The long term care marketplace is one of those sectors in healthcare delivery on the cusp of markedly innovative practices in this young century, buoyed by the sudden proliferation of the senior Boomer demographic. Sky’s the limit on the impact of care services and offerings a market-based approach can muster on the eve of reform. Unfortunately, certain models are ripe for abuse.
The DOJ said today it joined a whistleblower case against AseraCare in federal court in Birmingham, Alabama, accusing the closely held company of seeking to cheat Medicare for the hospice care of patients who weren’t terminally ill. The U.S. is seeking three times the damages and a penalty of $5,500 to $11,000 per claim.
The hospice company is owned by a national company that provides services within LTC. Whistleblowers prompted the government action when the hospice operation recruited Medicare beneficiaries and continued to fraudulently collect payments by inappropriately cycling those patients under the hospice benefit. The process would continue upon initial termination of Medicare payments for those services once the initial LTC services ceased. Multiple referrals for covered services later, the LTC contractor would continue to collect those payments, based upon allegedly fraudulent qualifying practices by the LTC contractor/company.
The case is an interesting one which will, hopefully, provide Medicare reform in yet another overlooked care sector that will only increase in prevalence as the rate of patients diagnosed with chronic disease and disability skyrockets. More here
This item comes as no surprise to those of us who primarily treat the elderly.
According to researchers, nearly 100,000 hospitalizations every year are linked to adverse drug events such as allergic reactions and unintentional overdoses. Nearly half, or 48.1 percent, of those hospitalized were adults 80 years old or older.
Those agents? Insulin, older generation anti-diabetic drugs (oral), aspirin, and warfarin. It is quite true — and as equally disturbing — that these medications are not only responsible for discrete adverse drug reactions in their own right, but their pharmacological behaviors are responsible for a substantial number of interactions whose iterative clinical manifestations are truly logarithmic in scope. | LINK | Abstract LINK
Just under 13 percent of skilled long term care facilities here in Minnesota are part of a project that is aimed at reducing the “supply side” of potentially unnecessary hospitalizations in the care of their elderly patients. The three year initiative is based upon data already gleaned from smaller tests and it essentially involves going back to the fundamentals of physical diagnosis — from all members of the skilled provider team.
“The problem is the doctors,” [Dr. Robert Kane, a University of Minnesota aging expert who is helping lead the experiment, said.] “Physicians familiar with nursing homes learn quickly to trust the precise information from nurses using the Interact tools. But for the others, especially nights or weekends, the default is hospitalization.”
I like to think of this as a recognition about what physicians have always known about medicine. Nothing substitutes for a thorough physical exam, regardless of who the examiner is. Any effort to utilize the good ol’ noggin to diagnose and treat without the knee-jerk rush to the hospital ED to provide primary care is always preferred, and it saves the proverbial bean counters on the acute care side of things (hospitals) of having to deal with yet another inappropriate admission. | LINK
One axiom is certain in medicine: there is always room for controversy. And that’s good, because it spurs further scholarly thought and research — both qualities can only help patients and providers in the long run. With the current discussion in the media regarding the utilization of the PSA in determining the course of action in prostate cancer screening, so many fundamental issues surrounding patient informed consent, unnecessary treatments, and the potential harms from treatments — can serve as valuable teaching points for patients and current and future physicians alike. The discussion — highlighted in the current NEJM — really brings this point home.
Watchful waiting and active surveillance may help prevent the conversion of overdiagnosis to overtreatment, mitigating the harms of screening that are so accurately portrayed by the task force. … we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve…
A new study out of Harvard finds that approximately a third of all Medicare beneficiaries in the last year of life chose to have a major surgical procedure. The operative (excuse the pun) issue here is whether such timed, elective surgeries are necessary — implying a possible increase in life expectancy. Problem is, no one knows when the beneficiary will die.
By analyzing Medicare claims data the study authors found that, in a group of almost 2 million elderly beneficiaries, all of whom died in 2008, almost one-third had inpatient surgery in the year before they died, almost one in five in the last month of their lives and almost one in 10 in the week before they took their last breath.
The study itself is a good lesson in who exactly “benefits” in these cases. As futile as these findings may sound, there is no question that any procedure done within FFS Medicare coverage remains a reimbursement cache for the provider and hospital, crudely suggesting a financial incentive. While this scenario is entirely possible, it really doesn’t seem to be the impetus for the study’s findings, in my humble opinion. Besides being reflective of a cynical and laconic way of approaching the study’s results, it really makes no sense in a healthcare delivery system increasingly focused on positive outcomes (read: anything but mortality or unacceptable morbidity). The study, however, does usher in the need to discuss the perennial issue of quality of life versus the “appropriateness” of acute surgical treatment among consenting patients with significant chronic illness.
As a geriatrician, another reminder of the work that I do and why it is so important in today’s delivery of healthcare as it relates to chronic, complex diseases (especially with the explosion in the sheer numbers of Boomers into that hallowed 65-and-older territory):
Some 89 percent of the state’s medium and larger hospitals offer palliative care — which focuses on easing pain and discomfort while often continuing aggressive treatment. That placed Minnesota among seven states getting an A in a report released Wednesday by the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City.
The report also cites cost-of-care decreases in aspects of delivery of care to the very infirmed while noting the provisions of dignified, compassionate care characteristic of established palliative care programs. Imagine that. | PDF LINK to report
Sign of the times: social media’s use in increasing interaction among patients with dementia. A researcher, part of a team, is busy at work on a web-based app based upon Facebook for utilization among cognitively impaired elders. She states:
“We have already carried out some practical testing of other web-based communications systems. Among other things, we have tested a “digital diary” and a “scrapbook” containing personal photos, newspaper cuttings and information found online.”
What is both curious and puzzling at the same time regarding this research is that it is being conducted in Norway, of all places. Why not here in the good ol’ U.S. of A? Innovation of this type began and germinated here. Social media’s global function of “keeping one in the loop”, including the elderly, can not be understated in its potential in non-pharmacologic dementia research. Here’s to hoping it gains ground on these shores.
Many physicians, including myself, who see a majority of elderly patients are always interested in ways we can educate patients and concerned family members of the wide spectrum of clinical presentations of cognitive decline. For many Boomers who are now just turning 65 (as the first and oldest cohort does this very year) the specter of that “senior moment” possibly belying something more ominous and progressive is a little more than just an afterthought that can be dismissed. When the moment came for a discussion with the patient and the family over the concern of cognitive impairment, it was always a delicate balance with respect to validating patient concerns with the real world possibility of subclinical disease.
New diagnostic indicators and guidelines for primary care providers and their patients as recommended and formulated by the National Institute on Aging are out to demystify the process, while making research more goal focused, tangible, and accessible with respect to discovering therapies that can actually reverse progressive dementia.
While laudable in these efforts, the three-stage set of guidelines for diagnosis and treatment insertion offered by the NIA and Alzheimer Association is just the beginning. It certainly complements what we geriatricians have been doing quite adeptly for a couple of decades now — informing and educating patients and their families while squelching myths that could delay or, worse, prevent treatment from ever occurring. Of course, the ability for researchers to recruit the most appropriate patients for targeted clinical trials doesn’t hurt, either.
For all of the policy posts here on Doctor Pundit, it is especially cool when we’re able to relay news based upon purely scientific discovery. It’s even more amazing if that discovery will lead to even more treatment avenues than previously expected or planned for. (I guess Pharma is taking note.)
Research into the pathophysiology of Alzheimer dementia (AD) continues at its earnest and deliberate pace. Each new genetic breakthrough finding gives greater insight in to previously known pathways into the development of the disorder. It’s been long known for the past 10 years, or so, that the altered tau protein hypothesis has been increasingly critical to the understanding of the progression of the disease after diagnosis. Consequently, drug development has focused on preventing or reversing the incidence of these and other proteins responsible for progression into the moderate phase of the disease.
Researchers at U Penn and in the United Kingdom have verified the existence of five new genes implicated in the very initial development in the pathology of AD. The findings are significant, as everything from laboratory testing based upon genomic information to sites of drug action can be gleaned from this discovery. All of this means that the initial development of disease is just as important to understanding how the disorder progresses.
The ADGC’s study, led by Gerard D. Schellenberg, Ph.D., at the University of Pennsylvania School of Medicine, involved researchers at 44 universities and research institutions in the U.S. The consortium analyzed genetic data from 11,000 AD patients and nearly the same number of elderly controls with no dementia. Three additional institutes contributed confirmatory data from new individuals, taking the total number of people analyzed in the study to over 54,000.
Amid all the fanfare of this news, it is important to note that we are no closer to obtaining information on the exact susceptibility of one for AD (remember apolipoprotein E?), but the breadth of information contained within this novel genetic discovery is enough to drive innovation in this sector of medical research.
In 2009, more than 1 million patients received some form of organized palliative or end of life care. The vast majority of hospice patients in this country (over 80 percent) are Medicare beneficiaries. A study out in this week’s JAMA takes a look at the types of patients enrolled in for-profit hospice care organizations as opposed to the non-profit providers and finds that the former group provides care to less intensive patients at EOL than latter — suggesting a preference for “less expensive” patients. Consequently, non-profits could be operating at huge potential losses, raising the cost of cares for poorly-equipped or staffed non-profit providers during a Medicare-covered 6 month run.
The team also found that the average length of stay for patients in for-profit hospice was 20 days, while the average length of stay in a nonprofit hospice was 16 days. Because costs are highest at the onset of enrollment and near death, longer stays in hospice are more profitable for providers.
Between 2000 and 2007 the number of for-profit hospice agencies more than doubled, from 725 to 1,660, while the number of nonprofit operators stayed about the same. For-profits have “significantly higher” profit margins than nonprofits, reported the researchers. Indeed, nonprofits, true to their name, operate at a loss.
Before reacting to this study on its face, it’s important to note that it tracked discharged patients from hospice care, lacking data on patients who died during cares; also, there is no indication or measure of quality of care given by for-profits as opposed to non-profit providers and if this contributed to the selection of patients by one provider organization over another. | LINK
MedPAC, the Medicare Payment Advisory Commission, is advising Congress to consider imposing a new charge — or copay — for seniors who receive home healthcare-based services. Until this point, home visits for a variety of conditions from nursing and other providers was free of charge. A payment of at least $150 would constitute the amount the commission is advising Congress to implement. It’s all a part of the effort to continue to streamline Medicare and attack waste.[1] So-called dually eligible patients (those on Medicaid, as well) would obviously not be affected.
More than 3M beneficiaries utilize home healthcare services, and, as expected, some lobbies (including the AARP) pushed hard against the imposition of such additional fees required of many patients with low-to-modest incomes. The charge would be collected for each home health agency admission, not for every visit by a nurse or provider. All of this news comes on the heels of a recommendation by MedPAC to increase the levels of Medicare reimbursement to providers by 1 percent in 2012.
From JAMA: Over 20 percent of patients who receive an AICD[1] fall out of established guidelines, ultimately facing a higher risk of death than those who properly are not treated with such a medical device. Although the study, published in this week’s edition, is of a retrospective design, it still does provide compelling data on the use of such devices, tracked by a national registry mandated by the federal government.
When the Centers for Medicare & Medicaid Services announced their expanded coverage for ICD implantation for the primary prevention of sudden cardiac death in January 2005, the agency mandated that data on all such implants in Medicare beneficiaries be entered into a national ICD Registry.
Tracked patients who received a device also tended to be sicker, carrying more chronic cardiac disease and other illnesses at time of implantation.
[P]atients who received a non–evidence-based ICD were more likely to have heart failure, atrial fibrillation or flutter, ischemic heart disease, cerebrovascular disease, chronic lung disease, diabetes, and end-stage renal disease. In addition, patients who received a non–evidence-based ICD were more likely to belong to a racial minority group (other than black) and to receive a dual-chamber ICD.
Finally, those patients who were implanted most appropriately were those most likely to have had the procedure performed by electrophysiologists — cardiologists specifically trained in all things AICD. The rate of appropriateness was statistically significant among those with this level of certification as opposed to non-EPS trained cardiologists. In previous studies, researchers had examined underuse of the devices and found that many patients who could benefit from the defibrillators did not get them. This study, obviously, looks at the converse — and provides interesting results in the process. PDF LINK
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
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DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
