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
After more than a century of service (102 years, to be exact), Walter Reed Hospital in DC is closing its doors. This seemed to be an inevitability, especially after the facility had a difficult time separating itself from its healthcare delivery scandals during the George W Bush administration.
The Walter Reed Army Medical Center in Washington, D.C., closed its doors for the final time Aug. 27 as the remaining 18 patients were moved to the National Naval Medical Center in Bethesda, Md., one day ahead of schedule, thanks to the approach of Hurricane Irene. Walter Reed had provided medical care to military service members for 102 years.
While the beacon of military medicine is shutting its doors, the Reed moniker will still be intact, as those final 18 patients are transferred to the Bethesda National Military Medical Center — which will now be known as the Walter Reed National Military Center. | LINK
It’s not every day that the typical Veterans Admin medical clinic sees a burgeoning number of female vets. Perhaps that’s why the VA has employed only around 60 percent of its female providers in all of its nationwide community-based clinics. Although there is a dedicated provider of womens health services at its more than 150 medical centers, the VA is acknowledging that there is a definite treatment deficit in this area of healthcare delivery.
The VA has been bringing doctors and nurse practitioners by the hundreds to mini-residency programs like this one outside Orlando, Fla., focused on women’s health. A key component of the training is performing pelvic exams on live models — typically volunteer nurses — who critique them.
These mini-residency type programs could grow in number in other (private, non-profit) settings as healthcare reform gets ramped up. In the case of the VA, the federal government is calling the shots to improve healthcare delivery to meet a patient-as-consumer need. In the general healthcare marketplace, Insurance could be making that call. | LINK
An observational trial published in the latest issue of Annals shows that the initial savings to overall healthcare costs incurred by acute hospitals with hospitalist (hospital-based physician) care are offset by increased costs to Medicare in spite of the earlier discharges of beneficiaries (0.5 day on average shorter than those patients without hospitalist care).
Most of the extra costs stemmed from re-admissions and patients being sent to nursing homes instead of home. But there’s no clear explanation for the findings.
“Under pressure to shorten length of stay, hospitalists may be willing to discharge sicker patients, leading to increased re-admissions,” Dr. Lena Chen and Dr. Sanjay Saint of Ann Arbor Veterans Affairs Medical Center wrote in an editorial, according to Reuters, which was first to report the study.But they added that unmeasured differences could also play a big factor.
Besides the fact that this study is observational in nature, and therefore immediately affected by selection bias, it does shed light on areas to be studied further — including disease-based criteria for discharges based upon DRGs, the effect of preventive medicine on readmission rates in Medicare patients, and the impact of undocumented acute care complications at discharge (eg, medical errors). The proverbial tip of the iceberg is at play here. Still an interesting read, though. | PDF LINK
The requirement that new insurance provisions and services under reform and HHS rules provide the gamut of preventive womens’ healthcare services will also cover the infamous morning-after pill. Other required free services under the new rules include all birth control methods approved in the U.S., domestic violence screening, and support for breastfeeding.
The HHS noted that not every health insurance plan must comply with the new directive, however. “The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services,” the agency said.
Perhaps most significantly, the rules prohibit charging a co-payment, co-insurance or deductible for this type of healthcare delivery — raising questions as to the feasibility for the feds to include such a provision in the short term. Medicare will also foot the bill for both dual-eligibles and dedicated beneficiaries. | LINK
Much has been written of late regarding the initial media presentations of the virus that causes AIDS and the de rigueur comparisons to how far awareness, activism, and innovation have propelled its discussion to every corner of the planet in 2011. Its chilling descriptions more than thirty years ago cannot belie the fact that, in spite of advances, there is still much to be done on the road to eradication and cure. Within this paradigm is the notion that an entire generation or two have witnessed how the existence of HIV/AIDS has shaped healthcare policy in this country and worldwide.
Here in the U.S., the specter of the aging patient with this now “manageable chronic disease”, the numbers of patients this will represent, and the availability of physicians knowledgeable enough to not only treat chronic HIV disease but also its unknown effects in the increasingly “geriatric” patient — are gaining consideration and acknowledgement in policy circles. Discussion almost always leads to the role of the primary care physician in not only screening but also becoming an active treatment provider.
In 2009, a record 82.9 million American adults were tested for HIV. [...] By 2015, the IOM estimates that half of Americans living with HIV/AIDS will be older than 50. For primary care doctors, this means a growing number of their patients will need care for chronic diseases as well as HIV.
Today’s generation of physicians has inhereted the mantle of providing care for a disease whose spurred innovations ranks as one of the greatest medical achievements of the last century. It is time to consider the primary care approach to chronic HIV disease as another fundamental skill set as reform redefines healthcare delivery in the 21st century. | LINK
How does obtaining health coverage (insurance) compare to not getting it at all? According to a trial published via the National Bureau of Economic Research (Harvard/MIT), beneficiaries’ quality of life was enhanced and made a “big difference” in those patients’ self-health perceptions and their daily outlook — according to the study’s lead author. A quick glance at the results confirms that all encompassing statement, especially since the study employed the diagnostic “gold standard” in trial research by utilizing a randomized, controlled design.
Taking a look at approximately the first year of coverage for Medicaid beneficiaries in the state of Orgeon, the study showed that healthcare expenditures for those who got coverage increased by almost $800/year. Those who received Medicaid were around 60 percent more likely to get mammograms. Medicaid recipients were over 50 percent more likely to have a regular primary-care doctor. They were also in better shape financially and less likely to have unpaid medical bills. Those who got Medicaid were also far more likely to report themselves in good or excellent health. ED admissions did not decrease; however, the increase in ED utilization by beneficiaries was not statistically significant.
It is clear from the results that coverage, in and of itself, has a positive effect on patients’ perceptions of health and wellness. What is not documented as much at this time is how this translates into outcomes with respect to various chronic problems such as obesity, diabetes, and risk factors (such as serum cholesterol, blood pressure, etc.) for heart disease. Also, it is unclear how these results translate into real numbers once reform increases Medicaid rolls substantially by 2014. Researchers plan on following the participants for at least another year. | LINK
There seems to be a neverending chorus on how Medicaid, as a payment system, fails on so many levels. Administrative hassles for short term gain multiplied many times during the average workweek for primary care physicians mired in all of the paperwork, all with no end in sight — unless the provider wishes to end the relationship, of course. Some states have made working with Medicaid beneficiaries more problematic, by lowering matching funding of the program on many levels. It seems like practically every state in the nation, except here in Minnesota, has taken a route in cutting their respective HHS budgets as a primary strategy to meet budgetary shortfalls head-on en route to a balanced result.
To curb rising Medicaid costs, about a dozen states are starting a new budget year by reducing payments to doctors, hospitals and other health care providers that treat the poor. Some health care experts say the cuts, most of which went into effect July 1 or will later this month, could add to a shortage of physicians and other providers participating in Medicaid.
With government projections of huge increases in Medicaid rolls by mid decade on the cusp of reform, insurers, policymakers, lawmakers, and healthcare systems are faced with the reality that numbers of beneficiaries will continue to add to the cost of care delivery in spite of reform. With the federal government planning to supplement spending to offset some of those costs, sky’s the limit on the share the feds will pay — increasing GOP fears of even more spending. With states’ assistance from stimulus (approx $100B) funds practically gone, it’s no surprise that of the 49 states with a budget, around half of those have met the deadline with Medicaid cuts to providers. HHS budgetary issues are on the table in Minnesota today as part of our state’s effort to balance the budget and end its government shutdown.
Getting the word out about all the preventive services available to Medicare beneficiaries is about as easy as wiping out fraud within CMS completely. But that’s not stopping HHS from pulling out all the stops in an effort to curtail future spending on preventable medical problems.
On Monday, HHS Secretary Kathleen Sebelius announced that the agency was launching a publicity campaign, known as “Share the News, Share the Health” to alert Medicare patients, their doctors and their relatives that the services are available at no charge. “Our job is to make sure every single Medicare beneficiary in the country knows,” Sebelius said.
Chalk it up to a (political) campaign by the federal government to get patients knowledgeable and accepting of the benefits afforded them under the reform law. Overall, this effort is a good thing. At its most superficial, it is a way to catch disease earlier, implement higher quality care delivery for less ill patients sooner, and it represents a time saver for the primary care physician, freeing him from informing the beneficiary in order to make the most of the covered physician service/visit. More profound, however, is the stark effect this initiative could have on patient empowerment — as only slightly more than 10 percent of beneficiaries takes advantage of at least one of the covered preventive medical screenings and services.
The issue may not be as salient or controversial as the discussion on whether to back the mandate provision in the PPACA during its annual policy meeting … but MedPAC, be warned; the AMA is staking out its position on proposed cuts in reimbursements for ambulatory imaging studies. Seen as another healthcare tax and spend mechanism in the primary care delivery sector by the payment commission, the AMA has marshaled the apparent bipartisan support of the main congressional regulator of payment activities of CMS — the House Energy and Commerce Subcommittee on Health — in fighting the proposed cuts.
The American Medical Association is circulating a draft letter to Congress urging lawmakers to reject Medicare payment proposals aimed at cutting back the use of imaging services. [...] The letter argues that the recommendations ‘could have a number of unintended consequences, including reducing payments to primary care physicians and driving more services out of physician offices and into more expensive hospital settings.’
The use of imaging and proposed cuts on that use would present a major problem for primary care as a discipline. In a medical specialty already beset by incremental government nickle-and-diming among those practices which continue to see beneficiaries, the curtailing of such use simply to take a slash-and-burn approach in penalizing all MA plans in the name of cost containment does nothing to increase care quality and everything to discourage continued healthcare access. | 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.
