Health Care

QUALITY: Dying Well Beats Dying Badly. And Expensively

Joanne Kenen — Fri, 20 Nov 2009 14:01:00 -0500

As we've written a lot on end of life care, we notice when others do the same. NPR's Joseph Shapiro this week reported on La Crosse, WI where 96 percent of the adults who die have an advanced directive. That extraordinarily high figure arises from the innovations and commitment from Gundersen Lutheran hospital. Careful, sensitive discussions by trained doctors and nurses -- they use a 12 page guide -- is time consuming. Medicare doesn't reimburse them for that time, A provision in the House health care bill would change that -- the provision that was caricaturized as a "death panel." The Senate bill doesn't contain it.

Shapiro's thoughtful piece shows many aspects of end of life decision-making, but one element we liked in particular was that it shows these decisions are not static. People can reflect, and can change. That's the beauty of advanced directives or advanced care planning. Joe Hauser, one of the patients profiled in the NPR piece, initially declined dialysis for his failing kidneys. His wife Janice begged him to reconsider. So he gathered more information and spoke to a nurse. He and his wife were trying to decide whether to visit a dialysis center, and a support group. He learned that if he tried dialysis, he would always have the option of stopping. When Shapiro last spoke to him, Hauser was still leaning against dialysis. But he wasn't sure:

There's a surprise. He extends his left arm across the kitchen table. He wants to show what he calls his "buzzer." It's a spot at his wrist where you can feel the vibration from an artery and a vein that a surgeon has joined together.

It turns out that Joe Hauser's decided to be ready, if he changes his mind. And if he decides he wants dialysis, then the needle of the dialysis machine can slip right in to that spot -- the fistula -- that the surgeon has prepared at his wrist.

We should point out that the Washington Post.'s Alec MacGillis also had a fine story about LaCrosse earlier this fall. Don't think we linked to it at the time. MacGillis looked at both the economics of end of life care, and some of the local cultural traits of La Crosse. The population is full of people of German or Scandinavian descent who seem to have a pretty pragmatic view of aging and dying. And the local doctors and nurses have a culture, too, that values communicating with patients, and respecting their wishes. People in LaCrosse spend far fewer days in the hospital in their final weeks and months of life than people elsewhere in the country. Not because the Wisconsin community doesn't want to spend the money, but because that's what the people who live there, and die there, choose.

This coming Sunday (Nov 22) 60 Minutes will do a piece on end of life, featuring our occasional guest blogger Dr. Ira Byock (read his posts here and here). The short preview on the CBS website focuses a lot on costs; we suspect the televised segment will tell a moving story about quality of care, and patient choice. Because we too have accompanied Dr. Byock in that ICU, and sat in on his team meetings, and we know that quality -- and care -- is what motivates them.

One last relevant link -- Oregon Democrat Rep. Earl Blumenauer, who authored the House provision on end of life conversations, wrote an op-ed in the New York Times this week, describing how a measure that had long and deep bipartisan roots turned into political poison: "The battle lines were being drawn. Little did I know how deep the trenches would be dug, nor how truth would be one of the first, and most obvious, casualties." Live and learn.

HEALTH POLITICS: Reach for the Positive, but Visualize the Negative

Joanne Kenen — Mon, 16 Nov 2009 14:14:00 -0500

Be careful what you wish for! Maggie Mahar, who writes the Century Foundation's Healthbeat blog, had a piece in the Washington Post's Sunday Outlook section calling for a public plan option -- but telling progressives who had yearned for a fully single payer system to visualize the downside. Just imagine, she wrote, if a movement conservative like Sarah Palin ends up making the rules. That could make the current controversy about abortion in the health insurance exchange seem tame. What about coverage of contraceptives? Or the ability to decline life support? Think the government wouldn't intrude on such sensitive private decisions? Ever heard of Terri Schiavo?

Of course, we do usually have checks and balances in our system. The party that controls the White House doesn't always control Congress, and it's even rarer for one party to control the White House, the House and a filibuster-proof Senate. And as anyone who has watched the long and winding road of President Obama's health reform agenda, even a filibuster-proof Senate has a mind (and politics) of its own. Still, Maggie makes a point:

I'm very happy to have a public plan as an option. But since I don't know who will be in the White House in the years to come, I'm glad that government-run health care won't be the only game in town. If you're not happy about the Stupak [abortion] amendment, imagine what other limits a conservative government could impose on our health care.

With such an administration in power, social conservatives might move to exert pressure on health-care decisions beyond abortion. For example, could women be told that their government insurance won't cover birth control? In 2001, President George W. Bush proposed eliminating the requirement that all Federal Employees Health Benefits plans include coverage for contraception. At the time, Susan Orr, who would later become Bush's deputy assistant secretary of health and human services for population affairs, applauded the president's suggestion, saying: "We're quite pleased because fertility is not a disease. It's not a medical necessity that you have [contraception.]"

... Or take end-of-life counseling, and hospice and palliative care. Do you remember how Jeb Bush, then governor of Florida, responded when Terri Schiavo's husband fought for her right to die? It's quite possible that under a single-payer system, conservatives would push to overturn laws that allow physicians to withhold food and water if this is what a dying patient has requested. Recently, Rep. Charles Boustany Jr. (R-La.) raised this issue, objecting to the fact that the House's health-care reform legislation does not prohibit the use of federal funds to pay for end-of-life care that involves denying nutrition and hydration. Boustany, a surgeon, doesn't want patients to have that choice. So much for death with dignity.

She also points out that right and left have different views of "affordability" and how much "skin in the game" consumers should have. So while she still strongly advocates for a public plan option, for now, she's happy to have it be just that. An option.

BTW, we liked Maggie's post from earlier this month, "Health Care Reform - Looking at the Glass Half-Full." It's a lengthy post, but we particularly liked her assessment of consumer protections in House and Senate bills. The bills do a lot to help low income people, and if the subsidies aren't quite as generous to the middle class as some had hoped, they are still getting Real Insurance -- protection against a bottomless pit of medical bills, and the threat of bankruptcy or losing their home in a medical crisis.

I think it is important to recognize that we cannot expect this first piece of health reform legislation to be anything but wildly imperfect. In fact, I'm impressed by the progress Washington has made in just ten months. I've been watching the struggle for health care reform since the early 1970s, and compared to what has happened over the past 39 years, this is mind -boggling.

We've been emphasizing this ourselves. (See posts here and here for instance.) There are provisions we aren't crazy about in these bills. There are problems we will still have to solve. But there is also a lot to embrace.

HEALTH CARE: Time for a Serious Discussion

Health Policy — Fri, 06 Nov 2009 15:06:00 -0500

We just posted on some of the measures within the House and Senate bills that may help lead us to improved care for people at the end of life. Here, Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., returns as a guest poster to tell us what it all means for his patients -- and the doctors who treat them. Byock, the author of Dying Well, has written for us before about the need to think more broadly about what kind of changes we need in our health care system -- and our communities -- to do a better job of caring for sick and frail people trying to get by in their homes.

It's back. The provision that ignited histrionic accusations of Democratic Death Panels and a Newsweek cover about Killing Granny has been resurrected, (so to speak) tucked away on page 641 of H.R. 3962, the House's Affordable Health Care for America Act. Section 1233 would reimburse doctors for a voluntary discussion with patients about their preferences for care at the end of life. Over the summer, Chairman Max Baucus excluded such a provision from the Senate Finance Committee's health reform bill at insistence of ranking Republican, Sen. Charles Grassley. This made little sense then, and even less now that bipartisanship has collapsed.

As I scanned this 1990 page legislation, I thought of a Sarah (a pseudonym), a patient, who is a granny herself. Sarah is generally fit, the result of a healthy diet and a habit of walking five or more miles daily. So, despite her 82 years, it was a shock to her to be diagnosed with colon cancer with a metastatic tumor in her liver. When I saw her in clinic and asked if she had an advance directive, she protested, "But the oncologist said he could cure me!" True, with a combination of chemotherapy and surgery, Sarah has a chance of being cured. Still, it is fair to describe her condition as life-threatening. Yet, neither her internist, nor the oncologist, gastroenterologist, surgeon, or radiation oncologist she has seen since being diagnosed has brought the subject up.

I explained that I expected that she would do well with treatment, but that at our cancer center, we routinely ask all our patients about advance directives. We believe that discussing people's values and treatment preferences and, at a minimum, knowing who they want to speak for them if they become critically ill are components of good medical care. I hoped to reassure her by sharing that I have an advance directive. So does every adult in my family.

Recently, I introduced this topic in a medical school class on palliative care and clinical ethics. In addition to recounting my discussion with Sarah, I told the students that my two daughters, who are in their late twenties, also have advance directives. A few of the students chuckled nervously. Young adults, after all, tend to think they are invincible. Medical students are no exception.

Responding to the chuckles, I pointed out that history shows otherwise. In 2005, we all watched the Terri Schiavo case. I can't bear the thought of one of my daughters being critically ill. The only thing worse would be having a judge or elected officials meddle in our family decisions and her treatment. So when my daughters asked what I wanted for Father's Day that spring, I requested that each of them fill out an advance directive.

That got more laughs in the lecture hall. Yet this is deadly serious. The very cases that have framed American ethics and law on medical decision-making -- Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo -- were all young women in apparently good health. You don't have to be dying for these discussions to matter. You just have to be mortal.

Without an advance directive, even society's most powerful members could get dragged into a drawn out legal mess at the end of their lives. Under state law in New Hampshire, where I live and practice, if Sen. Baucus or Sen. Grassley were to suffer critical injuries in an accident, their families would not have statutory authority to speak for them -- unless an advance directive on record specifically gave them that power. Otherwise, a court, the New Hampshire legislature -- or as in the Schiavo case, the U.S. Congress -- might weigh in on whether and how long life support should be maintained.

I teach physicians-in-training that it is their responsibility to talk about advance directives with all adult patients, no matter whether these conversations are reimbursable or not. Yes, it can be uncomfortable for both doctor and patient. That's no excuse. I wonder if the senators' doctors have raised the issue with them during routine health visits. If not, why not? It is time doctors and legislators faced this issue like responsible professionals.

HEALTH CARE: More Evidence about the $700 Billion Waste

Joanne Kenen — Mon, 26 Oct 2009 20:33:00 -0400

We've often cited estimates from the Dartmouth Atlas and others that about one out of every three dollars we spend on health care (which adds up to about $700 billion) adds no value whatsoever to our health. Zilch. Now a paper from Healthcare Analytics at Thomson Reuters confirms that figure, estimating that we waste between $600 and $850 billion a year:

In this white paper, we present evidence that supports the reasonableness of these claims. This evidence has been gathered from published research studies, expert opinion, and findings from our own Thomson Reuters analyses of our large healthcare databases. We describe the types of waste that are recognized by most experts along with estimates of the magnitude of that waste.

Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper said, "By attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care." (A copy of the full report is attached below. Here's a summary)

Here are some of the study's key findings and how they categorize the waste:

Unnecessary Care (40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics, unnecessary imaging and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
Fraud (19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services. Sometimes patients are complicit; sometimes providers bill for services for patients who have already died.
Administrative Inefficiency (17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
Healthcare Provider Inefficiency and Errors (12% of healthcare waste): This counts for $75 billion to $100 billion in unnecessary spending each year. It ranges from outright medical errors to overutilization of ICUs to inefficient OR scheduling.
Preventable Conditions (6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations addressing conditions, such as uncontrolled diabetes, that are significantly less costly to treat when individuals receive timely and effective outpatient care.
Lack of Care Coordination (6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to the duplication of tests, inappropriate treatments or treatment in inappropriate settings. This costs the system $25 billion to $50 billion annually. Avoidable hospitalization for nursing home patients, and wasteful and potentially dangerous drug interations fall in this category. The author cited studies showing more than a half million medication errors among the elderly in outpatient settings alone.

The paper doesn't address too many specific solutions, but here's the bottom line: We're wasting a ton of money. (Probably several tons but we really aren't sure how you would weigh $700 billion). We can fix it. Health reform will address it. Saving money does not mean "rationing."

HEALTH CARE: Why America is So FAT

Joanne Kenen — Mon, 19 Oct 2009 15:03:00 -0400

If you wonder why we now spend about $147 billion a year on the medical costs of obesity (double what we spent a decade ago) here's a clue:

In Miami for a workshop this weekend, I woke up early and made my way to the small hotel gym. Few machines, and even fewer working machines. The one I wanted was occupied. I mean occupied, not in use. A woman was sitting ON it. Watching TV. When her show was over, she left.

HEALTH CARE: CBO's Latest Tort Reform (GOP Style) Savings Estimates

Allison Levy — Wed, 14 Oct 2009 17:06:00 -0400

When there's health reform smoke, there's tort reform fire. Or something like that.

Senator Orrin Hatch (R-Utah) requested that the Congressional Budget Office update its analysis of how certain (GOP) tort reform proposals could affect annual health care spending. The updated CBO numbers are greater than 2008 estimates (page 21 of that long report) -- when CBO found that lowering premiums for medical liability insurance would reduce annual national health care expenditure by 0.2 percent. The impact tort reform would have on annual health care spending remains a controversial matter. And of course how to define and achieve malpractice reform is also in dispute.

In the updated study, the CBO included not only direct savings from anticipated lower premiums for medical liability insurance but -- this time around -- also included indirect savings from the reduced utilization of health care services (i.e. defensive medicine). Recent research, CBO explains, indicate that tort reform does decrease the use of health care services. (They previously chose not to include the effects of defensive medicine in their analysis as research generated inconsistent results.) It is very difficult to tease out how much of what we can regard as unnecessary care is defensive medicine, versus other financial incentives -- or just how some doctors practice medicine.

The CBO analysis states that enacting medical malpractice reforms would save Medicare, Medicaid and other federal programs $41 billion over the next 10 years while also raising an additional $13 billion in federal income taxes. Total medical malpractice reforms would reduce the federal deficit by $54 billion over the next 10 years and decrease annual expenditure on health care by 0.5 percent -- or $11 billion in 2009. (The 0.5 figure includes the direct reduction in spending due to lower liability premiums plus lower utilization.) The CBO estimate assumes that some potential savings have already been achieved since several states have already applied many of the reforms considered in the analysis.

In response to the CBO analysis, Sen. Hatch stated:

"I think this response from the CBO confirms that there is a growing problem regarding the costs of health care lawsuits. In years past, the CBO mainly focused on the cost [of] doctors' malpractice insurance premiums and did not adequately address the tendency of doctors to use ‘defensive medicine,' which does little to promote patient health and services only to help doctors avoid being sued. Think that this is an important step in the right direction and these numbers show that this problem deserves more than lip service from policy-makers."

My colleagues at New America -- like President Obama himself -- have argued in the past (here and here) that it's time to think about creative ways of breaking the long political impasse on malpractice. Not because it's a magic bullet for health costs -- it's clearly not, as the CBO shows, although we are in the every-billion-counts stage. Not because we favor arbitrary caps on patients that have been truly injured -- we don't. But we do think there are bipartisan alternatives that will go hand in hand with efforts to make health care more efficient, to improve (rather than impede) patient safety, care, quality -- and also, to encourage physicians to be a partner as we innovate and experiment with ways to change our health care system for the better.

HEALTH CARE: The Flu

Joanne Kenen — Fri, 09 Oct 2009 20:36:00 -0400

We aren't really "public health" bloggers but given that today is flu shot day at New America -- a few quick thoughts.

First, Michael Specter had a good short piece in the New Yorker, the "Fear Factor." He notes that it is hard to strike that correct balance between "comfort and terror" and that "fear spreads as quickly as any virus."

Nobody can predict the ways in which a new influenza virus will mutate, or how virulent it may become... With too much reassurance, people ignore the threat; with too little, they panic. The W.H.O. decided, sensibly enough, to emphasize the risks of pandemic. Then the summer months arrived, and for a while, with schools closed, the threat seemed to fade.

That hiatus provided an opening for the anti-vaccine, anti-government, and anti-science crowd, and they stormed through.

Also the ACP web site told us about this interesting program:

Emory University doctors licensed their interactive Web site to allow patients with potential H1N1 cases to self-screen using the same triage calculations their doctors and the CDC use. Questions about fever, symptoms and underlying health help patients determine whether they've got H1N1 flu, and what to do next -- rest, call their doctor or seek immediate treatment.

If you look at the site, you'll see plenty of information about privacy and opt-in and opt-out, and whether and how to make your information available to public health officials tracking disease outbreaks.

Finally, we doubled our own health policy staff participation in the flu shot clinic. (Ok, from two to four of us. 100 percent increase. Or 4 out of 9 participating...) Not sure if the increase was from blog-peer pressure, or if their mothers called.

HEALTH CARE: Practicing What We (Ouch) Preach

Joanne Kenen — Tue, 06 Oct 2009 22:07:00 -0400

Hmm. New America is doing a flu shot clinic (seasonal, not swine) at the office this week, I believe for the first time.

Apparently, only two of us in the health policy program (you know, the ones who write about prevention and wellness) have signed up for this free service.

Maybe everyone else already got theirs.

QUALITY: What Not To Overlook in a Health Care Bill

Joanne Kenen — Wed, 16 Sep 2009 20:06:00 -0400

With Baucus's bill now out, there will be ample and we expect acrimonious debate about subsidy levels and affordability, the mechanics of the insurance exchange, the financing, and of course the lack of a public plan option. (We wonder if the recent survey showing how popular the public plan is among US doctors will have a discernible impact.)

But we wanted to point out some of the less controversial measures (if there is such a thing as uncontroversial after this summer) that touch on some of the topics we've been writing about that aim, simply, to keep us healthy, or to reduce avoidable complications and deterioration when we get sick. As Sen. Baucus himself put it, steps toward changing how we deliver and pay for health care are often overlooked in the national debate but can have a "transformative" effect on enhancing quality while holding down costs.

Preventive care will get more emphasis, and Medicare patients won't have a co-pay for certain screening tests and preventive services proven to be effective. Medicare patients would also get a "wellness visit" annually (which isn't covered now.)

Hospitals with high rates of avoidable hospital-acquired infections and certain errors will face penalties.

New ways of delivering more coordinated care will be tested and/or introduced. These include patient-centered medical homes (including for Medicaid beneficiaries with one or more chronic diseases), accountable care organizations, "bundled payments" (to include acute as well as post-acute care). Payments to doctors and hospitals will be based, in part, on quality of care over quantity of procedures. New models will be tested to provide more coordinated and home-based care for chronic disease, including more care and monitoring for patients in their own homes.

The bill incudes several approaches to reducing unnecessarily rehospitalizations, including a renewed focus on successfully transitioning patients from the hospital back into a community setting, making sure, for instance, that they get in to see their own doctor quickly after a hospitalization. (You would think this would be part of routine care. It is not.)

There is also (on page 53) a small but important provision expanding palliative care to dying children under Medicaid, so that they can basically get hospice-type care at the same time they can still be getting "disease-modifying" treatments aimed at slowing down a terminal illness and prolonging life. Quite a few states had been trying to do this on a one-by-one waiver basis, this national approach woudl be far less cumbersome.

The Finance draft is only one step on the road to health reform -- albeit an important one. It will go through a lot of changes, and lots of compromises as it goes through committee, gets melded first with the Senate HELP bill and then with the House version. But as the process unfolds -- and we suspect, at times, explodes -- it's important to remember that there's a lot more to health reform than fighting about mandates, money and markets.

COST: This Time, There is No Plan B

Joanne Kenen — Tue, 15 Sep 2009 21:42:00 -0400

We posted twice today about cost trends in the employer-sponsored insurance, and it brought to mind some comments Dallas Salisbury, CEO of the Employee Benefit Research Institute, made at a recent Alliance for Health Reform briefing, called "The Next 100 Days: Some Final Hurdles to Health Reform " (He spoke from a vantage point a few days before President Obama's speech to Congress)

Plan A, simply stated, was to pass President Clinton's health reform plan after reshaping it more to business's liking. If that failed, Plan B was to kill it. Plan B, as we all recall, prevailed.

This time around, Salisbury said, there is no Plan B.

In other words, businesses have come to understand the unsustainability of our health care system. They understand the cost -- to themselves, taxpayers, workers and the government. And they understand the importance of offering health benefits on the job. The workplace-health insurance link may be a product of historical circumstances, but business now perceives it as a crucial component in attracting and retaining workers.

Now that doesn't mean that businesses, large or small, like everything in the bills pending in Congress. Not by a long shot. As Salisbury put it, they don't like state coverage mandates, they don't like individual mandates, they don't like employer mandates, and "any form of employment pay-or-play mandate at this point is generally uniformly opposed. "

They don't like the public health insurance option either or major government intervention in the market. And they don't want any more cost-shifting. And they don't want any change in taxation of health benefits, or tinkering with ERISA. And they don't want to be told they have to DO anything that they don't want. And while we're at it, they are a little fuzzy about the difference between coverage and access to coverage.

But they understand the costs and the trends. They understand the economics of wellness and prevention and chronic disease. They understand the role health plays in worker productivity. So even though they dislike so much of what's being talked about, they hate doing nothing even more. Inaction is just too expensive.

Salisbury said:

"Will there be a bill? My response would be yes, I think there will be -- largely because of what I mentioned in the front end, which is most all of the interest groups involved with this business, labor, insurers, PhRMA, et cetera are still sticking to "we have a Plan A, which is we need health reform."

He said that whether the bill is bipartisan or Democrats only with their strange-bedfellow allies, result will be a bill that is "relatively comprehensive."

"I'll close with the final irony. Plan A is the necessity of comprehensive reform because the current system is unsustainable. There is no plan B they all say. There must be reform."