The Medicare Modernization Act of 2003 was supposed to bring the Medicare program into the 21st century. It was going to ensure that good health care was a reality for both America’s elderly and its disabled citizens. It didn’t succeed.
The 45 million Americans who are enrolled in Medicare are certainly far better off than the 47 million Americans who have no health insurance at all. Some of them are better off today than they were before the MMA was passed since they now have a prescription drug benefit. In fact, for those elders who are in good health, Medicare is a model program: designed in 1965 to cover acute, time-limited illness, it does that very well. The problem is what Medicare does not do so well. It does not provide coordinated and preventive care for those with chronic illness; it favors institutional over home care; and it offers excellent end of life care only to the minority of patients willing to forgo hospitalization and palliative treatment and to enroll in hospice. And Medicare has no good way to control costs.
When the first of the baby boomers turns 65 in 2010, Medicare costs are expected to reach 3.3% of GDP; they will jump to 6.3% of GDP in 2030 and reach a staggering 8.4% in 2050. Forget all the concern about Social Security—it’s the Hospital Trust Fund, which pays for Medicare Part A, that is on track to go bankrupt. The latest report from the Trustees, hot off the press, projects this will happen by 2017.
What Medicare is best at is treating a disease like pneumonia: the patient gets sick quickly, is hospitalized for at most a week, and then goes home with a prescription for a few days’ worth of oral antibiotics. But Medicare patients today have multiple chronic conditions: the 21% of Medicare beneficiaries with 5 or more chronic diseases account for 68% of all Medicare spending.
Patients with chronic medical problems need a very different model of care. They need a coordinated, integrated approach. Right now one of the few ways to get this kind of treatment is through the Program for All Inclusive Care for the Elderly (PACE), a program for the frailest of the frail--elders who are dually enrolled in Medicare and Medicaid and who are impaired enough to qualify to live in a nursing home to boot. PACE has been very successful not only in keeping such patients out of the nursing home but also at keeping them out of the hospital, while providing high quality care. But the model for addressing chronic disease in the MMA was not the capitated PACE program, but rather “case management,” typically provided by an outside agency that does the medical equivalent of trying to direct traffic by phone rather than through the physician’s office. Not surprisingly, these programs have in general been a disappointment.
Because Medicare is geared towards treatment of acute illness, it is built on hospital-based care, not community care. In 2007, 30% of Medicare spending went to hospital treatment. Much smaller chunks went to skilled nursing facility (SNF) care (5%) and to home care (4%). And there are incentives for patients to be treated in institutions rather than at home. For example, patients must spend three nights in a hospital before going to a SNF, even though some simple problems such as pneumonia could easily be treated in the SNF. Similarly, there is an incentive for patients to move into a nursing home—and be covered by Medicaid—rather than to receive care at home.
One of the jewels in the Medicare crown is its hospice benefit. Enacted in 1982, the hospice benefit allows patients with a prognosis of 6 months or less to receive intensive services focusing on their comfort, care which in 95% of cases is delivered at home. The program has gotten excellent marks from families in satisfaction surveys and in formal research studies.
Hospice grown dramatically: between 2000 and 2007, the number of Medicare certified hospices increased by 41%, and the number of hospice patients doubled from 513,000 to one million. But the problem with Medicare hospice is that it forces patients to make a diabolical choice. In order to qualify for the home care services most patients want at the end of life, they have to agree to forgo treatments that can offer significant palliation. Contemporary medicine can enhance the quality of life for many patients with advanced disease through relatively non-invasive treatments such as oral chemotherapy or blood transfusions. But the reimbursement structure of the Medicare hospice benefit—a fixed per diem rate—simply does not allow for these treatments.
How can Medicare do all these things—and continue to provide acute medical care? Providing additional benefits seems like the last thing the Medicare program should do: the costs of the Medicare program have already been skyrocketing, partly due to the growing number of older individuals, but to a much larger extent due to the insatiable American appetite for health care and the introduction of new, expensive technology. Fortunately, the reality is that while Medicare is failing to provide a variety of services that are critically important for older patients, it is simultaneously providing an enormous amount of care that is useless and in many cases even harmful. In fact, when Medicare patients with a heart attack, hip fracture, or colorectal cancer were followed over a five year period, those living in parts of the country with higher spending on medical care experienced higher mortality.
Medicare routinely pays for burdensome, expensive treatments for patients at the end of life. Similarly, it reimburses physicians and hospitals generously for diagnostic tests and procedures of dubious benefit. And it pays for costly medications and treatments when cheaper, equally effective treatments exist. How can Medicare move from today’s reality, in which it fails to provide all kinds of care it should offer and systematically encourages the use of all kinds of care it should not?
In terms of chronic disease, the secret to success lies within the PACE program, which provides coordinated care within a capitated system. HMOs got a bad name in the 1990s, but the truth is that only when an integrated health care system operates within a fixed budget that we can expect to see appropriate allocation of resources. With respect to new technology, which is the principal driver behind escalating costs in the Medicare program, the trick will be to stimulate innovation without allowing technology to diffuse unchecked.
One solution is to allow cost effectiveness analysis to enter into CMS reimbursement decisions, not as the sole criterion, but along with other ethical principles such as preferential treatment for the most vulnerable. Finally, to provide good end of life care to all Medicare patients who die, not just those who currently opt for hospice, many of whom enroll in the program within days or even hours of death, we need to create a new benefit. This would provide much of what is currently available through hospice but allow for some hospital care and many palliative treatments in exchange for forgoing the most expensive types of care such as major surgery and ICU care.
The current discussions of health care reform have appropriately emphasized the importance of universal access. And right now those over 65 do have access through Medicare—though median out-of-pocket health spending as a percent of income has been rising for older individuals, going from 11.9% in 1997 to 16.1% in 2005, potentially jeopardizing access. But Medicare deserves significant attention as well, both to quality and costs, two goals that are sometimes in conflict. The good news is that truly modernizing Medicare—paying attention to the most important health needs of older individuals and focusing on care that works—can actually improve quality while constraining cost.
This article also appeared in the new Hastings Center Blog, the Health Care Cost Monitor.
May 27, 2009
April 20, 2009
Follow the Money?
Most Americans have probably never heard of it, but MedPAC is arguably one of the most influential organizations in the health care arena. The Medical Payments Advisory Commission is a non-partisan, independent Congressional agency established by Congress in 1997 to advise on issues relating to the Medicare program. That translates mainly into advice on reimbursement policies, but MedPAC’s mandate also includes addressing access and quality of care.
What is MedPAC and just what does it do? It is comprised of 17 commissioners, including a chairman, who serve staggered 3-year terms. They are appointed by the Comptroller General—another important position that most of us have never heard of. While the 17 members of MedPAC are a distinguished group of professionals who come from diverse fields including medicine, nursing, health policy, and economics, they all have other jobs and could not possibly carry out their mission without a strong staff to do the heavy lifting. In fact, MedPAC’s website lists an executive director, an associate director, a deputy directory, 8 principal policy analysts, 9 senior analysts, 2 analysts, and 2 research assistants, along with miscellaneous other aides and consultants. Based on my experience as a member of the Massachusetts Public Health Council, the supposed seat of health care policy in the state, it is the staff that does most of the work and holds the real power.
The work of MedPAC is evident in its “Reports to Congress,” which appear in March and June of each year, as well as in an annual Data Book. The most recent Report, released in March 2009, all 424 pages of which are available on the web, gives some indication of the breadth and depth of MedPAC’s work. The introduction by Chairman Glen Hackbarth (who incidentally is a founding member of the multi-specialty group practice where I work, Harvard Vanguard Medical Associates), sets the scene. Hackbarth identifies 5 major imperatives for Medicare reform: redesigning and rebuilding primary care, moving beyond fee for service to a more integrated and coordinated model of care, revamping the Medicare Advantage program to reward excellent performance, working to constrain costs by modifying the reimbursement system, and investing in comparative effectiveness research.
To get a flavor of just how far MedPAC goes in its recommendations, consider just 3 of its specific suggestions, those dealing with updating the payment system, revising the Medicare Advantage Program, and modifying the reimbursement system for hospice. Every year, MedPAC tells Congress what changes to make in how much Medicare pays for a variety of services. One of the areas the report addresses this year is payments for expensive imaging services—payments for MRI and CT and PET scan studies. Hidden behind its very dry language, MedPAC does something quite radical: The Commission recognizes that its system for deciding how much to pay for such procedures has been based on the assumption that the equipment is operated 25 hours/week. As a result, providers have an incentive to purchase expensive machinery, even if they have only modest needs, but then to use it as much as possible. The latest report advises modifying the reimbursement formula by assuming that equipment is in operation many more hours each week, thus decreasing the per scan reimbursement and potentially slowing the rapidly rising number of imaging studies ordered each year.
A second area tackled by MedPAC is the Medicare Advantage program. To encourage older individuals to sign up for a private plan rather than the government program, third party payers have been encouraged to come up with capitated plans as alternatives to conventional fee for service Medicare. Some of these plans offer coordination of care and a truly integrated model of health care, which are widely held to be desirable for older patients. Others don’t offer such a comprehensive program but nonetheless receive roughly 14% more from Medicare than do fee-for-service plans providing comparable care. MedPAC wants to make sure that it’s getting value for its money by eliminating what it sees as the windfall offered to capitated programs.
Finally, the report discusses Medicare hospice reimbursement, which has been essentially unchanged since the hospice benefit was introduced in 1982. Between 2000 and 2007, about 1000 new hospice providers entered the market, almost all of them for-profit agencies. The Commission recognizes that many of these hospices are making a sizable profit by enrolling lots of long stay patients: Hospices are paid a fixed per diem rate, so if they care for many low-maintenance patients over an extended period of time, they make money. The new proposal is to pay hospices a higher daily fee initially, when the hospice spends a disproportionate amount of time and effort evaluating a patient and providing whatever medications and equipment the patient needs, then pay a lower fee for intermediate days, and pay a higher fee for the last few days of life, when resource utilization goes up. While this approach is entirely rational as a way to prevent hospices from bilking Medicare by, for example, enrolling nursing home patients with dementia for long periods of time, it has the potential to further discourage hospices from enrolling cancer patients who are interested in pursuing palliative but expensive treatments such as radiation therapy or oral chemotherapy.
MedPAC’s suggestions are based on an extensive analysis of Medicare data—data which are published in its annual data book. They are often very reasonable strategies to improve the existing system of care. But while the Commission has an excellent grasp of the context within which reimbursement occurs and professes interest in developing a correspondingly broad set of recommendations, its concrete proposals tend to deal fairly narrowly with payment issues. The main job of the Commission, after all, is to advise on Medicare payment.
Proposals for reforming America’s health care system are multiplying faster than any other type of innovation in medicine—in fact, I haven’t had written a blog posting in some time because each time I prepare to respond to one plan, another one appears. The New England Journal of Medicine, Health Affairs, and the Annals of Internal Medicine have all featured numerous articles on health care reform. One piece just published this month, emanating from something called the FRESH-Thinking Project, boasts a record 50 authors. Most of these articles, like MedPAC, focus on reforming the reimbursement system. They assume that financial incentives drive medical practice. And they are of course right to follow the money, as Deep Throat famously told journalist Bob Woodward. But important as finances are, and insightful and pragmatic as MedPAC is, there is more to health care reform than modifying the payment system. The payment system is essentially the same throughout the country and yet there is enormous variation in the way medicine is practiced. Very little of that variation is due to differences in how sick people are in New Jersey (the highest spending area of the country) and North Dakota (the lowest spending area). The root cause of variation is differences in the culture of medicine. It is the sociology of medicine that we must understand before turning to MedPAC to implement change in the reimbursement system.
What is MedPAC and just what does it do? It is comprised of 17 commissioners, including a chairman, who serve staggered 3-year terms. They are appointed by the Comptroller General—another important position that most of us have never heard of. While the 17 members of MedPAC are a distinguished group of professionals who come from diverse fields including medicine, nursing, health policy, and economics, they all have other jobs and could not possibly carry out their mission without a strong staff to do the heavy lifting. In fact, MedPAC’s website lists an executive director, an associate director, a deputy directory, 8 principal policy analysts, 9 senior analysts, 2 analysts, and 2 research assistants, along with miscellaneous other aides and consultants. Based on my experience as a member of the Massachusetts Public Health Council, the supposed seat of health care policy in the state, it is the staff that does most of the work and holds the real power.
The work of MedPAC is evident in its “Reports to Congress,” which appear in March and June of each year, as well as in an annual Data Book. The most recent Report, released in March 2009, all 424 pages of which are available on the web, gives some indication of the breadth and depth of MedPAC’s work. The introduction by Chairman Glen Hackbarth (who incidentally is a founding member of the multi-specialty group practice where I work, Harvard Vanguard Medical Associates), sets the scene. Hackbarth identifies 5 major imperatives for Medicare reform: redesigning and rebuilding primary care, moving beyond fee for service to a more integrated and coordinated model of care, revamping the Medicare Advantage program to reward excellent performance, working to constrain costs by modifying the reimbursement system, and investing in comparative effectiveness research.
To get a flavor of just how far MedPAC goes in its recommendations, consider just 3 of its specific suggestions, those dealing with updating the payment system, revising the Medicare Advantage Program, and modifying the reimbursement system for hospice. Every year, MedPAC tells Congress what changes to make in how much Medicare pays for a variety of services. One of the areas the report addresses this year is payments for expensive imaging services—payments for MRI and CT and PET scan studies. Hidden behind its very dry language, MedPAC does something quite radical: The Commission recognizes that its system for deciding how much to pay for such procedures has been based on the assumption that the equipment is operated 25 hours/week. As a result, providers have an incentive to purchase expensive machinery, even if they have only modest needs, but then to use it as much as possible. The latest report advises modifying the reimbursement formula by assuming that equipment is in operation many more hours each week, thus decreasing the per scan reimbursement and potentially slowing the rapidly rising number of imaging studies ordered each year.
A second area tackled by MedPAC is the Medicare Advantage program. To encourage older individuals to sign up for a private plan rather than the government program, third party payers have been encouraged to come up with capitated plans as alternatives to conventional fee for service Medicare. Some of these plans offer coordination of care and a truly integrated model of health care, which are widely held to be desirable for older patients. Others don’t offer such a comprehensive program but nonetheless receive roughly 14% more from Medicare than do fee-for-service plans providing comparable care. MedPAC wants to make sure that it’s getting value for its money by eliminating what it sees as the windfall offered to capitated programs.
Finally, the report discusses Medicare hospice reimbursement, which has been essentially unchanged since the hospice benefit was introduced in 1982. Between 2000 and 2007, about 1000 new hospice providers entered the market, almost all of them for-profit agencies. The Commission recognizes that many of these hospices are making a sizable profit by enrolling lots of long stay patients: Hospices are paid a fixed per diem rate, so if they care for many low-maintenance patients over an extended period of time, they make money. The new proposal is to pay hospices a higher daily fee initially, when the hospice spends a disproportionate amount of time and effort evaluating a patient and providing whatever medications and equipment the patient needs, then pay a lower fee for intermediate days, and pay a higher fee for the last few days of life, when resource utilization goes up. While this approach is entirely rational as a way to prevent hospices from bilking Medicare by, for example, enrolling nursing home patients with dementia for long periods of time, it has the potential to further discourage hospices from enrolling cancer patients who are interested in pursuing palliative but expensive treatments such as radiation therapy or oral chemotherapy.
MedPAC’s suggestions are based on an extensive analysis of Medicare data—data which are published in its annual data book. They are often very reasonable strategies to improve the existing system of care. But while the Commission has an excellent grasp of the context within which reimbursement occurs and professes interest in developing a correspondingly broad set of recommendations, its concrete proposals tend to deal fairly narrowly with payment issues. The main job of the Commission, after all, is to advise on Medicare payment.
Proposals for reforming America’s health care system are multiplying faster than any other type of innovation in medicine—in fact, I haven’t had written a blog posting in some time because each time I prepare to respond to one plan, another one appears. The New England Journal of Medicine, Health Affairs, and the Annals of Internal Medicine have all featured numerous articles on health care reform. One piece just published this month, emanating from something called the FRESH-Thinking Project, boasts a record 50 authors. Most of these articles, like MedPAC, focus on reforming the reimbursement system. They assume that financial incentives drive medical practice. And they are of course right to follow the money, as Deep Throat famously told journalist Bob Woodward. But important as finances are, and insightful and pragmatic as MedPAC is, there is more to health care reform than modifying the payment system. The payment system is essentially the same throughout the country and yet there is enormous variation in the way medicine is practiced. Very little of that variation is due to differences in how sick people are in New Jersey (the highest spending area of the country) and North Dakota (the lowest spending area). The root cause of variation is differences in the culture of medicine. It is the sociology of medicine that we must understand before turning to MedPAC to implement change in the reimbursement system.
February 12, 2009
A Tale of Two Patients
The primary caregiver for her three grandchildren, 59-year-old Lola Sanchez tried unsuccessfully to go to the kitchen to prepare a snack for the four-year-old and found something was terribly wrong with her right leg. She managed to call an ambulance, but by the time the paramedics arrived, Mrs. Sanchez could no longer speak distinctly and her entire right side was paralyzed. Her blood pressure and her blood sugar were sky high. When she reached the hospital emergency room, she was in a coma. Two days later she was dead, a victim of a massive intracerebral hemorrhage, caused by untreated high blood pressure and inadequately controlled diabetes. Mrs. Sanchez had no health insurance.
In the intensive care unit of the same hospital, Samuel Wang, a 92-year old man with advanced dementia, lay curled up in an ICU bed, dependent on a ventilator to breathe. He had been brought in from a nursing home two weeks earlier with pneumonia. Mr. Wang, who could no longer speak or recognize his family, had aspirated—his food had gone into his lungs, a common occurrence in the final stage of Alzheimer’s disease. Because his family asked the physicians to “do everything” to prolong his life, he remained attached to the ventilator, receiving artificial nutrition through a feeding tube in his stomach. A pacemaker helped keep his heart going. One month after admission, he died after an unsuccessful attempt at cardiopulmonary resuscitation. Mr. Wang was enrolled in Medicare, which together with his supplementary medical insurance, paid the entire $125,000 cost of his hospital stay.
These two scenarios are far from uncommon. According to a recent Urban Institute report, 27,000 Americans died of preventable causes because they lacked medical insurance in 2006. Since most people like Mrs. Sanchez with high blood pressure are asymptomatic, they often do not visit the doctor if they are uninsured. But over the long run, untreated hypertension predisposes to stroke. In the same year, according to researchers at the Dartmouth Institute for Health Policy and Clinical Practice, Medicare spent $10 billion on non-beneficial care for elderly individuals with chronic disease such as Mr. Wang. Expenditures on diagnostic tests, physician visits, and hospitalization are three times higher in some areas of the U.S. than in others, without resulting in any better outcomes.
The current administration hopes to help people like Lola Sanchez by increasing access to care. Access is critical: fully 75 million adult Americans are uninsured or under-insured, resulting in the U.S. coming in last among 19 industrialized nations in the rate of preventable deaths, according to a new analysis by the Commonwealth Fund. But it is irresponsible to improve access, adding to the total government expenditure on medical care, without simultaneously addressing its cost. Currently, Medicare and Medicaid alone account for nearly 5% of GDP and Peter Orszag, Director of the Office of Management and Budget, has projected this will rise to 20% by 2050 unless we take dramatic steps to curb escalating growth.
In the move toward health care reform, cost has received short shrift except to stimulate exhortations to limit waste and inefficiency. Waste—ordering duplicate diagnostic tests because of a lack of an electronic medical record, or prescribing expensive brand name medications instead of far cheaper generic equivalents—makes a modest contribution to spiraling medical costs. The main culprit, according to most medical economists, is the American obsession with high tech medicine. Physicians, patients, and families believe that more is better. The faith in technology is further fueled by device-manufacturers, pharmaceutical companies and the media, as well as by our health care reimbursement system. As health care reform proceeds, we should focus on access, quality, and cost. That will mean using our technology selectively in those who have a reasonable chance of benefiting. It will mean changing the medical culture to ensure that patients nearing the end of life do not routinely undergo pacemaker insertion and are not regularly admitted to the ICU, but instead receive competent and compassionate palliative care.
In the intensive care unit of the same hospital, Samuel Wang, a 92-year old man with advanced dementia, lay curled up in an ICU bed, dependent on a ventilator to breathe. He had been brought in from a nursing home two weeks earlier with pneumonia. Mr. Wang, who could no longer speak or recognize his family, had aspirated—his food had gone into his lungs, a common occurrence in the final stage of Alzheimer’s disease. Because his family asked the physicians to “do everything” to prolong his life, he remained attached to the ventilator, receiving artificial nutrition through a feeding tube in his stomach. A pacemaker helped keep his heart going. One month after admission, he died after an unsuccessful attempt at cardiopulmonary resuscitation. Mr. Wang was enrolled in Medicare, which together with his supplementary medical insurance, paid the entire $125,000 cost of his hospital stay.
These two scenarios are far from uncommon. According to a recent Urban Institute report, 27,000 Americans died of preventable causes because they lacked medical insurance in 2006. Since most people like Mrs. Sanchez with high blood pressure are asymptomatic, they often do not visit the doctor if they are uninsured. But over the long run, untreated hypertension predisposes to stroke. In the same year, according to researchers at the Dartmouth Institute for Health Policy and Clinical Practice, Medicare spent $10 billion on non-beneficial care for elderly individuals with chronic disease such as Mr. Wang. Expenditures on diagnostic tests, physician visits, and hospitalization are three times higher in some areas of the U.S. than in others, without resulting in any better outcomes.
The current administration hopes to help people like Lola Sanchez by increasing access to care. Access is critical: fully 75 million adult Americans are uninsured or under-insured, resulting in the U.S. coming in last among 19 industrialized nations in the rate of preventable deaths, according to a new analysis by the Commonwealth Fund. But it is irresponsible to improve access, adding to the total government expenditure on medical care, without simultaneously addressing its cost. Currently, Medicare and Medicaid alone account for nearly 5% of GDP and Peter Orszag, Director of the Office of Management and Budget, has projected this will rise to 20% by 2050 unless we take dramatic steps to curb escalating growth.
In the move toward health care reform, cost has received short shrift except to stimulate exhortations to limit waste and inefficiency. Waste—ordering duplicate diagnostic tests because of a lack of an electronic medical record, or prescribing expensive brand name medications instead of far cheaper generic equivalents—makes a modest contribution to spiraling medical costs. The main culprit, according to most medical economists, is the American obsession with high tech medicine. Physicians, patients, and families believe that more is better. The faith in technology is further fueled by device-manufacturers, pharmaceutical companies and the media, as well as by our health care reimbursement system. As health care reform proceeds, we should focus on access, quality, and cost. That will mean using our technology selectively in those who have a reasonable chance of benefiting. It will mean changing the medical culture to ensure that patients nearing the end of life do not routinely undergo pacemaker insertion and are not regularly admitted to the ICU, but instead receive competent and compassionate palliative care.
January 02, 2009
Movies, Restaurants, Hotels—and Now Nursing Homes
With considerable fanfare, the Centers for Medicare and Medicaid Services (CMS) released a new rating system for nursing homes in mid-December. Depending on your perspective, the state where I live, Massachusetts, either did very well—it was among the top 10 states in the US—or not so well—it has a lower percentage of five-star and a higher percentage of one-star nursing homes than neighboring New Hampshire, Connecticut or Maine.
All rating systems are subject to criticism and this latest one is no exception. For some time, CMS has published Nursing Home Compare, which allows consumers to see how a particular nursing home scores using a variety of indicators. The new approach tries to boil down all the assessments to a single summary statistic. That statistic (the number of stars) in turn depends on just three measures: the result of health inspections, the staffing ratio, and a quality measure. Arguably the most important—and controversial—of these is the quality measure. For long stay nursing homes, the rating system uses 7 different measures to come up with its rating, ranging from the percent of residents who report untreated pain (a good measure but dependent on self-reporting by the facility) to the frequency of urinary tract infections (of dubious importance as many nursing home residents have bacteria in their urine that is of no significance). For short stay facilities (rehab or post-acute care), the rating system uses only 3 different measures to derive its composite quality rating: the presence of acute confusion (delirium), pain, and pressure ulcers. None of the three is corrected for the severity of illness of the patients in the facility. It’s not clear to me that this simplified rating system is an improvement over the previous more nuanced reports. But what is indisputable is that nursing homes in Massachusetts vary enormously. Facilities awarded five stars are probably pretty good and those with one star are probably pretty poor. What, then, should the state do to promote better quality?
The prevailing approach to ensuring quality relies on an extensive system of federal regulations that are enforced by the state Department of Public Health. Teams of surveyors make unscheduled inspections to determine whether facilities are in compliance with the regulations and issue citations for any “deficiencies.” The results of these surveys are public and may result in penalties ranging from fines to loss of Medicaid and Medicare certification. Nursing home quality has improved over the past 10 years, and the regulations probably played a role in stimulating change, particularly when combined with a mandatory resident assessment system, but clearly there is more work to be done.
How should Massachusetts promote further improvement? Perhaps it is time to move from a punitive system to one that offers incentives for achieving quality. An interesting experiment that bears watching is underway in Minnesota, which has introduced pay-for-performance into nursing homes. But pay-for-performance tends to encourage institutions to concentrate only on those areas in which they know they will be measured, to the detriment of other areas. And by rewarding facilities for outcomes rather than for improvement, they decrease reimbursement to precisely those sites that need an infusion of funds to improve.
Over the long run, Massachusetts can hope to improve nursing homes by making a career in long-term care attractive. Physician interest in nursing home care has grown, though modestly: medical directors of nursing homes now have their own professional society and an academic journal. Nurse practitioners are playing an increasing role as primary care clinicians in the nursing home, where they have contributed to better medical care and decreased hospitalization rates along with a high degree of family satisfaction.
The last frontier is the nursing assistant, who continues to be poorly paid, to have limited opportunities for advancement, and to suffer from high rates of job-related injury.
The Massachusetts Act to Promote Cost Containment, signed into law in August, 2008, commits the state to a major effort to attract primary care physicians and nurses through enhanced educational opportunities and loan forgiveness programs. We need to broaden that initiative by developing a career ladder for nursing assistants, creating a variety of positions between the Certified Nursing Assistant (who typically receives 75 hours of classroom training and 100 hours of on-the-job training) and the Registered Nurse (who may have spent 4-5 years getting a Bachelor of Science in Nursing). Only when all those caring for nursing home residents take pride in their work, when they receive respect for what they do and have autonomy in their jobs, can we expect both quality of care and quality of life to improve in nursing facilities.
A shorter version of this posting appeared on Commonhealth
All rating systems are subject to criticism and this latest one is no exception. For some time, CMS has published Nursing Home Compare, which allows consumers to see how a particular nursing home scores using a variety of indicators. The new approach tries to boil down all the assessments to a single summary statistic. That statistic (the number of stars) in turn depends on just three measures: the result of health inspections, the staffing ratio, and a quality measure. Arguably the most important—and controversial—of these is the quality measure. For long stay nursing homes, the rating system uses 7 different measures to come up with its rating, ranging from the percent of residents who report untreated pain (a good measure but dependent on self-reporting by the facility) to the frequency of urinary tract infections (of dubious importance as many nursing home residents have bacteria in their urine that is of no significance). For short stay facilities (rehab or post-acute care), the rating system uses only 3 different measures to derive its composite quality rating: the presence of acute confusion (delirium), pain, and pressure ulcers. None of the three is corrected for the severity of illness of the patients in the facility. It’s not clear to me that this simplified rating system is an improvement over the previous more nuanced reports. But what is indisputable is that nursing homes in Massachusetts vary enormously. Facilities awarded five stars are probably pretty good and those with one star are probably pretty poor. What, then, should the state do to promote better quality?
The prevailing approach to ensuring quality relies on an extensive system of federal regulations that are enforced by the state Department of Public Health. Teams of surveyors make unscheduled inspections to determine whether facilities are in compliance with the regulations and issue citations for any “deficiencies.” The results of these surveys are public and may result in penalties ranging from fines to loss of Medicaid and Medicare certification. Nursing home quality has improved over the past 10 years, and the regulations probably played a role in stimulating change, particularly when combined with a mandatory resident assessment system, but clearly there is more work to be done.
How should Massachusetts promote further improvement? Perhaps it is time to move from a punitive system to one that offers incentives for achieving quality. An interesting experiment that bears watching is underway in Minnesota, which has introduced pay-for-performance into nursing homes. But pay-for-performance tends to encourage institutions to concentrate only on those areas in which they know they will be measured, to the detriment of other areas. And by rewarding facilities for outcomes rather than for improvement, they decrease reimbursement to precisely those sites that need an infusion of funds to improve.
Over the long run, Massachusetts can hope to improve nursing homes by making a career in long-term care attractive. Physician interest in nursing home care has grown, though modestly: medical directors of nursing homes now have their own professional society and an academic journal. Nurse practitioners are playing an increasing role as primary care clinicians in the nursing home, where they have contributed to better medical care and decreased hospitalization rates along with a high degree of family satisfaction.
The last frontier is the nursing assistant, who continues to be poorly paid, to have limited opportunities for advancement, and to suffer from high rates of job-related injury.
The Massachusetts Act to Promote Cost Containment, signed into law in August, 2008, commits the state to a major effort to attract primary care physicians and nurses through enhanced educational opportunities and loan forgiveness programs. We need to broaden that initiative by developing a career ladder for nursing assistants, creating a variety of positions between the Certified Nursing Assistant (who typically receives 75 hours of classroom training and 100 hours of on-the-job training) and the Registered Nurse (who may have spent 4-5 years getting a Bachelor of Science in Nursing). Only when all those caring for nursing home residents take pride in their work, when they receive respect for what they do and have autonomy in their jobs, can we expect both quality of care and quality of life to improve in nursing facilities.
A shorter version of this posting appeared on Commonhealth
December 04, 2008
Don't Just Do Something, Sit There
All over the country, hospitals are setting up “rapid response teams.” The idea is to intervene quickly when a patient looks as though he might be going downhill—for example if his blood pressure is falling or he’s breathing very rapidly. The expectation is that this preventive approach will avoid cardiac arrests, emergencies in which a patient’s heart stops and respiration ceases. Massachusetts recently passed a law that requires hospitals to put rapid response teams in place (The Act to Promote Cost Containment, Transparency, and Efficiency in the Delivery of Quality Health Care). The only problem is that there is now pretty good evidence that the teams don’t save lives.
A study in this week’s Journal of the American Medical Association is the first large, carefully conducted study of the effect of a rapid response team, taking into consideration normal seasonal variability in the rate of cardiac arrest and death. Carried out at a medium sized tertiary care hospital in Kansas City, Missouri, the investigators found there was no decrease in the frequency of cardiac arrest after the intervention was introduced and no change in the mortality rate at the hospital.
What was particularly striking about the study is that at first glance, it looked as though the rapid response teams were effective: the crude code rate (number of cardiac arrests per 1000 hospital admissions) fell from 11.2/1000 to 7.5/1000. But when the physicians carrying out the study adjusted for normal month-to-month changes in the frequency of cardiac arrests, the differences vanished. Failure to look at the consequences of rapid response teams over a long enough period of time and to calculate the effect of seasonal changes may have accounted for the positive results in earlier, preliminary studies.
The other startling finding in this study is that of the 70 patients who died despite the rapid response team interventions, fully 46 decided on a do-not-resuscitate status after their evaluation. In other words, the rapid response team stimulated a discussion among physicians, patients, and families about the fact that the patient was very ill and doing poorly. The result of this discussion, in many cases, was an explicit decision to limit invasive and painful interventions that had only a small chance of success.
What can we learn from this provocative study? The first is that it’s a bad idea to institute sweeping changes in medicine without good evidence that the changes will have the desired effect. Several physicians expressed skepticism about rapid response teams when they were becoming the vogue (for example, "Rapid Response Teams—Walk Don’t Run," JAMA 2006). A review of the subject done by the Cochrane Collaborative, a group that undertakes systematic reviews of all kinds of questions in medicine to determine whether the preponderance of evidence support their use, found no evidence of benefit from rapid response teams. But despite these calls for caution, the Institute for Healthcare Improvement recommended that all hospitals adopt rapid response teams. The intervention may turn out to be more effective than the current study suggests—the JAMA study was at a single hospital and used a particular combination of two ICU nurses and a respiratory therapist with ICU physician backup; other institutions using other types of clinicians may achieve different results. But what is clear is that sweeping policy changes in medicine, changes that involve many resources and great expense, should be preceded by correspondingly extensive evaluation.
The second conclusion to be drawn is that the best time to engage patients and families in advance care planning—talking about what approach to medical care they want if they are extremely ill—may not be when they are doing well and may not be when they are in the middle of a crisis. Rather, the best time to consider what they hope treatment will accomplish for them, and what treatments are consistent with their goals, may be when they have just come through a serious illness. We know, for example, that patients are particularly susceptible to advice to stop smoking right after they had had a heart attack. That, of course, is a bit late, but a recent study found that after any hospitalization, whatever the medical problem, patients are good candidates for giving up smoking (Rigotti et al, “Smoking Cessation Intervention for Hospitalized Smokers," Archives of Internal Medicine, October 2008). While it would be premature to conclude that advance care planning is best done right after a close call—just as it was premature to conclude that rapid response teams are the way to go based on very preliminary data—it’s an area to explore further.
A study in this week’s Journal of the American Medical Association is the first large, carefully conducted study of the effect of a rapid response team, taking into consideration normal seasonal variability in the rate of cardiac arrest and death. Carried out at a medium sized tertiary care hospital in Kansas City, Missouri, the investigators found there was no decrease in the frequency of cardiac arrest after the intervention was introduced and no change in the mortality rate at the hospital.
What was particularly striking about the study is that at first glance, it looked as though the rapid response teams were effective: the crude code rate (number of cardiac arrests per 1000 hospital admissions) fell from 11.2/1000 to 7.5/1000. But when the physicians carrying out the study adjusted for normal month-to-month changes in the frequency of cardiac arrests, the differences vanished. Failure to look at the consequences of rapid response teams over a long enough period of time and to calculate the effect of seasonal changes may have accounted for the positive results in earlier, preliminary studies.
The other startling finding in this study is that of the 70 patients who died despite the rapid response team interventions, fully 46 decided on a do-not-resuscitate status after their evaluation. In other words, the rapid response team stimulated a discussion among physicians, patients, and families about the fact that the patient was very ill and doing poorly. The result of this discussion, in many cases, was an explicit decision to limit invasive and painful interventions that had only a small chance of success.
What can we learn from this provocative study? The first is that it’s a bad idea to institute sweeping changes in medicine without good evidence that the changes will have the desired effect. Several physicians expressed skepticism about rapid response teams when they were becoming the vogue (for example, "Rapid Response Teams—Walk Don’t Run," JAMA 2006). A review of the subject done by the Cochrane Collaborative, a group that undertakes systematic reviews of all kinds of questions in medicine to determine whether the preponderance of evidence support their use, found no evidence of benefit from rapid response teams. But despite these calls for caution, the Institute for Healthcare Improvement recommended that all hospitals adopt rapid response teams. The intervention may turn out to be more effective than the current study suggests—the JAMA study was at a single hospital and used a particular combination of two ICU nurses and a respiratory therapist with ICU physician backup; other institutions using other types of clinicians may achieve different results. But what is clear is that sweeping policy changes in medicine, changes that involve many resources and great expense, should be preceded by correspondingly extensive evaluation.
The second conclusion to be drawn is that the best time to engage patients and families in advance care planning—talking about what approach to medical care they want if they are extremely ill—may not be when they are doing well and may not be when they are in the middle of a crisis. Rather, the best time to consider what they hope treatment will accomplish for them, and what treatments are consistent with their goals, may be when they have just come through a serious illness. We know, for example, that patients are particularly susceptible to advice to stop smoking right after they had had a heart attack. That, of course, is a bit late, but a recent study found that after any hospitalization, whatever the medical problem, patients are good candidates for giving up smoking (Rigotti et al, “Smoking Cessation Intervention for Hospitalized Smokers," Archives of Internal Medicine, October 2008). While it would be premature to conclude that advance care planning is best done right after a close call—just as it was premature to conclude that rapid response teams are the way to go based on very preliminary data—it’s an area to explore further.
October 28, 2008
Medicare for More
The next administration will have an historic opportunity to reform the American health care system. The federal government might actually do something about the fact that 45 million Americans are uninsured, that health care costs are soaring (with spending on Medicare and Medicaid alone now accounting for 4.6% of GDP and on track to reach 20% by 2050), and that despite our extraordinary level of expenditure on health care, the U.S. ranks in last place among 19 industrialized nations in terms of quality of care (see my posting ‘F’ is for Failure on 7/22/08). Unfortunately, neither Obama nor McCain has put forward a plan that is likely to solve our problems.
What would fix the situation would be to expand Medicare to cover all Americans, as proposed by Senator Edward Kennedy (see “Kennedy and Dingell Fight for Medicare for All,” http:/kennedy.senate.gov/newsroom/press). This approach has the potential to insure everyone while reducing costs and enhancing quality. And it would finally bring the U.S. in line with all other developed nations: countries such as Australia, England, France, Germany, and Canada all provide some form of mandatory universal health insurance for their citizens. They also all have lower infant mortality rates, lower rates of preventable death in people under 75—at a per capita cost half that of the U.S.
When Congress created the Medicare program in 1965, it acted in the belief that older people were somehow exceptional—they were sicker, they lived on fixed incomes, and they did not have employer-based health insurance. While some physicians, politicians, and economists hoped that Medicare would be the wedge opening the door to health insurance for all, Medicare was passed precisely because it did not promise mandatory health insurance (see the chapter, “Medicare for the Middle Class” in David Rothman’s insightful book, Beginnings Count: The Technological Imperative in American Health Care, NY: Oxford University Press, 1997). Single payer insurance was touted then and continues to be seen today as “socialized medicine,” but the expansion of Medicare does not imply a government-run system. While Medicare is publicly financed, it is a private health care system administered by private intermediaries that gives patients an extensive array of choices of physicians and hospitals.
Ironically, there is one part of the health care system in which government is actually in the business of providing medical care, and it’s a part of U.S. health care that McCain vigorously supports. That’s the Veterans Health Administration. The VHA operates the largest integrated health care system in America, which includes hospitals, outpatient clinics, nursing homes, and rehabilitation facilities. A uniform medical benefits package is available to all veterans and covers primary care, outpatient and inpatient services, and prescription drugs. Additional benefits, such as nursing home care and dental care, are available to some vets, depending on their “priority level.” The VA system is known for its pioneering work in managing chronic conditions, for its comprehensive electronic medical record, and for other quality improvement measures.
No one is recommending expansion of the VA system—it’s just not a politically tenable solution. But expanding Medicare, while clearly a difficult sell, would make a great deal of sense. Medicare is far more efficient than private health insurance plans: Medicare’s overhead is about 2%, whereas private insurers take an average of 13% of premium dollars for overhead and profit, with large managed care plans taking as much as 30% (see David Himmelstein and Steffie Woollhandler, “Why the US Needs a Single Payer Health System,” www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_systemphp). Not only would it be simple and efficient, but paradoxically, the existing Medicare program would do a better job serving the non-elderly than it does with those it currently covers.
Medicare was established to cover acute, time-limited illness. By far the largest component of Medicare expenses continues to be for hospitalization. Of the $402 billion spent by Medicare in 2006, 29% went to inpatient care, compared to 15% for physicians, 12% for outpatient drugs, and 3% for home health care (see the MedPac report, www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf). Medicare was designed to address a disease such as pneumonia in which the patient rapidly develops a significant illness, is hospitalized for a week or so (covered after a deductible), and is then discharged home to complete his treatment by taking a few days’ worth of oral antibiotics. By contrast, the typical Medicare patient today has multiple chronic conditions, which are best cared for using a model of chronic disease management: 75% of the elderly have at least one chronic disease and 50% have two or more chronic illnesses. While the Medicare Modernization Act of 2003 addressed some of the needs of today’s older patients, principally by offering a prescription drug plan, the program is still heavily weighted toward the treatment of acute illness. Its incentives, for example, promote hospital care rather than treatment in the home or the nursing home (see chapter 4, “The Trouble with Medicare,” in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, Cambridge, MA: Harvard University Press, 2006). But this focus on acute care is precisely what most younger, healthier patients need. Some middle aged individuals have congestive heart failure or chronic obstructive pulmonary disease and similarly, some children suffer from chronic conditions such as asthma or diabetes; the majority do not.
The most rational approach to American health care reform is to offer Medicare to everyone, perhaps the existing plan for younger Americans and a modified version for the elderly and the disabled. The U.S. should guarantee health insurance by providing a basic insurance plan (Medicare) paid for out of tax revenues. Patients could choose to exchange their Medicare benefit for a private plan or to supplement their basic plan with a more comprehensive plan for which they would pay directly. A new, expanded Medicare program would be ideally positioned to address the other pressing issue that both Congress and the presidential candidates have largely ignored—the soaring costs of care (see my blog posting, “Going for Broke” on 12/28/2007) by controlling what medical interventions it is willing to cover and how much it will pay for them.
What would fix the situation would be to expand Medicare to cover all Americans, as proposed by Senator Edward Kennedy (see “Kennedy and Dingell Fight for Medicare for All,” http:/kennedy.senate.gov/newsroom/press). This approach has the potential to insure everyone while reducing costs and enhancing quality. And it would finally bring the U.S. in line with all other developed nations: countries such as Australia, England, France, Germany, and Canada all provide some form of mandatory universal health insurance for their citizens. They also all have lower infant mortality rates, lower rates of preventable death in people under 75—at a per capita cost half that of the U.S.
When Congress created the Medicare program in 1965, it acted in the belief that older people were somehow exceptional—they were sicker, they lived on fixed incomes, and they did not have employer-based health insurance. While some physicians, politicians, and economists hoped that Medicare would be the wedge opening the door to health insurance for all, Medicare was passed precisely because it did not promise mandatory health insurance (see the chapter, “Medicare for the Middle Class” in David Rothman’s insightful book, Beginnings Count: The Technological Imperative in American Health Care, NY: Oxford University Press, 1997). Single payer insurance was touted then and continues to be seen today as “socialized medicine,” but the expansion of Medicare does not imply a government-run system. While Medicare is publicly financed, it is a private health care system administered by private intermediaries that gives patients an extensive array of choices of physicians and hospitals.
Ironically, there is one part of the health care system in which government is actually in the business of providing medical care, and it’s a part of U.S. health care that McCain vigorously supports. That’s the Veterans Health Administration. The VHA operates the largest integrated health care system in America, which includes hospitals, outpatient clinics, nursing homes, and rehabilitation facilities. A uniform medical benefits package is available to all veterans and covers primary care, outpatient and inpatient services, and prescription drugs. Additional benefits, such as nursing home care and dental care, are available to some vets, depending on their “priority level.” The VA system is known for its pioneering work in managing chronic conditions, for its comprehensive electronic medical record, and for other quality improvement measures.
No one is recommending expansion of the VA system—it’s just not a politically tenable solution. But expanding Medicare, while clearly a difficult sell, would make a great deal of sense. Medicare is far more efficient than private health insurance plans: Medicare’s overhead is about 2%, whereas private insurers take an average of 13% of premium dollars for overhead and profit, with large managed care plans taking as much as 30% (see David Himmelstein and Steffie Woollhandler, “Why the US Needs a Single Payer Health System,” www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_systemphp). Not only would it be simple and efficient, but paradoxically, the existing Medicare program would do a better job serving the non-elderly than it does with those it currently covers.
Medicare was established to cover acute, time-limited illness. By far the largest component of Medicare expenses continues to be for hospitalization. Of the $402 billion spent by Medicare in 2006, 29% went to inpatient care, compared to 15% for physicians, 12% for outpatient drugs, and 3% for home health care (see the MedPac report, www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf). Medicare was designed to address a disease such as pneumonia in which the patient rapidly develops a significant illness, is hospitalized for a week or so (covered after a deductible), and is then discharged home to complete his treatment by taking a few days’ worth of oral antibiotics. By contrast, the typical Medicare patient today has multiple chronic conditions, which are best cared for using a model of chronic disease management: 75% of the elderly have at least one chronic disease and 50% have two or more chronic illnesses. While the Medicare Modernization Act of 2003 addressed some of the needs of today’s older patients, principally by offering a prescription drug plan, the program is still heavily weighted toward the treatment of acute illness. Its incentives, for example, promote hospital care rather than treatment in the home or the nursing home (see chapter 4, “The Trouble with Medicare,” in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, Cambridge, MA: Harvard University Press, 2006). But this focus on acute care is precisely what most younger, healthier patients need. Some middle aged individuals have congestive heart failure or chronic obstructive pulmonary disease and similarly, some children suffer from chronic conditions such as asthma or diabetes; the majority do not.
The most rational approach to American health care reform is to offer Medicare to everyone, perhaps the existing plan for younger Americans and a modified version for the elderly and the disabled. The U.S. should guarantee health insurance by providing a basic insurance plan (Medicare) paid for out of tax revenues. Patients could choose to exchange their Medicare benefit for a private plan or to supplement their basic plan with a more comprehensive plan for which they would pay directly. A new, expanded Medicare program would be ideally positioned to address the other pressing issue that both Congress and the presidential candidates have largely ignored—the soaring costs of care (see my blog posting, “Going for Broke” on 12/28/2007) by controlling what medical interventions it is willing to cover and how much it will pay for them.
September 04, 2008
Massachusetts Health Care Reform--Act 2
Why isn’t everyone talking about the new Massachusetts Health Care Reform law? Is it that the Governor signed the legislation into law during the dog days of summer? Is it that the act, which introduces cost containment measures and quality improvement measures, isn’t a single issue bill like the first health care reform law, which expanded coverage to almost all Massachusetts residents?
The “Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care,” (S2863) is an important piece of legislation which should be getting a great deal more local and national attention than it has. But for all its virtues, it also has some major flaws—and it won’t make much of a dent in the skyrocketing cost of health care.
The law calls for two new programs: a pharmacy drug detailing program and a health care workforce center. The detailing program is modeled on an intervention proposed by Harvard researchers Jerry Avorn and Stephen Soumerai 25 years ago: they wondered whether the same kind of clever strategies used by drug companies to promote their wares could be used to provide physicians with accurate information about the safety and cost-effectiveness of drugs by using trained pharmacists as “un-sales reps.” Their 4-state randomized trial found that academic detail men were accepted by the overwhelming majority of physicians—and that the program saved $2 for every $1 in costs (Jerome Avorn and Stephen Soumerai, “Improving Drug-Therapy Decisions Through Educational Outreach. A Randomized Controlled Trial of Academically Based ‘Detailing,” New England Journal of Medicine 1983; 308: 1457-63). With the new health reform law, the Massachusetts Department of Public Health has been charged with arranging face to face visits to “inform prescribers about drug marketing intended to circumvent competition from generics.” How effective this strategy will be in 2008 is unclear, now that drug companies are not only targeting physicians but are also pouring money into direct-to-consumer advertising.
The law also calls for the establishment of a Health Care Workforce Center whose main purpose is to increase the number of primary care physicians in the state. Specifically, the program will set up a loan repayment program for doctors who go into primary care. A related part of the bill requires the University of Massachusetts Medical School to increase its enrollment, to add residency slots for primary care, and to waive tuition for applicants who agree to practice in under-served areas. Taking steps to enhance primary care is laudable, but as demonstrated in the recent Institute of Medicine Report, Retooling for An Aging America: Building the Health Care Workforce (see my blog entry, “the Boomers are Coming, the Boomers are Coming,” from May 9, 2008), what we desperately need is not just primary care physicians and nurses, but also a diverse array of individuals equipped to care for our growing geriatric population.
One of the few provisions of the new law that did garner quite a bit of attention is the “gift ban,” which requires health care providers to publicly report any gifts they receive from pharmaceutical or medical device manufacturing companies and which bans certain kinds of gifts altogether. Drug companies protested loudly, but as Dr. Jerome Kassirer argued in his book, On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Life ( NY: Oxford University Press, 2005), the standards promulgated under the law constitute are not radical or draconian: they simply represent a basic, ethically justifiable set of guidelines for corporate and professional conduct.
Massachusetts Health Reform, Act 2 contains a hodgepodge of other provisions designed to improve quality and efficiency of care. It requires hospitals to develop rapid response teams for “deteriorating patients,” a measure that could lead to the installation of “panic buttons” in every patient room—not necessarily a good idea. The concerns of families need to be respected and addressed, but surely it should be professional judgment and not anxious families that dictate the summoning of an emergency response team. The act will require hospitals to implement computerized physician order entry systems by 2012 and electronic medical records by 2005—which is probably a good thing, but not as well-supported by hard evidence as I would like. As Drs. Pamela Hartzband and Jerome Groopman argue in their essay, “Off the Record: Avoiding the Pitfalls of Going Electronic” (New England Journal of Medicine 2008; 358: 1656-8), electronic medical records can “constrain creative clinical thinking” and computers can “become a barrier between patients and physicians.” And the act calls for new initiatives in end of life care and in home care—laudable but at this point vague and without substance.
All these components of the new law focus on improving the efficiency and quality of medical care. The only measure that seeks to control costs by actually changing the way we do things in medicine, not merely by ensuring that we do what we have been doing but with greater efficiency, is the requirement that physicians wishing to build ambulatory surgery centers apply for and receive a “Determination of Need” certificate. The engine that drives costs is technology and right now hospitals and medical groups can build new outpatient centers for doing procedures with essentially no restrictions. And in medicine, if you build a new machine, it will be used, regardless of whether one more scanner or surgical suite actually improves the population’s health. Dr. John Wennberg of Dartmouth, who has devoted his career to the exploration of regional variations in American health care, has found repeatedly that the number of elective procedures in various parts of the country depends not on need but on the capacity to perform those procedures (see for example John Wennberg and Alan Gittlesohn, “Small Area Variation in Health Care Delivery,” Science 1973; 182: 1102-8). Controlling the untrammeled growth of technology by evaluating the need for the centers that house that technology has the potential to have an enormous effect on the future cost of medical care. The caveat is that the legislation needs to have teeth, and it is unclear how the requirement that ambulatory surgical centers demonstrate “need” will play out: how is “need” to be defined and measured? Will the cost of the center be a consideration or if there is “need” (read “demand”), is any cost acceptable? Unfortunately, current Massachusetts Determination of Need regulations for hospitals include no such considerations.
Massachusetts Health Care Reform—Act 2 is an important step in the right direction. But if we want to truly change the way health care is delivered and provide high quality care at an affordable cost, we better start working on Massachusetts Health Care Reform—Act 3.
The “Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care,” (S2863) is an important piece of legislation which should be getting a great deal more local and national attention than it has. But for all its virtues, it also has some major flaws—and it won’t make much of a dent in the skyrocketing cost of health care.
The law calls for two new programs: a pharmacy drug detailing program and a health care workforce center. The detailing program is modeled on an intervention proposed by Harvard researchers Jerry Avorn and Stephen Soumerai 25 years ago: they wondered whether the same kind of clever strategies used by drug companies to promote their wares could be used to provide physicians with accurate information about the safety and cost-effectiveness of drugs by using trained pharmacists as “un-sales reps.” Their 4-state randomized trial found that academic detail men were accepted by the overwhelming majority of physicians—and that the program saved $2 for every $1 in costs (Jerome Avorn and Stephen Soumerai, “Improving Drug-Therapy Decisions Through Educational Outreach. A Randomized Controlled Trial of Academically Based ‘Detailing,” New England Journal of Medicine 1983; 308: 1457-63). With the new health reform law, the Massachusetts Department of Public Health has been charged with arranging face to face visits to “inform prescribers about drug marketing intended to circumvent competition from generics.” How effective this strategy will be in 2008 is unclear, now that drug companies are not only targeting physicians but are also pouring money into direct-to-consumer advertising.
The law also calls for the establishment of a Health Care Workforce Center whose main purpose is to increase the number of primary care physicians in the state. Specifically, the program will set up a loan repayment program for doctors who go into primary care. A related part of the bill requires the University of Massachusetts Medical School to increase its enrollment, to add residency slots for primary care, and to waive tuition for applicants who agree to practice in under-served areas. Taking steps to enhance primary care is laudable, but as demonstrated in the recent Institute of Medicine Report, Retooling for An Aging America: Building the Health Care Workforce (see my blog entry, “the Boomers are Coming, the Boomers are Coming,” from May 9, 2008), what we desperately need is not just primary care physicians and nurses, but also a diverse array of individuals equipped to care for our growing geriatric population.
One of the few provisions of the new law that did garner quite a bit of attention is the “gift ban,” which requires health care providers to publicly report any gifts they receive from pharmaceutical or medical device manufacturing companies and which bans certain kinds of gifts altogether. Drug companies protested loudly, but as Dr. Jerome Kassirer argued in his book, On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Life ( NY: Oxford University Press, 2005), the standards promulgated under the law constitute are not radical or draconian: they simply represent a basic, ethically justifiable set of guidelines for corporate and professional conduct.
Massachusetts Health Reform, Act 2 contains a hodgepodge of other provisions designed to improve quality and efficiency of care. It requires hospitals to develop rapid response teams for “deteriorating patients,” a measure that could lead to the installation of “panic buttons” in every patient room—not necessarily a good idea. The concerns of families need to be respected and addressed, but surely it should be professional judgment and not anxious families that dictate the summoning of an emergency response team. The act will require hospitals to implement computerized physician order entry systems by 2012 and electronic medical records by 2005—which is probably a good thing, but not as well-supported by hard evidence as I would like. As Drs. Pamela Hartzband and Jerome Groopman argue in their essay, “Off the Record: Avoiding the Pitfalls of Going Electronic” (New England Journal of Medicine 2008; 358: 1656-8), electronic medical records can “constrain creative clinical thinking” and computers can “become a barrier between patients and physicians.” And the act calls for new initiatives in end of life care and in home care—laudable but at this point vague and without substance.
All these components of the new law focus on improving the efficiency and quality of medical care. The only measure that seeks to control costs by actually changing the way we do things in medicine, not merely by ensuring that we do what we have been doing but with greater efficiency, is the requirement that physicians wishing to build ambulatory surgery centers apply for and receive a “Determination of Need” certificate. The engine that drives costs is technology and right now hospitals and medical groups can build new outpatient centers for doing procedures with essentially no restrictions. And in medicine, if you build a new machine, it will be used, regardless of whether one more scanner or surgical suite actually improves the population’s health. Dr. John Wennberg of Dartmouth, who has devoted his career to the exploration of regional variations in American health care, has found repeatedly that the number of elective procedures in various parts of the country depends not on need but on the capacity to perform those procedures (see for example John Wennberg and Alan Gittlesohn, “Small Area Variation in Health Care Delivery,” Science 1973; 182: 1102-8). Controlling the untrammeled growth of technology by evaluating the need for the centers that house that technology has the potential to have an enormous effect on the future cost of medical care. The caveat is that the legislation needs to have teeth, and it is unclear how the requirement that ambulatory surgical centers demonstrate “need” will play out: how is “need” to be defined and measured? Will the cost of the center be a consideration or if there is “need” (read “demand”), is any cost acceptable? Unfortunately, current Massachusetts Determination of Need regulations for hospitals include no such considerations.
Massachusetts Health Care Reform—Act 2 is an important step in the right direction. But if we want to truly change the way health care is delivered and provide high quality care at an affordable cost, we better start working on Massachusetts Health Care Reform—Act 3.
July 22, 2008
"F" is for Failure
Federal Reserve president Ben Bernanke stood in front of the Senate Finance Committee a month ago and delivered some bad news: the cost of health care is spiraling out of control. And costs will continue to “rise relentlessly,” he said, unless Congress substantially overhauls the health care system (Robert Pear, “Fed Chief Addresses Health Care and Its Cost,” New York Times, June 17, 2008), which it has shown no inclination to do.
At the same time, Bernanke pointed to two other problems with U.S. health care: access and quality. It is these two areas that get most of the attention from lawmakers. Just how poorly the U.S. is doing in these two domains was emphasized yet again in a report released last week by the Commonwealth Fund. The results of the “National Scorecard on U.S. Health System Performance, 2008” are shockingly poor. Lumping all 37 indicators of quality devised by the Fund into one measure, the U.S. scored a 65 out of 100 (down from 67 in 2006). (“Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008,” available at www.commonwealthfund.org.) I'd call that a failing grade.
In terms of access, the average score was 58, with 75 million working age adults—42% of the population—either uninsured or underinsured, up from 61 million (35%) in 2003. The direct consequence of lack of coverage is that the U.S. is now in last place among 19 industrialized nations in terms of deaths that could have been prevented with timely and effective care. In terms of quality, only 41% of adults with hypertension were adequately treated—and only 21% of those with hypertension who had no health insurance.
What continues to get relatively little attention is Bernanke’s first point, the high cost of health care. The Commonwealth report notes that the U.S. spends twice as much per capita as other major industrialized countries on health care, though it fares worse on virtually all outcome measures. Even within the U.S., higher levels of spending often translate paradoxically into lower quality care: among Medicare patients treated for heart attacks, hip fractures, or colorectal cancer, the regions of the country with the lowest mortality rates also had lower total costs.
The presidential candidates say laughably little about health care costs. A side-by-side comparison of their statements on health care reveals only a few points about cost. The democratic and republican proposals are limited, unimaginative—and remarkably similar (see the analysis by the Henry J. Kaiser Family Foundation, “2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary,” at www.health08.org.)
Both Obama and McCain advocate malpractice reform and greater competition among insurance plans. Both candidates allude to the high cost of prescription drugs and favor encouraging the use of generics, and both talk in general terms about the need for increased attention to preventive care and the treatment of chronic conditions. These are all important issues but they will not solve the problem of the high cost of care. Obama specifically advocates investing in electronic medical records and health information technology (to improve efficiency) and McCain wants to give consumers more information about treatment options (in the naïve hope that they will choose less expensive care). But neither talks about the real culprit—the excessive use of high cost technology, even when it is of little or no benefit (see for example Kenneth Thorpe et al, “Which Medical Conditions Account for the Rise in Health Care Spending? Health Affairs, August 25, 2004).
The New York Times, by contrast, is finally beginning to understand the role of technology in driving up the cost of medical care. Over the last month, the Times has featured an article about the use of Avastin (Bevacizumab), a form of chemotherapy costing as much as $100,000/patient/year (Gina Kolata and Andrew Pollack, “Costly Cancer Drug Offers Hope, But Also a Dilemma,” New York Times, July 6, 2008) and another article about the use of an implantable defibrillator in a 99 year old woman (Anemona Hartcollis, “Rise Seen in Medical Effort to Treat the Very Old,” New York Times, July 18, 2008). But both articles wistfully conclude that we are facing a heart-rending dilemma, what the journalists view as an insoluble conflict between the legitimate wish of sick patients to get better and the societal need to constrain costs.
In fact, there is a perfectly reasonable solution: physicians should be restricted in their use of expensive technology to situations in which it has been demonstrated to be beneficial; and Medicare should set reimbursement for high tech interventions at a level reflecting their cost-effectiveness. In the case of Avastin, for example, it may be rational to prescribe the drug for those forms of cancer for which it has been shown to be beneficial, even when the benefit is the prolongation of life by only several months, but not for other forms of cancer for which efficacy is entirely speculative. Moreover, Medicare should set reimbursement at a rate commensurate with benefit, as is done in Australia. When this has been done in the U.S., as when the Centers for Medicare and Medicaid set the reimbursement rate for the left ventricular assist device (an invasive, expensive, but occasionally modestly effective means of treating advanced heart failure) well below the manufacturer’s charges, the rate of use stayed very low. In the case of the defibrillator/pacemaker, which in the Times example was inserted to prevent symptoms of dizziness and weakness, it would have sufficed to implant a pacemaker (cost $11,712 in FY 2005). There is no need to deprive a patient of an effective treatment that will ameliorate symptoms simply to control costs. The problem is that the patient was given a combination defibrillator/pacemaker, a sophisticated device intended to prevent sudden death as well as to counteract a low heart rate—more than doubling the cost ($28,442 in FY 2005) without conferring any advantage in terms of quality of life. The total annual spending on implantable defibrillators in the U.S. is over $1 billion/year, some of which is clearly beneficial, but some of which is not.
Improving access and quality, while tremendously important, will just exacerbate the cost issue if we tackle them without simultaneously addressing cost. It is time for Congress, the Administration, the presidential candidates, and the American people to stop burying their heads in the sand. U.S. health care just got a failing grade: if you sent your child to an expensive private school and he came home with F’s and D’s on his report card, would you blithely and unquestioningly continue to fork out exorbitant tuition payments because the headmaster assured you the school was the best in the world?
At the same time, Bernanke pointed to two other problems with U.S. health care: access and quality. It is these two areas that get most of the attention from lawmakers. Just how poorly the U.S. is doing in these two domains was emphasized yet again in a report released last week by the Commonwealth Fund. The results of the “National Scorecard on U.S. Health System Performance, 2008” are shockingly poor. Lumping all 37 indicators of quality devised by the Fund into one measure, the U.S. scored a 65 out of 100 (down from 67 in 2006). (“Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008,” available at www.commonwealthfund.org.) I'd call that a failing grade.
In terms of access, the average score was 58, with 75 million working age adults—42% of the population—either uninsured or underinsured, up from 61 million (35%) in 2003. The direct consequence of lack of coverage is that the U.S. is now in last place among 19 industrialized nations in terms of deaths that could have been prevented with timely and effective care. In terms of quality, only 41% of adults with hypertension were adequately treated—and only 21% of those with hypertension who had no health insurance.
What continues to get relatively little attention is Bernanke’s first point, the high cost of health care. The Commonwealth report notes that the U.S. spends twice as much per capita as other major industrialized countries on health care, though it fares worse on virtually all outcome measures. Even within the U.S., higher levels of spending often translate paradoxically into lower quality care: among Medicare patients treated for heart attacks, hip fractures, or colorectal cancer, the regions of the country with the lowest mortality rates also had lower total costs.
The presidential candidates say laughably little about health care costs. A side-by-side comparison of their statements on health care reveals only a few points about cost. The democratic and republican proposals are limited, unimaginative—and remarkably similar (see the analysis by the Henry J. Kaiser Family Foundation, “2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary,” at www.health08.org.)
Both Obama and McCain advocate malpractice reform and greater competition among insurance plans. Both candidates allude to the high cost of prescription drugs and favor encouraging the use of generics, and both talk in general terms about the need for increased attention to preventive care and the treatment of chronic conditions. These are all important issues but they will not solve the problem of the high cost of care. Obama specifically advocates investing in electronic medical records and health information technology (to improve efficiency) and McCain wants to give consumers more information about treatment options (in the naïve hope that they will choose less expensive care). But neither talks about the real culprit—the excessive use of high cost technology, even when it is of little or no benefit (see for example Kenneth Thorpe et al, “Which Medical Conditions Account for the Rise in Health Care Spending? Health Affairs, August 25, 2004).
The New York Times, by contrast, is finally beginning to understand the role of technology in driving up the cost of medical care. Over the last month, the Times has featured an article about the use of Avastin (Bevacizumab), a form of chemotherapy costing as much as $100,000/patient/year (Gina Kolata and Andrew Pollack, “Costly Cancer Drug Offers Hope, But Also a Dilemma,” New York Times, July 6, 2008) and another article about the use of an implantable defibrillator in a 99 year old woman (Anemona Hartcollis, “Rise Seen in Medical Effort to Treat the Very Old,” New York Times, July 18, 2008). But both articles wistfully conclude that we are facing a heart-rending dilemma, what the journalists view as an insoluble conflict between the legitimate wish of sick patients to get better and the societal need to constrain costs.
In fact, there is a perfectly reasonable solution: physicians should be restricted in their use of expensive technology to situations in which it has been demonstrated to be beneficial; and Medicare should set reimbursement for high tech interventions at a level reflecting their cost-effectiveness. In the case of Avastin, for example, it may be rational to prescribe the drug for those forms of cancer for which it has been shown to be beneficial, even when the benefit is the prolongation of life by only several months, but not for other forms of cancer for which efficacy is entirely speculative. Moreover, Medicare should set reimbursement at a rate commensurate with benefit, as is done in Australia. When this has been done in the U.S., as when the Centers for Medicare and Medicaid set the reimbursement rate for the left ventricular assist device (an invasive, expensive, but occasionally modestly effective means of treating advanced heart failure) well below the manufacturer’s charges, the rate of use stayed very low. In the case of the defibrillator/pacemaker, which in the Times example was inserted to prevent symptoms of dizziness and weakness, it would have sufficed to implant a pacemaker (cost $11,712 in FY 2005). There is no need to deprive a patient of an effective treatment that will ameliorate symptoms simply to control costs. The problem is that the patient was given a combination defibrillator/pacemaker, a sophisticated device intended to prevent sudden death as well as to counteract a low heart rate—more than doubling the cost ($28,442 in FY 2005) without conferring any advantage in terms of quality of life. The total annual spending on implantable defibrillators in the U.S. is over $1 billion/year, some of which is clearly beneficial, but some of which is not.
Improving access and quality, while tremendously important, will just exacerbate the cost issue if we tackle them without simultaneously addressing cost. It is time for Congress, the Administration, the presidential candidates, and the American people to stop burying their heads in the sand. U.S. health care just got a failing grade: if you sent your child to an expensive private school and he came home with F’s and D’s on his report card, would you blithely and unquestioningly continue to fork out exorbitant tuition payments because the headmaster assured you the school was the best in the world?
May 09, 2008
The Boomers are Coming, the Boomers are Coming
I often wonder just how many billions of dollars Americans spend every year on producing reports. Think tanks, government agencies, and academic departments, not to mention corporations, are forever releasing reports. Most of them are filed away, largely unread, certainly unheeded. Every so often a report actually has a major impact—on policy, on behavior, or on public understanding. The Surgeon General’s Report, The Health Consequences of Smoking, first released in 1971, led to a campaign to promote health by quitting smoking. As a result, per capita cigarette consumption is down in the U.S., as are the incidence of lung cancer and the death rate from heart disease, the primary diseases attributable to smoking.
Several weeks ago, the Institute of Medicine released a new report, Retooling for an Aging America: Building the Health Care Workforce. With luck, this will be one of those reports that triggers a response, but given its low key presentation, unsexy topic, and unpopular message, I fear it will be ignored.
Written in the non-inflammatory, academic style of the IOM, Retooling quietly argues that if we are to provide high quality care for the baby boomers in their old age, we need to geriatricize both health care professionals and personal caregivers. In an equally subdued voice, the report’s writers also conclude that we need to overhaul our entire approach to medical care. They’re right. I hope someone is listening.
The first of the 78 million baby boomers will turn age 65 in 2011. When the last baby boomer turns 65 in 2030, “older adults” will make up 20% of the population, up from the current 12%. Unless we find a cure for Alzheimer’s disease in the immediate future, which is extremely unlikely, and unless we can prevent or cure osteoarthritis, diabetes, and vascular disease, the boomers will develop all these problems in phenomenal numbers. Although they will be healthier than their counterparts a decade ago, many will eventually develop multiple medical problems and will need both health care and personal care if they are to hope to have a reasonable quality of life.
What the new IOM report tells us is that we do not have enough physicians, nurses, social workers, and physical therapists with special expertise in taking care of older adults to handle this enormous wave. We do not have enough home health aides and other personal care attendants to assist older people with basic “activities of daily living” such as dressing, bathing, and eating, given that we can expect that in 2030, over 9 million people will need this kind of help (that’s based on another important report, this one by Robert Friedland, writing for the Georgetown University Long-Term Care Financing Project in 2004: Caregivers and Long-term Care Needs in the 21st Century: Will Public Policy Meet the Challenge?) And informal caregivers—the family members and friends who provide the bulk of the care to frail older Americans—are already overwhelmed physically, emotionally, and financially by their responsibilities.
Retooling for an Aging America tells us very clearly what steps we need to take to begin to fix this problem. It uses the bland language of “increasing recruitment and retention” of personnel, but quickly gets to the central issue: few people are going to jump at the chance to take care of the elderly, whether they be physicians, nurses, or home health aides, unless they receive appropriate recognition, social and financial, for their work. That means compensation needs to go up—a lot. Currently, geriatricians earn on average less than the primary care physicians who see a more diverse population of adults, who in turn earn far less than gastroenterologists or cardiologists. Taking care of frail older people takes extra time, it requires coordination of multiple services, and it necessitates discussions with family members, all of which are reimbursed poorly or not at all. The suggestion that public and private payers provide financial incentives to increase the number of geriatric specialists in all health professions is key. So too is the recommendation that professionals with special expertise in geriatrics receive enhanced reimbursement, though given budgetary constraints, it seems more plausible that physician incomes will need to be redistributed than that payment to those on the bottom end of the totem pole will rise. Similarly, aides who provide hands on care for older people are among the most poorly paid workers in our society, they have the highest rates of on the job injury, and they have few opportunities for advancement. Without better wages, adequate fringe benefits, and an attractive career ladder, it’s hard to imagine the situation will change. The recommendation that state Medicaid programs increase pay and fringe benefits for direct care workers and establish wage floors is an important first step. It does not, however, go nearly far enough, and is not as sweeping as another report that is probably already collecting dust—the study prepared by the much maligned President’s Council on Bioethics in 2005, Taking Care: Ethical Caregiving in Our Aging Society.
It is in the arena of “redesigning models of care” that the report is at its most radical. It begins with the tepid comment that “care that is currently provided to older adults often falls short of acceptable levels of quality.” Then it heats up a bit, acknowledging that the vision of health care services it proposes represents “a major departure from the current system” that will require changes in the ways services are “organized, financed, and delivered.” The report recommends three fundamental changes: care must be comprehensive, it must be efficient, and it must rely on the active participation of older adults.
By comprehensive care, the report means that our current fragmented system has to go. Right now, Medicare doesn’t have an incentive to provide home care because it would be cheaper for patients to go into a nursing home (paid by Medicaid or private funds) than it is for patients to stay at home and have a visiting nurse and physical therapist (paid by Medicare). Today, physician practices shy away from using multidisciplinary teams, the backbone of good geriatric care, because this kind of care is inadequately compensated. Comprehensive care means including both acute care and long term care (at home, in assisted living, and in nursing homes--currently the stepchild of the American health care system) under one umbrella.
By efficient care, the report means that we need to create seamless transitions between the sites where older people receive health care such as the office, the hospital, the skilled nursing facility, and the home setting. This will require better systems of communication and widespread adoption of a single electronic medical record.
By active participation, the report implies that effective management of chronic diseases—and almost a quarter of Medicare beneficiaries have at least 4 chronic diseases—requires self-management. Given that many older patients cannot, by themselves, engage in self-management, a more realistic recommendation would be the involvement of families in all aspects of health care.
So far, Retooling has been written up in the Wall Street Journal and the LA Times but not, as best I can determine, in the New York Times or the Washington Post. This mild-mannered report, which makes reasonable suggestions but says little about how its recommendations might be implemented (or paid for) could well be destined for the dustbin. Let’s hope not. We really need to do something to prepare for the baby boomers, and we need to start now. Write your congressman. Whisper in the ear of the presidential candidates, who have said little or nothing about long term care. Act now.
Several weeks ago, the Institute of Medicine released a new report, Retooling for an Aging America: Building the Health Care Workforce. With luck, this will be one of those reports that triggers a response, but given its low key presentation, unsexy topic, and unpopular message, I fear it will be ignored.
Written in the non-inflammatory, academic style of the IOM, Retooling quietly argues that if we are to provide high quality care for the baby boomers in their old age, we need to geriatricize both health care professionals and personal caregivers. In an equally subdued voice, the report’s writers also conclude that we need to overhaul our entire approach to medical care. They’re right. I hope someone is listening.
The first of the 78 million baby boomers will turn age 65 in 2011. When the last baby boomer turns 65 in 2030, “older adults” will make up 20% of the population, up from the current 12%. Unless we find a cure for Alzheimer’s disease in the immediate future, which is extremely unlikely, and unless we can prevent or cure osteoarthritis, diabetes, and vascular disease, the boomers will develop all these problems in phenomenal numbers. Although they will be healthier than their counterparts a decade ago, many will eventually develop multiple medical problems and will need both health care and personal care if they are to hope to have a reasonable quality of life.
What the new IOM report tells us is that we do not have enough physicians, nurses, social workers, and physical therapists with special expertise in taking care of older adults to handle this enormous wave. We do not have enough home health aides and other personal care attendants to assist older people with basic “activities of daily living” such as dressing, bathing, and eating, given that we can expect that in 2030, over 9 million people will need this kind of help (that’s based on another important report, this one by Robert Friedland, writing for the Georgetown University Long-Term Care Financing Project in 2004: Caregivers and Long-term Care Needs in the 21st Century: Will Public Policy Meet the Challenge?) And informal caregivers—the family members and friends who provide the bulk of the care to frail older Americans—are already overwhelmed physically, emotionally, and financially by their responsibilities.
Retooling for an Aging America tells us very clearly what steps we need to take to begin to fix this problem. It uses the bland language of “increasing recruitment and retention” of personnel, but quickly gets to the central issue: few people are going to jump at the chance to take care of the elderly, whether they be physicians, nurses, or home health aides, unless they receive appropriate recognition, social and financial, for their work. That means compensation needs to go up—a lot. Currently, geriatricians earn on average less than the primary care physicians who see a more diverse population of adults, who in turn earn far less than gastroenterologists or cardiologists. Taking care of frail older people takes extra time, it requires coordination of multiple services, and it necessitates discussions with family members, all of which are reimbursed poorly or not at all. The suggestion that public and private payers provide financial incentives to increase the number of geriatric specialists in all health professions is key. So too is the recommendation that professionals with special expertise in geriatrics receive enhanced reimbursement, though given budgetary constraints, it seems more plausible that physician incomes will need to be redistributed than that payment to those on the bottom end of the totem pole will rise. Similarly, aides who provide hands on care for older people are among the most poorly paid workers in our society, they have the highest rates of on the job injury, and they have few opportunities for advancement. Without better wages, adequate fringe benefits, and an attractive career ladder, it’s hard to imagine the situation will change. The recommendation that state Medicaid programs increase pay and fringe benefits for direct care workers and establish wage floors is an important first step. It does not, however, go nearly far enough, and is not as sweeping as another report that is probably already collecting dust—the study prepared by the much maligned President’s Council on Bioethics in 2005, Taking Care: Ethical Caregiving in Our Aging Society.
It is in the arena of “redesigning models of care” that the report is at its most radical. It begins with the tepid comment that “care that is currently provided to older adults often falls short of acceptable levels of quality.” Then it heats up a bit, acknowledging that the vision of health care services it proposes represents “a major departure from the current system” that will require changes in the ways services are “organized, financed, and delivered.” The report recommends three fundamental changes: care must be comprehensive, it must be efficient, and it must rely on the active participation of older adults.
By comprehensive care, the report means that our current fragmented system has to go. Right now, Medicare doesn’t have an incentive to provide home care because it would be cheaper for patients to go into a nursing home (paid by Medicaid or private funds) than it is for patients to stay at home and have a visiting nurse and physical therapist (paid by Medicare). Today, physician practices shy away from using multidisciplinary teams, the backbone of good geriatric care, because this kind of care is inadequately compensated. Comprehensive care means including both acute care and long term care (at home, in assisted living, and in nursing homes--currently the stepchild of the American health care system) under one umbrella.
By efficient care, the report means that we need to create seamless transitions between the sites where older people receive health care such as the office, the hospital, the skilled nursing facility, and the home setting. This will require better systems of communication and widespread adoption of a single electronic medical record.
By active participation, the report implies that effective management of chronic diseases—and almost a quarter of Medicare beneficiaries have at least 4 chronic diseases—requires self-management. Given that many older patients cannot, by themselves, engage in self-management, a more realistic recommendation would be the involvement of families in all aspects of health care.
So far, Retooling has been written up in the Wall Street Journal and the LA Times but not, as best I can determine, in the New York Times or the Washington Post. This mild-mannered report, which makes reasonable suggestions but says little about how its recommendations might be implemented (or paid for) could well be destined for the dustbin. Let’s hope not. We really need to do something to prepare for the baby boomers, and we need to start now. Write your congressman. Whisper in the ear of the presidential candidates, who have said little or nothing about long term care. Act now.
April 16, 2008
Don't Look Back
For 35 years, the Dartmouth Atlas of Health Care has been publishing startling data on regional variation in the amount of money spent on medical care in the U.S. It has consistently shown—and the newest version of the Atlas, released this month, is no exception—that Medicare spending on chronically ill patients during the last 2 years of life varies enormously across states (Dartmouth Atlas of Health Care 2008, www.dartmouthatlas.org.) . In recent years, for example, California spent $57,914/patient compared to Iowa, which spent $33,864/patient in the 2 years before death. When the brains behind the Atlas looked at what all the extra money is spent on in “high expenditure” states like California, they found that it’s not spent on effective care (interventions that have been shown unambiguously to be beneficial) and it’s not spent on preference-sensitive care (treatments that some patients select while other patients choose other equally effective treatments with a different side effect profile). Rather, it is lavished on supply-sensitive care: services whose supply determines utilization, without any clear-cut benefit. In states like Massachusetts, for example, with a disproportionately high number of specialists and lots of technology, patients have correspondingly more doctor visits with specialists and receive more high tech diagnostic tests.
It’s not that some areas have more specialists and fancy equipment per capita because they have a higher percentage of sick people in the population. When age and gender are taken into consideration, the rates of illness in California and Iowa are remarkably similar. California just has more medical resources per person, so it devotes more resources to the care of Californians. As a result, patients with chronic illness in some parts of the country spent 6 days in the hospital during their last 6 months of life, while patients in other regions spent 22 days.
The critical question is whether there is any added value to the extra expenditures, and if so, is it worth the additional cost? The creators of the Dartmouth Atlas say there is no additional value, since all the patients they studied died, regardless of what was spent on them.
But this analysis looks only at chronically ill patients who died and then asks what kind of care they received in the 2 years before their deaths. There’s a problem with looking back in this way. The problem is that 2 years before they died, their physicians did not know they were going to die. The real question is, did those chronically ill patients who lived benefit from all the extra medical care they got? What we need to do to answer this question is to study a group of chronically ill patients in a high roller state like New York and the same number of comparable patients in a low spending state like North Dakota. Some of these people, if followed for the next two years, will live and some will die, no matter how much is expended on them. After two years have passed, we can determine not only what fraction lived in each of the two states, but also what happened to the ones who lived. Did they live longer in New York than their counterparts in North Dakota? Was their quality of life any better? If neither those who lived nor those who died benefited from all the additional resources devoted to their care, then clearly New York was spending too much. But if some people benefited, even if others did not, then the issue is more complex. It’s complicated further if those who lived benefited but those who died were made worse off because of the resources spent on them—if they underwent painful procedures and spent a great deal of time in the Intensive Care Unit. In either case, we need to come up with a way—cost-effectiveness analysis is an example—to decide whether we derive sufficient value from the added money spent to make it worthwhile.
To be fair, the creators of the Dartmouth Atlas perfectly well recognize the desirability of looking forward instead of backwards. An important study carried out by this group based on data from 1993-1995 and published in 2003 did exactly that. Elliott Fisher, David Wennberg, and their colleagues studied a group of patient hospitalized for either a hip fracture, colon cancer, or a heart attack, as well as a large representative sample of other Medicare patients. They then asked what happened over the next 5 years: within each group, was there any difference in mortality, in functional status (the ability to care for oneself), or in patient satisfaction, depending on how much money was spent on medical care? What they found was that those people who lived in regions with the highest spending received 60% more medical care than those with the lowest level of spending, with no differences in outcomes (Elliott Fisher, David Wennberg, Therese Stukel et al, “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 2003; 138: 288-298). But this study relies on data that’s 15 years old, and it’s just one study. I think it’s very likely that the regional differences in expenditures uncovered in the 2008 Dartmouth Atlas similarly do not translate into benefit for patients—neither for those who lived nor for those who died. But we could be far more confident in this result if we conducted more studies that looked forward instead of back.
If the conclusions of the Dartmouth Atlas are correct, we need to put a stop to the endless proliferation of sub-specialists, of expensive diagnostic equipment such as PET scanners, and of facilities such as outpatient surgical centers. We should instead identify what medical interventions truly make a difference and limit the supply of those that do not.
It’s not that some areas have more specialists and fancy equipment per capita because they have a higher percentage of sick people in the population. When age and gender are taken into consideration, the rates of illness in California and Iowa are remarkably similar. California just has more medical resources per person, so it devotes more resources to the care of Californians. As a result, patients with chronic illness in some parts of the country spent 6 days in the hospital during their last 6 months of life, while patients in other regions spent 22 days.
The critical question is whether there is any added value to the extra expenditures, and if so, is it worth the additional cost? The creators of the Dartmouth Atlas say there is no additional value, since all the patients they studied died, regardless of what was spent on them.
But this analysis looks only at chronically ill patients who died and then asks what kind of care they received in the 2 years before their deaths. There’s a problem with looking back in this way. The problem is that 2 years before they died, their physicians did not know they were going to die. The real question is, did those chronically ill patients who lived benefit from all the extra medical care they got? What we need to do to answer this question is to study a group of chronically ill patients in a high roller state like New York and the same number of comparable patients in a low spending state like North Dakota. Some of these people, if followed for the next two years, will live and some will die, no matter how much is expended on them. After two years have passed, we can determine not only what fraction lived in each of the two states, but also what happened to the ones who lived. Did they live longer in New York than their counterparts in North Dakota? Was their quality of life any better? If neither those who lived nor those who died benefited from all the additional resources devoted to their care, then clearly New York was spending too much. But if some people benefited, even if others did not, then the issue is more complex. It’s complicated further if those who lived benefited but those who died were made worse off because of the resources spent on them—if they underwent painful procedures and spent a great deal of time in the Intensive Care Unit. In either case, we need to come up with a way—cost-effectiveness analysis is an example—to decide whether we derive sufficient value from the added money spent to make it worthwhile.
To be fair, the creators of the Dartmouth Atlas perfectly well recognize the desirability of looking forward instead of backwards. An important study carried out by this group based on data from 1993-1995 and published in 2003 did exactly that. Elliott Fisher, David Wennberg, and their colleagues studied a group of patient hospitalized for either a hip fracture, colon cancer, or a heart attack, as well as a large representative sample of other Medicare patients. They then asked what happened over the next 5 years: within each group, was there any difference in mortality, in functional status (the ability to care for oneself), or in patient satisfaction, depending on how much money was spent on medical care? What they found was that those people who lived in regions with the highest spending received 60% more medical care than those with the lowest level of spending, with no differences in outcomes (Elliott Fisher, David Wennberg, Therese Stukel et al, “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 2003; 138: 288-298). But this study relies on data that’s 15 years old, and it’s just one study. I think it’s very likely that the regional differences in expenditures uncovered in the 2008 Dartmouth Atlas similarly do not translate into benefit for patients—neither for those who lived nor for those who died. But we could be far more confident in this result if we conducted more studies that looked forward instead of back.
If the conclusions of the Dartmouth Atlas are correct, we need to put a stop to the endless proliferation of sub-specialists, of expensive diagnostic equipment such as PET scanners, and of facilities such as outpatient surgical centers. We should instead identify what medical interventions truly make a difference and limit the supply of those that do not.
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