December 2010 Archives

The Obama Administration has decided to pay doctors for discussing end of the life issues with their Medicare patients. You may recall that this would have been permitted by the 2010 health law, but the provision was dropped in the face of withering criticism by opponents of health reform, who dubbed these important conversations "death panels." 

The new rules are an important first step. Doctors absolutely should be paid for the time it takes to have these difficult conversations. But compensation alone is not nearly enough.

Here's why: Early one morning in a hospital intensive care unit, I was shadowing a care team on their rounds. A patient in her 90s had been admitted from a nursing home with severe breathing problems.She had Stage IV lung cancer and congestive heart failure. A doctor, nurse, and social worker explained to her that she was very ill and gave her two options: They would stop aggressive treatment but make her comfortable. And she would likely die in a day or two. Or they could hook her up to a ventilator. They explained that the device would probably keep her alive for a few months, but also described how uncomfortable she would be.

The woman, who seemed surprised by her prognosis, chose the ventilator. And I could not help but wonder: Why did nobody talk to her about these choices long before this crisis? How could the system have failed her so badly?      

If physicians are going to counsel patients on end-of-life choices, they first need to learn how to talk about these issues with their patients. They not only have to be trained in how to use the right words and body language, many need to fundamentally rethink their own attitudes about treatment and death. Today, too many physicians equate the death of a patient as failure. As a result, they and their patients suffer.

Dr. Dan Sulmasy, who is both a physician and a Franciscan friar, has written powerfully about the intersection of medicine, faith, and death. In one article, he says that doctors "have three great attachments: The need to be in control. The need to be effective. And the need to be right."

Death confounds all three.

But giving patients the information they need to confront the end of life will take more than just retraining doctors. It will also require hospitals, nursing homes, and other health facilities to change they way they approach the dying. For instance, once a patient is admitted to a hospital, it is too easy to become sucked into the powerful and seemingly inexorable cycle of treatment and diagnostic tests. The pressure is always to "do more" and it is reinforced by both a perverse payment system and, often, the demands of family members.

We know how to break that cycle. For example, well-designed palliative care programs can increase the comfort of chronically-ill patients. And while terminally-ill palliative care patients often request less treatment, they also live longer. 

But palliative or hospice care remain an after-thought in too many hospitals. These programs are not given the resources they need. They are not well-integrated into the hospital's practice of care. And attending physicians often wait too long before requesting palliative care consults and then ignore their advice.

Conservative critics are still opposed to these end-of-life dicussions. Robert Pear's New York Times piece that first reported the new rules quoted Elizabeth D. Wickham of a group called LifeTree as saying that end-of-life counseling would encourage patients to forgo or curtail care, thus hastening death. "Patients will lose the ability to control treatments at the end of life," she told The Times.

Of course, Wickham has it exactly backwards. Good physician-patient discussions will give patients more control over their treatment at the end of the life, not less. But only if health providers are fully prepared to have these conversations.  

Last year, the Minnesota Citizen's League asked me to help with a very ambitious project: The group wanted to find ways to improve our broken system of long-term care financing. Earlier this month, the non-profit, non-partisan League came up with its recommendations. I don't agree with them all, but among their far-reaching proposals are some ideas that I hope have legs. 

The League's white paper, called "Moving Beyond Medicaid: Long-Term Care for the Elderly as a Life Quality and Fiscal Imperative" makes three basic recommendations--all aimed at increasing the role of personal responsibility for long-term care while maintaining a safety net for the most needy.

The group would restructure Medicaid, encourage innovative financial products to help families pay for long-term care, and begin a broad education campaign through civic organizations and employers.Their goal is for half of Minnesotans to have some financial planning in place for long-term care by 2015. 

Here is a brief summary of each proposal:

Medicaid: The state/federal insurance program would remain a safety net for the very poor, but middle-class families would be expected to self-finance some of their long-term care costs. While Medicaid would supplement coverage, families would either rely on savings, private long-term care insurance, or home equity to pay their share. They could also buy coverage through the the CLASS Act, the new voluntary national long-term care insurance program that was included in the 2010 health reform law.

New Financing Tools: These include a program to offer prizes to low- and middle-income households who open new savings accounts, a design modeled on an existing program in Michigan. My favorite idea, however, is a new hybrid home equity/reverse mortage product that would provide a low-fee way for people to tap into the equity in their homes for long-term care needs. Today, reverse mortgages can serve that purpose but their fees are too high.

In the League model, Minnesota could create a new low-cost product. I've written about a similar model where the state itself could lend money to those who need long-term care and, get, in return, a lien on the recipient's home. After the person getting care and their spouse died, the loan would be repaid with interest. Such a design would give people broad flexibility in designing their own care, an advantage not available with Medicaid.           

Education: Finally, the League, which has close ties to the local business community, urged companies to play a larger role in encourgaing workers to plan for their long-term care needs.It calls on business to encourage workers to increase both savings and consider home equity or insurance projects to prepare for care in old age. 

This would be a major change. Today, only one in seven workers has access to long-term care insurance through their workplace, according to the SCAN Foundation. And while the CLASS Act is built on workers buying government long-term care insurance through their job, there is little evidence that employers will be willing to offer the coverage as part of their benefit packages.  

The League has built a sturdy foundation for long-term care reform--education, better savings vehicles, and a broad reform of Medicaid. Minnesota's state-funded long-term care program is, like most states, under tremendous financial pressure these days. I hope the state gives some of the League suggestions a try.       

I'm just back from a two day conference sponsored by the Catholic Health Association on ways we can do a better job integrating both medical and personal care for chronically-ill seniors. There may be no more important issue for the delivery of care to this population. If you don't believe me, ask Don Berwick, who runs the Medicare and Medicaid programs for the federal government, Dr. Berwick, the administrator for the Centers for Medicare and Medicaid Services, recently said, "If there is one hallmark, centering idea to achieve better care, better health, and lower cost...it is through integrated care."

CHA asked me to write a paper for this conference and gave me the opportunity to visit providers around the country who are leading the effort to meet this challenge. And the conference allowed about 100 of the nation's top faith-based care providers to get together and exchange ideas. To read my paper, and to see presentations of other participants, go here.   

The idea of integrated care is simple to describe: Ideally, it is a seamless system that provides seniors with medical treatment for chronic and acute disease even as it meets their personal care, social, and spiritual needs. The description may fit on a (long) bumper sticker, but it is not easy to implement. Building such a system requires hospitals, doctors, nursing facilities, home health agencies, assisted living facilities, care managers, families, and communites to work together. And for many reasons, including a perverse payment and regulatory system and the inability of health providers to talk to one another, this rarely happens today.

But some providers are making it work. In researching this paper I learned about projects such as:

The Congregational Health Network: Methodist LeBonheur Health Care in Memphis--a 7 hospital, 1,000-bed system-- is working with 250 churches to improve care for chronically-ill congregants. The keys to this program: hospital-based patient navigators and church-based volunteer liaisons who work together to help patients while they are hospitalized and build a care plan and follow-up after they are discharged.

Schervier Nursing Center's Cardio-Pulmonary Program: Schervier, a Bronx (N.Y.) skilled nursing facility operated by the Bon Secours health system, has dedictated a 39-bed unit to providing sub-acute and post-acute care to patients who have undergone major heart surgery at local hospitals. Rather than recovering in the hospital, where care is extremely expensive and risks of infection and delerium are high for elderly patients, they can recover and undergo rehab at Schervier.

Guided Care at Kaiser Permanente focuses on elderly patients at high-risk of hospitalization. Designed by Dr. Chad Boult at Johns Hopkins University, the Guided Care model is built around an RN who is fully integrated into primary care practices. She visits patients at home, reponds to their telephone calls, and works with families, physicians, and patients to build an easy-to-follow care plan. Kaiser is now deciding whether to make this experimental program a regular part of its healh delivery system.    

Making these creative solutions work today is a huge challenge. But the new health law includes some important incentives, such as accountable care organizations, that mayl encourage more providers to find innovative ways to deliver integrated care.

After spending two days with CHA's health system members, I am optimistic. I was really impressed with their commitment to turn the concept of integrated care into a reality that can both improve the health of chronically ill seniors and be financially sustainable for providers.  

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Senior Obama Administration official Richard Frank says he is "cautiously optimistic" that the Department of Health and Human Services (HHS) can build a viable government sponsored long-term care insurance program under the CLASS Act. CLASS is a national, voluntary long-term care insurance system that was included in the 2010 health reform law.

Frank, a highly respected professor of health policy at Harvard Medical School, is Deputy Assistant Secretary for Policy and Evaluation at HHS. He told a group of long-term care industry representatives, researchers, and elder advocates today that while HHS faces major challenges, the agency can design a workable insurance program under the controversial law, 

Although a deficit reduction commission appointed by Obama recommended last week that CLASS be either repealed or reformed, Frank says he is squarely in the reform camp. And, while he acknowledges it will be a major challenge to create policies that consumers will be willing to buy, he thinks that goal can be reached without changes to the law. CLASS, Richard says, "is designed to change the terms under which we buy and sell long-term supports and services in this country." And, he adds, "it has a great deal of potential."

I agree. But I worry that a real insurance market may never develop under CLASS. The problems are many: CLASS is a voluntary program for both consumers and their employers. The government is barred from refusing coverage to anyone over 18 who works even part-time, no matter what their health status. Anyone who makes more than $1,100 a year is eligible to participate, and low-income workers may buy insurance for only $5-per-month. This arrangement will encourage many working people with disabilities to buy, but also threatens to drive premiums so high that others will be discouraged from purchasing.

Richard acknowledges the problem, and says he assumes initial participation rates will be quite low--likely well below 10 percent. He also says HHS is wrestling with a number of technical issues, such as how to encourage employers to participate in the program, how CLASS will work for those who are also using home care services under Medicaid, how to manage the risk of rapidly-rising long-term care costs, and how to deermine eligibility, especially for those with mental illness. The mentally ill are not usually covered by long-term care insurance but some will be eligible for CLASS benefits.

Making CLASS work will be a huge challenge, but at least today, two years before HHS is due to begin selling policies, Frank still thinks the agency can pull it off. I hope he's right.    

Erskine Bowles and Alan Simpson, the co-chairs of President Obama's deficit reduction commission, have called the CLASS Act "unsustainable" and are proposing that it be either reformed or repealed. They say the national voluntary long-term care insurance program passed as part of this year's health reform law "is viewed by many experts as financially unsound."

The first version of the Bowles-Simpson plan, released last month, was silent about CLASS although sources were warning it was on the panel's radar screen. However, in an effort to win votes from members who have been skeptical about CLASS since it was enacted, the co-chairs added their call to repeal or reform the law in a way that is "credibly sustainable over the long-term."

Unfortunately, the co-chairs dodged the question of how they'd do that. And that was a serious mistake. 

As regular readers of this blog know, I support the concept of CLASS but have argued since before it passed that it needs to be redesigned. The commission chairs provide no clues about how they would do that. Do they support a mandatory program? Would they make technical changes to try to make the insurance more attractive to buyers in a voluntary system? Do they really want to repeal the whole thing?

It is unlikely that the Bowles and Simpson deficit plan will even win the support of their own commission when the panel votes later this week. And if it did, it is hard to imagine Congress ever approving it. However, it is an indication of the mood of Washington these days, and of the discomfort over CLASS in the context of massive ongoing budget deficits. Most dangerous for the program, should Congress ever tackle the deficit, it is hard to see where CLASS would find the support it needed to survive an assault.