—if they could be treated where they live. Are they? If
not, why not?
The answer is that they aren’t cared for in the
nursing facility as often as they should be. The single most important factor
determining if a person is treated in the nursing home or sent to the hospital
is the availability of on-site medical care, both physicians (or advanced
practice clinicians such as physician assistants or nurse practitioners) and diagnostic
modalities (such as x-rays).
Suddenly this conclusion had a familiar ring and I remembered
that 35 years ago, during my fellowship in geriatric medicine, I decided to
study why nursing home residents were transferred to the acute care hospital. I
spent many long hours in the emergency department of Boston City Hospital
examining medical records—I didn’t stop until I had identified 100 patients who
arrived in the ED from any of 22 area nursing homes. During the same period,
338 older individuals who lived in the community, in their own homes, had
sought care, and these people served as controls. What I found was that the
patients coming from the nursing home were remarkably similar to those coming
from home in terms of their severity of illness. They were, on average, older
(83 compared to 77), whiter (92 percent compared to 56 percent), and more
likely to be female (64 percent compared to 51 percent). They were more apt to
present with fever or a change in their mental status, both common problems
with increasing age. But otherwise, the two groups looked very similar from a
medical perspective. I concluded that we could increase the efficiency of
medical resource utilization and promote better care if we simply improved on-site care in nursing homes.
Almost exactly what MedPAC found in its analysis today.
To be sure, some nursing homes have programs in place
that go a long way to rectifying the situation, and CMS has supported several
pilot programs designed to avoid hospitalizing nursing home residents. These
programs have several features in common: they enhance the treatment available
in the nursing home by using advanced practice clinicians or providing
in-service training to other staff members; and they encourage advance care
planning by residents and their families to promote discussions of prognosis,
preferences, and planning for future illness.
So why, after over three decades, do we still
transfer many patients from the nursing home to the hospital? Why don’t we
provide more on-site medical care? The reasons are complex and include an
historical lack of interest by physicians in the frailest, oldest patients as
well as poor reimbursement for nursing home medical care. But fundamentally,
what the enduring problem shows is that we continue to fail to recognize that
people in nursing homes—and their families—do want treatment of their medical
problems. They may be willing to forgo the most invasive and burdensome forms
of treatment—such as ICU care, ventilator care, and major surgery—but that
doesn’t mean they are satisfied with a focus exclusively on comfort. If all the
nursing home can offer is Tylenol and oxygen, perhaps along with morphine or
other opioids, then nursing home residents will want to go to the hospital when
they become acutely ill.
We need to offer nursing home residents a viable alternative to the extremes
of comfort care only, on the one hand, or maximally aggressive care on the
other. And we need to explain what the various approaches to treatment would mean for them. Only then will we stanch the flow from the nursing home to the hospital.
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