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
Nobody said that it would be cheap. The Alzheimer Disease International (ADI) report projects worldwide costs of over $600 for 2010. It’s no coincidence that this news comes out today — on World Alzheimer’s Day. The ADI report combines the most recent global data on disease prevalence and research. ADI predicts that as populations age, dementia cases will almost double every 20 years to around 66 million in 2030 and 115 million in 2050 — much of the rise from disease incidence in poorer nations.
On these shores, it is known only too well that the costs of treating the symptoms, developing drugs to reverse the disease process itself, covering ancillary costs associated with caregiving, and the constant research in the race for a cure will add to the burden President Obama’s healthcare initiatives must overcome in the next 10 years. The main advocacy organization in the U.S. isn’t waiting; it has already begun pushing for the funding and implementation of a national “dementia plan”. | LINK [PDF]
The response of seniors and healthcare providers to a new Medicare bidding program for so-called durable medical equipment (DME) will be somewhat compelling to Democratic legislators in Congress who will not apparently stand in the way of House Energy and Commerce Chairman Henry Waxman (D-CA) and his push for the program. Under the tenets of the bill [HR-3790], reimbursements for devices such as wheelchairs and oxygen supply units would be cut as an inevitable consequence of the bidding process. Unknown is whether this legislation (which will be tested in some markets beginning in Jan. ’11) would eventually make this sector of healthcare more expensive — increasing costs in other sectors, such as acute care (longer hospital stays) or subacute care (augmented skilled nursing and physical therapeutic delivery systems). | LINK
The use of medical technology is as commonplace today as the doctor’s ubiquitous black bag was sixty years ago. Technological advances have been both blessing and bane, allowing those who benefit to live longer, as with their chronic diseases. Of course, for many patients, this means being sicker longer. In end of life care scenarios, one such advance is creating complications — the automatic internal cardioverter-defibrillator (AICD), a life changing device use to pace and assist heart failure patients whose disorder would have shortened lives just a few years ago. An interesting tidbit of medical news today notes that the willful disconnection of such a device rarely occurs in such end of life discussions with patients and families in the way that cessation of drugs and other aspects of medical care are. An advocacy group of cardiologists and other medical subspecialists is out to change that. It has released guidelines on the withdrawal of support in the hospice and palliative patient and the ethics surrounding such an action. | LINK
Although the prevalence rate of dementia is higher overall in women over 65; this is due to a variety of factors — overall elderly age demographic prevalence, hormonal declines (circulating estrogens), and the presence of certain vascular related disorders, just to name a few. But what about the incidence of dementia in a male spouse as an association for the incidence of dementia in females — both of whom had no signs of the disorder initially?
A trial published in the latest Journal of the American Geriatrics Society shows that over 1000 patients (married couples in a single Utah county) were followed for a period of at least 12 years[1]. Initially without the diagnosis of Alzheimer dementia, those caregiving wives developed dementia along with their husbands in 30 cases. Although the study did not specifically examine wives as caregivers using explicit criteria, most lived in the same space as the male spouse at the time of diagnosis. An interesting result that should spur more study in the gerontological (social scientific) realm of dementia treatment and incidence in the community. | LINK
Pennsylvania’s Corrections Department is getting creative in the healthcare delivery to its aging prison population. With funding courtesy a grant from the National Institute of Nursing Research, the state will be bringing together the appropriate caregiving provider contingent to study the cheapest and most effective ways to deliver end of life (EOL) care. This pro-active move will likely be a point of reference as state budgets come under increasing pressure to provide this level of service to this patient population in the unique ”perfect storm” of declining state budgets devoted to healthcare delivery; exponential growth of geriatric populations/units in correctional facilities; and competition for federal healthcare dollars as the result of the Obama reform package (whenever that occurs).
The project will develop an intervention toolkit for use by staff at any prison in the country. [..] Prison workers, including health care professionals, chaplains, prison society volunteers and corrections officers, will provide information on current limitations, strengths, existing perceptions of end-of-life care among prison stakeholders and areas of care that bear improvement. Using the data collected, researchers will create a set of educational strategies for use by prison staff that they can tailor to fit individual prison’s needs.
The devotion of grant money to fund this type of research is appealing and compelling on many fronts — not the least of which is a shared national discourse which is sure to follow on such unique EOL care initiatives. | LINK
The relationship between Medicare funding/reimbursement patterns and nursing home operational expenses has always been a factor in long term care delivery — often taking the brunt of state Medicaid systems’ lapses in payments to facilities for healthcare services. That relationship just became a little more tenuous. Faced with looming cuts courtesy of Medicare adjustments that call for at least a $15B drop in long term care funding over the next 10 years, skilled nursing facilities could see more urgent staff layoffs and outright closure. For example, some facilities in Connecticut were forced to shut doors when proposed state Medicaid payment increases promised by lawmakers there fell by the wayside — presumptively because of recession influenced budgetary issues.
Could long term care delivery to the nation’s rapidly increasing elderly population (last year, nursing homes housed almost 1.9M elderly and disabled residents — an increase of around 4% over the previous year) be getting short shrift in the entire healthcare debate? It would certainly appear so — setting up a perfect storm of deep federal and state cuts and sharp increases in geriatric patient care needs. | LINK
Recently, CMS published data on the readmission rates for hospitals as part of an ongoing effort to make transparent quality indicators from which hospitals could improve healthcare delivery. A recent U of MN study which just wrapped shows how focusing on patients at risk of rehospitalization can cut those potential costs by directly screening for and averting those risks in the nursing home following discharge.
One of the study participants, Theresa McCarthy MD (under whom I once trained), hails the results as they apply to future cost savings in geriatric care. By utilizing a transitional care team made up of the geriatrician, pharmacist, and critical ancillary staff, rates of readmission from patients in this particular care facility fell by 20 per cent. Not only are unnecessary costs averted, potential lives are saved (as many readmitted elderly may become sicker and more susceptible to preventable problems once back in the hospital), but new treatment paradigms are also possible. Smart. | LINK
What should I do as a physician rounding on one of my many patients on my nursing home service with dementia, complicated by the fact that they are also are suffering from some of its effects on mood? While institutionalized skilled care remains the standard for these patients who are not able to care for themselves, the agitation and delusional thinking suffered by many patients with dementia syndromes puts a new wrinkle on the next level of care — other drugs which carry a certain risk of mortality.
Anti-psychotic drugs commonly used to treat Alzheimer’s disease may double a patient’s chance of dying within a few years, suggests a new study that adds to concerns already known about such medications. [...] Ballard and colleagues followed 165 patients aged 67 to 100 years with moderate to severe Alzheimer’s disease from 2001 to 2004 in Britain. Half continued taking their anti-psychotic drugs, which included Risperdal, Thorazine and Stelazine. The other half got placebos. Of the 83 receiving drugs, 39 were dead after a year. Of the 82 taking fake pills, 27 were dead after a year. Most deaths in both groups were due to pneumonia
In this country, the risk associated with both the newer and older agents essentially requires physicians to frankly discuss risks and benefits with the patient’s family, principal decision makers, and other stakeholders in their care prior to using. For some, the use of these medications (which primarily are used in the mentally ill) represent the only option in dementia with extreme mood and behavioral instability. For others, options are myriad and should be sought. | LINK
Long known to be a risk factor for infarct-related dementia, cerebral ischemia (lowered blood flow to the brain) is now being postulated as a potential cause for primary degenerative (Alzheimer) dementia. The key is in the development of a signal protein harbinger of the abnormal neural types found later in the chronic course of the disorder. Apparently, the risk for the presence of this protein is inversely related to the vascular perfusion of the brain in aging individuals.
“This finding is significant because it suggests that improving blood flow to the brain might be an effective therapeutic approach to prevent or treat Alzheimer’s,” said [Robert] Vassar, a professor of cell and molecular biology at the Feinberg School. A simple preventive strategy people can follow to improve blood flow to the brain is getting exercise, reducing cholesterol and managing hypertension. “If people start early enough, maybe they can dodge the bullet,” Vassar said. For people who already have symptoms, vasodilators, which increase blood flow, may help the delivery of oxygen and glucose to the brain, he added.
You can add this hypothesis to the inflammatory mediation and spinal fluid postulates currently being actively researched in the fight against Alzheimer dementia. | 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.
