Perspectives On Aging

When Lawyers Practice Medicine

2010-01-04T10:17:00.001-05:00

I sat with my elderly parents and their estate planning lawyer, going over documents. The lawyer had updated their will, revised their powers of attorney, and done various other lawyerly things. She handed my parents page after page for them to sign. After an hour of this, my eyes began glazing over. But then I heard her say “and here’s your living will,” and I was all ears.

My work as a geriatrician and palliative care specialist revolves around advance care planning, discussions with patients about their preferences for medical care in the event they lose the ability to make decisions. It’s a complicated enterprise that begins with clarifying the person’s overall health, then moves on to determine the goals of care—what is most important at that point in time—and then seeks to translate those goals into a plan of action. What I have learned by doing this with hundred of patients and their families, as well as by studying and writing about it, is that it is a process. Other researchers and practitioners in the field agree that advance care planning is not about completing a form, it’s about discussing prognosis, it’s about explaining what medical interventions can and cannot achieve and the burdens associated with them, and it’s about factoring the patient’s values and preferences into this complex discussion. What was an estate lawyer doing handing out a living will document and saying “sign here?”

Clearly the lawyer thought the document was self-explanatory and that most people would want to sign such a form. Clearly she believed it was her responsibility to offer such a form to my parents and she felt she was providing them the opportunity to retain control over their medical care at the end of life.

The irony is that Massachusetts, where this encounter between my parents and their attorney took place, does not have living will legislation. In Massachusetts, the only legally recognized form of advance care planning is a health care proxy—choosing who is empowered to make decisions if the patient loses the capacity to speak for himself. The Massachusetts legislature deliberately opted not to accord official status to living wills because they are vague, ambiguous, and seldom applicable to real life medical situations.

The living will my parents were given is a classic example of pseudo-precision: “If a situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications or artificial means or procedures which serve only to prolong the process of my dying,” it begins. What is a “reasonable expectation of recovery?” A fifty-fifty chance? Is a 30% chance good enough? 10%? What does “recovery” mean anyway? Going home and living independently? Living in a nursing home and needing help with bathing and dressing? Going from unconsciousness and total paralysis to wakefulness and the ability to move one finger?

But there is more—the document seems, at first glance, to spell out the answers to these questions. It says “without limitation, I intend these instructions to apply if I am (i) terminally ill, (ii) permanently unconscious, or (iii) conscious, but have irreversible brain damage and there is no reasonable expectation that I will regain the ability to make decisions and express my wishes.” What is meant by “terminally ill?” Does it mean conforming to the Medicare hospice definition of having a life-expectancy of 6 months or less, if the disease follows its usual course? Does it mean death is imminent—in the next few hours or days? Or does it mean having a disease that is uniformly fatal, such as Alzheimer’s disease, which lasts 3-5 years, sometimes longer, from diagnosis until death? What is “extreme physical or mental disability?” Does this mean the most advanced stage of Alzheimer’s, or does moderately severe dementia—in which the individual can walk and talk, but has completely lost his short term memory and needs help with bathing, toileting, and personal care—qualify?

That’s not all. If my parents did seem to fall into any of the 3 categories of terminal illness, permanent unconsciousness, or irreversible brain damage, then it specifies that they would not want “ (a) electrical or mechanical resuscitation of my heart when it has stopped beating; (b) artificial nutrition or hydration when I am unable to take nourishment by mouth; (c) mechanical respiration when I am no longer able to sustain my own breathing; and (d) medications, tests and treatments for any purpose other than comfort.” There is no explanation of what any of these interventions entails and their benefits and burdens, nor is there any explanation of what the alternative might be. In principle, if my parents had a stroke that impaired decision-making capacity and the ability to swallow, but were awake and alert, they would not be given a feeding tube for nutrition, even if they were hungry and indicated they wanted to eat. In principle, if they were diagnosed with a fatal cancer and had a life expectancy of less than six months and were unable to make decisions for themselves, they could not receive radiation treatments to prolong life or antibiotics to cure a pneumonia.

Not only does this kind of living will potentially limit the use of treatment that might well be entirely appropriate and consistent with my parents’ wishes (if they understood what they were signing), but it also fails to protect them from overtreatment in most of the clinical situations which they are likely to encounter.

Whatever is meant by being “terminally ill” or suffering from “irreversible brain damage” with “no reasonable expectation that I will regain the ability to make decisions,” these are not the situations in which older people commonly find themselves. They find themselves in a whole host of situations in which they might well want limitation of treatment. Many 85-year olds, for example, have mild dementia, heart disease, arthritis, and diabetes. If they develop a severe pneumonia, another common scenario, this might well precipitate “delirium,” an acute confusional state in which they were unable to make medical decisions. Would they want to be put in an intensive care unit on a ventilator? The living will, which is supposed to guide proxies and physicians, is silent on this issue.

This seemingly innocuous living will, in short, failed to protect my parents from excessively burdensome treatments in a variety of very possible medical situations, and could prevent them from receiving desirable treatments in other situations. So how could they assure they would get the kind of treatment they wanted if they were unable to speak for themselves?

The answer is that they could discuss with their physician what sorts of medical interventions are consistent with their goals. Frail elders, for instance, if they wish to remain independent as long as possible, even if it means a few months less life, should opt to forgo attempted cardiopulmonary resuscitation. The reason is that CPR, when performed in this setting, is rarely successful, and in those instances where the person survives, he almost always experiences a significant decline in his ability to function on his own. Ideally, the health care proxy is present when the physician talks to the patient about preferences for care, so he will be well-positioned to carry out the patient’s wishes. It is important for the physician to document such discussions in the patient’s medical record. Formal “instructional directives” that spell out just which procedures a patient thinks he would want under what circumstances may be useful as a supplement to advance care planning discussions. An example is the “Five Wishes,” available from Aging With Dignity.

It is entirely appropriate for lawyers to give their clients a health care proxy form to sign—although it should be pointed out that no legal input is required to choose a surrogate. Anyone can print up the official Massachusetts health care proxy form and sign it, with two adult witnesses. There is no need to pay an attorney $100/hour for such a form. It is also reasonable to recommend to clients that they discuss with their doctor their preferences for medical care—in the context of their medical situation and their personal goals. At best, presenting clients with a living will and suggesting they sign it reduces the complex process of advance care planning to filling out a form. At worst, it is practicing medicine without a license. Is the lawyer in any position to explain the benefits and burdens of the medical interventions referred to in the living will, such as a ventilator (“mechanical respiration when I am no longer able to sustain my own breathing”), a feeding tube (“artificial nutrition…when I am unable to take nourishment by mouth”), or cardiopulmonary resuscitation (“electrical or mechanical resuscitation of my heart when it has stopped beating”)?

Physicians have shirked their responsibility by only sporadically engaging in advance care planning with their patients. The result is that lawyers are taking up the slack. Many state legislatures have contributed to the unfortunate conceptualization of advance medical planning as a legal issue through advance directive legislation: unlike Massachusetts, most states have living will laws as well as health care proxy laws and even prescribe what forms are legally recognized in their state. We need to reclaim advance care planning as a medical intervention that can prevent both over-treatment and under-treatment near the end of life.

The Heart of the Matter

2009-11-30T14:51:00.002-05:00

Just before the annual deluge of holiday visitors began inundating the Magic Kingdom, over 20,000 people gathered in Orlando, Florida to attend the American Heart Association annual meeting. At one late-breaking scientific session, Dr. Joseph Rogers, a Duke University cardiologist, presented the results of a study of a nifty new cardiac device, the HeartMate II (to distinguish it from its predecessor, HeartMate I, also known as HeartMate XVE). This remarkable 390-gram contraption is the next best thing to a heart transplant for patients with severe heart failure. It is a “ventricular assist device,” (VAD) implanted in the abdomen, hooked up to the heart to propel blood through a failing ventricle, and powered by an external generator. The study, published the very same day in the online version of the New England Journal of Medicine, showed that patients with the new device lived longer and better, with fewer complications, than those who got the earlier variety.

Just six years ago, the Centers for Medicare and Medicaid Services (CMS) approved use of the HeartMate I in Medicare patients as “destination” or definitive treatment of severe heart failure. Based on the results of a 2001 study, the REMATCH (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure) trial, CMS concluded that the device was “reasonable and necessary” for the treatment of advanced heart failure and therefore, as required by its 1965 Congressional mandate, agreed to pay for implantation of the device.

Physicians, however, were not convinced the device was reasonable or necessary. In fact, the number of patients receiving a ventricular assist device has fallen every year since CMS approved its use. Between March, 2006 and June, 2009, a total of only 1664 HeartMate I’s were implanted (just under 500 per year) and 90% of them were used as “bridge to transplant,” that is to tide patients over until a heart became available for transplant, rather than as “destination therapy,” or permanent treatment. Physicians evidently were not impressed by the data that patients who had a ventricular assist device lived longer than those receiving “maximal medical therapy.” Even with the device, one-year mortality remained high at 48% and two-year mortality at 77%. Moreover, HeartMate I recipients were at risk of stroke, infection, and device malfunction.

Will physicians be more enthusiastic about the new HeartMate II? It is smaller—small enough to fit into a woman, unlike the earlier version. It uses a continuous rotary system rather than a pulsatile mechanism, which means it’s quieter and more durable. And the new device is clearly superior to the old one—the randomized study reported in Orlando found that 46% of those with the new device were alive after 2 years without having sustained a debilitating stroke or required replacement of the device, compared to 11% of those who got the original model. Quality of life was also improved, with recipients of the new HeartMate able to walk further and do more for themselves.

Are these results good enough? They will almost surely be good enough for the Food and Drug Administration to approve use of the device as destination therapy and for Medicare to follow suit by approving reimbursement in Medicare patients—currently Medicare pays an average of $177,000 for a hospitalization in which a ventricular assist device is inserted. Whether physicians will regard the new pump as ready for prime time remains to be seen.

The deeper question is whether we should be putting more and more resources into shoring up failing hearts in patients near the end of life or whether, instead, we should concentrate on palliative care for patients dying of heart failure and on prevention to avoid the development of heart failure in the first place.

Palliative care is an effective, well-regarded approach to end stage heart failure. It focuses on comfort and on supporting patients and their families as the end draws near and may involve enrollment in hospice. Individuals whose heart cannot pump properly repeatedly suffer from fluid backing up into their lungs, swelling their legs, and filling their abdomen, causing shortness of breath, difficulty walking, and fatigue. Instead of hospitalizing these patients, often transferring them to the Intensive Care Unit where they may be attached to a ventilator that forces oxygen into their lungs and put on an intravenous drip to try to stimulate the heart to contract more forcefully, palliative care strives to keep them home. At home they use oxygen and medication such as morphine to help them breathe. Interestingly, the studies of the left ventricular assist device compare patients receiving one particular device to those getting another type (the new study) or patients receiving a device to patients receiving “maximal medical therapy” (the earlier study), but never compare patients receiving a device to those getting palliative care.

Prevention makes a lot of sense in the case of heart failure. Heart failure is the leading cause of hospitalization in individuals over age 65. Americans have a 20% life time risk of developing the condition and treatment costs the US upwards of $30 billion per year. But we know what causes the heart to fail: it is high blood pressure, diabetes, or coronary artery disease (which in turn is caused by some combination of high blood pressure, diabetes, high cholesterol and smoking). And every one of these predisposing conditions is treatable or preventable. While there are few good studies of what it would cost to institute a comprehensive set of measures to prevent heart failure, we do know that 82% of the cardiac events in one observational study, the Nurses Health Study, were attributable to diet and lifestyle issues. An Australian analysis suggests that the best way to prevent heart failure is by a combination of medical preventive strategies (proceeding patient by patient to assess risk factors and intervene to treat high blood pressure, diabetes, and high cholesterol) and public health strategies (using legislative and environmental approaches to promote a healthy lifestyle).

America has its heart set on the technological fix—the HeartMate II is the latest in a series of ingenious approaches to treating the chronic diseases afflicting older people. But its time to get to the heart of the matter, trying to prevent the major scourges that we have the knowhow to avoid, and palliating those who, despite our best efforts, are dying.

Balking at Baucus?

2009-10-15T16:13:00.002-04:00

Democrats and Republicans alike are balking at the Baucus proposal, the latest health care reform proposal to emerge from Congress. Not surprisingly, this enormous bill has something for everyone to hate. It attempts to legislate improvements in access and quality while simultaneously addressing cost.

But what is sometimes lost in the furor is that there are actually two kinds of costs that reform must deal with: the cost of implementing the new programs (principally the cost of requiring that most Americans have health insurance, which means subsidizing premiums for individuals with low incomes); and the rising cost of health care, principally the Medicare program, which is expected to run out of money in 2017.

The Baucus proposal has a price tag of $774 billion over 10 years (though in the last few days, various modifications have added another $28 billion), which refers to the first kind of cost. But how does the Baucus proposal address the second cost issue, containing spending?

The Congressional Budget Office predicts that total spending on health care will reach 36 percent of gross domestic product by 2035, with Medicare costs alone comprising 8 percent of GDP. The vast majority of the increase in Medicare costs will be attributable to increased spending per enrollee, not to the aging of the population. And the single most important factor accounting for the increases is the emergence, adoption, and widespread diffusion of new medical technologies.

Some of these technologies are clearly beneficial; others are beneficial to some of those who receive the new drugs or devices, but are unnecessary or even harmful to numerous others for whom they are also prescribed. And some of the beneficial technologies produce only a very small benefit but at an extremely high cost, as set by the pharmaceutical or device manufacturing industries. Effective Medicare cost control will need to go beyond appealing proposals of dubious financial benefit such as expansion of preventive services and elimination of Medicare fraud (though this could save as much as $17.2 billion per year if fraud were totally eradicated).

What else does the Baucus bill suggest? It makes three significant proposals that actually might work. Collectively, they seek to modify the culture of medicine by altering the way medical care is delivered and how it is paid for.

The beauty and the peril of its strategy is to create an infrastructure for designing a program rather than actually spelling out what the program will be. The beauty is that it does not require making politically unpalatable claims, for example that CMS may need to stop reimbursing for technologies that are not cost effective. The peril is that the various centers and institutes the plan will spawn may not in fact do what they need to in order to control costs. Just what are these centers and institutes?

The most familiar one, because it is also found in the “Affordable Health Choices Act” of both the Senate and the House, is a nonprofit patient-centered outcomes research institute. This would conduct research comparing the clinical effectiveness of medical treatments. To be effective, its work would need to translate into the CMS reimbursement policies: it would have to become an extra-government agency along the lines of the much-maligned but crucially necessary British National Institute for Health and Clinical Excellence (NICE).

The second new institution is an independent Medicare commission charged with submitting proposals for reducing excess Medicare cost growth. Strong wording would effectively require Congress to do what the commission requested or come up with a fiscally equivalent alternative. This is an example of the politically astute approach of leaving open just what the independent commission would recommend.

The third institution is an innovation center within CMS to test, evaluate, and expand different payment structures and methodologies to foster patient-centered care, improve quality, and slow Medicare cost growth. Among other endeavors, the center is mandated to pilot the development and evaluation of a system of bundled payments for a single episode of care – that is, a single payment covering care in the office, the hospital, and the skilled nursing facility. For bundling to work, doctors, nursing facilities, and hospitals will need to band together to form accountable care organizations, and Baucus promotes the establishment of these organizations by offering them a share in the cost savings they generate.

Will the research institute, the commission, and the innovation center, with it assorted pilot programs, do the job? Without knowing just what they will recommend, it is impossible to be sure. But their focus will be on the right areas: figuring out what works and what doesn’t, determining who benefits from new technologies and by how much, and developing systems of care that assure that patients get the interventions that work but not those that don’t. It’s our best shot to date.

This article appeared on the Hastings Center HealthCareCostMonitor on September 24, 2009.

Read more: http://healthcarecostmonitor.thehastingscenter.org/murielgillick/baulking-at-baucus/

End-of-Life Planning is No Conspiracy

2009-10-15T16:07:00.002-04:00

Far from a left-wing conspiracy to deprive you of desirable care near the end of life, advance care planning - talking with one’s physician about goals and preferences for medical care in the event of incapacity - is the best way to ensure that your wishes are respected if you lose the capacity to speak for yourself. Because it is widely recognized as the ideal way to prevent both over-treatment and under-treatment, it has become the standard of care over the past 15 years.

Survey after survey indicates that most patients want to have end-of-life discussions but most do not have them. For example, a 2005 AARP survey in Massachusetts of members over age 50 found that 89 percent of those polled rated having honest answers from their doctor about end-of-life conditions as very important but only 17 percent had discussed their preferences for such care with their physicians. Study after study also shows that American patients continue to die in pain, on ventilators, and in the intensive care unit, though many of them did not want such treatment at the end of their lives. For instance, the Robert Wood Johnson study “Means to A Better End: A Report on Dying in America Today’’ found that 42 percent of all nursing home residents were persistently in pain, and the Dartmouth Atlas of Health Care found that 18 percent of deaths nationwide take place in intensive care units and 32 percent in the hospital, although the majority of Americans say they would prefer to die at home.

When physicians are asked why they do not regularly engage in advance care planning with their patients, they report that they do not have the time for such conversations. The legislation under consideration in Congress that would allow physicians to be reimbursed for an advance care planning discussion with their patients is simply an attempt to correct the imbalance between what patients want and clinical reality.

The current proposal is far from the first attempt to facilitate advance care planning. The federal Patient Self-Determination Act of 1990 mandates that all patients admitted to a healthcare facility receiving Medicare or Medicaid funding be asked if they have an advance directive (a written document specifying their wishes in the event of incapacity) and be given information about advance directives if they do not have one. Every state as well as the District of Columbia has advance directive legislation, which provides for the use of a living will (a statement about preferences in particular clinical situations) or designation of a healthcare proxy (a person to make medical decisions in the event the patient loses the capacity to do so) or both.

The only question we should be discussing is whether a federal mandate to allow physicians to bill specifically for discussions about goals and directives for care will actually succeed in stimulating advance care planning. That is why the bill calls for monitoring the use of the planning code - if it is ineffective in promoting end-of-life discussions, then we will need to find other strategies. The issue is not whether advance care planning is desirable; it is how best to encourage patients, families, and clinicians to have such conversations.

The reason it is important to have the conversations is that death is not optional. What is optional is how we will experience life’s last stage: Will we be in pain or will we be comfortable? Will we be in the hospital or at home? Will we be in an intensive care unit or enrolled in hospice? Discussions about end-of-life care have been shown to result in patients experiencing less depression, less pain, and less anxiety in their final days. Advance care planning gives us the opportunity to avoid both over- and under-treatment by allowing us to express our preferences and by discussing them with our personal physician.

This article appeared as an op-ed in the Boston Globe on August, 12, 2009.

Falling Down on the Job

2009-10-15T15:52:00.004-04:00

It’s not often that a report appears that identifies a problem and at the same time, another report is released that offers a solution to that problem. But that may be what happened this month with the publication of an article describing the frequency of hip fractures and their complications and another article detailing an intervention that reduced the complication rate after hip fracture.

The first study presents data on hip fractures in the U.S. between 1985 and 2005. Previous data indicated that there are about 350,000 hip fractures every year in the U.S., almost all of them in people over 65 and the vast majority in people over age 75. Half of those who break their hip never return to their baseline level of mobility, 20% die within a year, and 25% of those who lived independently before the fracture require permanent nursing home care afterwards. The new report concludes that hip fracture rates and subsequent mortality among people over 65 are declining. But closer inspection of the data shows a different picture.

What the report really shows, as the authors indicate in the discussion section of their paper, is that there were two distinct time periods worthy of analysis. Between 1986 and 1995, the incidence of fractures increased in both men and women (corrected for age) but between 1995 and 2005, the incidence declined steadily. It declined a lot: among women, the incidence fell 25% and among men it fell 19%. But the mortality story is another matter. Looking at death rates at 1 month, 6 months, and at a year after hip fracture, the study found that between 1986 and 1995, mortality fell, but between 1996 and 2005, there was no improvement in mortality whatsoever.

The decline in the rate of hip fractures is good news, though it’s not entirely clear what caused it. The authors point to lifestyle factors, such as greater intake of vitamin D and calcium, along with increased exercise. They also point out that bisphosphonates, medications used to treat osteoporosis, were introduced at just about the same time that hip fracture rates began to fall, but these drugs can account for at most 40% of the reduction in risk.

The lack of improvement in mortality in the recent 10-year period, however, is troubling. Much of it reflects the fact that older people who fracture a hip are frail—and their frailty predisposes them to other medical problems in the following year. But the second article on hip fractures that appeared in a major medical journal this month offers a ray of hope. Reporting on the impact of co-management of hip fracture patients by orthopedists and geriatricians, investigators from the University of Rochester School of Medicine found enormous improvements in outcomes with their model.

Patients cared for in the “Geriatric Fracture Center” in Rochester were older than their counterparts who received standard orthopedic care (mean age 84.7 vs 81.6), they were more likely to have dementia (53% vs 21.5%), and they were much more likely to come from nursing homes and assisted living facilities (60.6% vs 12.2%). Despite all these differences, the co-managed patients fared far better. They went to the operating room much more quickly (in an average of 24.1 hours vs 37.4 hours), which has been shown to lead to better results. They stayed in the hospital less long (4.6 days on average vs 8.3 days) and they had fewer complications (30.6% vs 46.3%). In particular, they were less likely to develop delirium (acute confusion), infection, and blood clots, all of which predispose to early death.

The finding that “co-managed” patients did better than those cared for exclusively by orthopedists does not necessarily translate into improved survival rates. Some of the long-term mortality is unrelated to the hip fracture and simply reflects the reality that people who break a hip tend to be old and sick and that people who are old and sick die. But the component of the mortality from hip fractures that is amenable to intervention probably involves the post-operative management of patients. It is precisely those nasty complications of surgery that, over time, cause death. Finding a way to take care of individuals with hip fractures that decreases their risk of complications is an excellent strategy for preventing death.

Is the “Comanaged Geriatric Fracture Center” really the answer? It may be. The Rochester study was a retrospective cohort analysis, so it is possible that the findings reflect undetected differences between the patients or other differences in the institutions where care was provided. A randomized trial, in which some patients receive one form of care and others, chosen randomly, get the other type of care, would demonstrate decisively whether and how much co-management helps. But joint care by orthopedists and geriatricians is in widespread use in other countries such as Australia and New Zealand, with good results. And similar but less potent strategies have been used in the U.S., such as the use of geriatric consultation for patients on the orthopedic service. When this multidisciplinary approach was instituted at Oregon Health Sciences University and at the Johns Hopkins Bayview Medical Center, fewer complications, decreased length of stay, and earlier surgery were all observed. These systematic ways to assure improved care for older people with hip fractures can be instituted now. There’s pretty compelling evidence that they work and cost calculations suggest they save money, too. If we don’t start introducing this model into practice, we’re falling down on the job.

Messing with Medicare

2009-08-26T16:59:00.002-04:00

Senior citizens have been coming out in droves to express concern that health care reform legislation will deprive them of what they now have. Although most of the provisions of the proposed bills deal with ensuring access to health care for the currently uninsured and with regulating private insurance companies, Medicare enrollees are worried that “the government” will “mess with Medicare,” a program which many seem not to realize is the paradigmatic “public option.” Just how would health insurance reform affect Medicare—in fact, not in fantasy?

Both the Senate’s “Affordable Health Choices Act” and the House of Representatives’ “America’s Affordable Health Choices Act of 2009” address access, quality, and cost-containment. The majority of the many sections of these bills deal with such areas as individual mandates, employer requirements, premium subsidies, insurance pooling mechanisms, and benefit design. Only a few have anything to do with Medicare. One provision, expansion of Medicaid, would increase the number of older people who are “dually eligible,” i.e. who would qualify for both Medicaid and Medicare. This would increase the coverage available to older individuals, not decrease it.

Under cost containment, the Senate bill would establish a “Health Care Program Integrity Coordinating Council” to prevent health care fraud, waste, and abuse, in both public and private coverage. Who could be against eliminating fraud and abuse? In fact, a recent article in the New England Journal of Medicine estimated that the annual price tag for fraud and abuse is $60 billion, with fully $36 billion of this related to Medicare and Medicaid, the current public programs--enough to pay for health care reform. The House bill has a few more provisions under the cost containment heading. These include reducing payments for potentially preventable hospital readmissions—that just means giving hospitals an incentive to solve your medical problem the first time you are hospitalized, instead of making you come back again and again to get it taken care of. In a similar vein, the House bill calls for hospitals to report hospital-acquired infections and suggests eliminating Medicaid payments for preventable infections (Medicare already does this), a strategy intended to encourage hospitals to keep you from getting such an infection in the first place.

In the arena of improving quality, both the Senate and the House version of the bills call for financial incentives to health care institutions to promote efficiency, for example by supporting a “medical home” that coordinates complex patient care. They also call for more research to study the effectiveness of health care services and procedures. This has nothing to do with taking away coverage for useful treatments. If physicians don’t know what works, they can’t treat patients in an optimal way. It’s that simple. And right now there is overwhelming evidence that doctors have routinely used ineffective therapy or have started with expensive and burdensome treatment when less expensive and often less invasive treatment would work just as well, simply because they did not know what would work best.

The bills also contain specific recommendations dealing with prevention that would increase coverage of preventive services under Medicare—for those preventive services that have been shown to improve outcomes. That means many beneficial screening tests that are not currently paid for would be covered in entirety and a few that other covered but that do not improve health would not be. So yes, a few things might be taken away from seniors—tests that are not helpful. But is this being deprived? Why would anyone want to undergo a screening test that doesn’t lead to better health? Knowing sooner that you have a disease just means suffering longer if it does not translate into more effective treatment of the disease.

The Senate and House bills actually include provisions for long term care insurance. Until now, no one in the legislature ever talked about long term care although it is critical to the health and well-being of millions of older people who need home care services or nursing home care. Medicare does not pay for nursing homes, so the 1.5 million people living in nursing homes either pay out of pocket or “spend down” and enroll in Medicaid.

Finally, there are a few miscellaneous provisions in both bills that would affect older people. The House version, for example, would eliminate the notorious “doughnut hole” in the Medicare Part D prescription drug plan, which requires older patients to pay in full for prescription drugs after they have spent $2510 and until they qualify for “catastrophic coverage,” once they have reached a whopping $4350 in out-of-pocket expenditures. The Senate version calls for educational reform to increase the supply, education, and training of doctors, nurses, and other health care workers in geriatrics and primary care.

What’s not to love?

Waste Not, Want Not

2009-06-19T17:22:00.002-04:00

A recent commentary in JAMA begins with the sweeping condemnation: “An epidemic of waste blights the US health care delivery system.”Sad as this claim is, it is also encouraging, for who wouldn’t want to get rid of waste? Any attempt at reforming American health care should start by eliminating waste—but to do so, we need to know exactly where to find the waste in the system and how best to dispose of it.

Waste comes in several varieties. A RAND study identifies 3 principal flavors: administrative waste (such as excess expenditures on running a health insurance plan); operational inefficiency (for example, duplication of diagnostic tests); and clinical waste (for instance spending money on expensive drugs when cheaper ones would be equally effective).

A good starting point in thinking about reform would be to enumerate all the types of each of these forms of waste and to put a dollar amount on each of them. It turns out that the McKinsey Global Institute, the economics research arm of the McKinsey management consulting firm, has done exactly this kind of analysis.
In fact, McKinsey first undertook to identify where the waste is in the US health care system using 2003 data and then repeated the analysis with 2006 data. What’s fascinating about the report is both seeing where the waste is and discovering how much has changed in 3 short years.

The McKinsey report compares US expenditures on health care with those of a group of 13 countries belonging to the Organization for Economic Cooperation and Development (OECD). Reasoning that richer countries are more willing to spend money on health care, the report computes the Estimated Spending According to Wealth (ESAW), a prediction of how much a given country would spend if it were like the OECD average, adjusted for per capita GDP. In 2006, the US spent nearly $2.1 trillion on health care, or $6800 per person, eating up 16% of GDP. This was an increase of $363 billion since 2003—and $643 billion more than the average spent in the 13 comparison countries (Austria, Canada, the Czech Republic, Denmark, Finland, France, Germany, Iceland, Poland, Portugal, South Korea, Spain, and Switzerland) after adjusting for per capita wealth, or the ESAW

The excess spending produced no discernible health benefit for Americans. In fact, comparisons of the US health care system to that of OECD peers typically find that the US performed worse than everyone else. On one report card, where 1 is the best score and 6 is the worst, the US managed to achieve scores of 5 or 6 on 5 measures: quality care, access, efficiency, equity, and healthy lives.

The waste, according to the McKinsey Report, is in 5 areas: outpatient care ($436 billion or 68% of the excess), drugs ($98 billion or 15%), administrative costs ($91 billion or 14%), investments in health ($50 billion or 7%), and inpatient care ($40 billion or 6%).

By outpatient care, the Report means visits to physicians’ offices, same day surgery, dental care, and treatment in ambulatory surgical centers, diagnostic imaging centers, and other outpatient clinics. What’s striking is that this is the fastest growing component of wasteful care, growing at 7.5% each year since 2003. The higher costs in this sector are due principally to two factors: how much physicians are paid in the U.S. and the high profit margins for ambulatory surgery centers and diagnostic imaging centers. Extremely generous physician compensation adds $64 billion of costs to the system each year. This reflects what we pay specialists and our extravagant use of specialist care: while generalists in the US are paid somewhat better than their counterparts in the comparison countries, specialists are paid much more highly than in the rest of the developed world. Both ambulatory surgery centers and imaging centers are proliferating rapidly, attracted by operating margins of as much as 25%. The result is that the US has 4 times as many CT scanners and MRI machines as the average OECD country, and does 4 times as many imaging studies each year, again with no measurable benefit in terms of patient outcomes.

Drugs are the second major area of wasted spending (this includes both drugs spent by outpatients and drugs spend by hospitals). What’s interesting here is that Americans actually take 10% fewer prescription drugs than the average OECD patient each year. The source of the waste is that drug companies charge on average 50% more for brand name drugs in the U.S. than elsewhere in the world and Americans use a more expensive mix of drugs (a large fraction of brand name or newly released drugs).

Health care administrative costs are next on the list. Most of this relates to operating expenses and profits among private health insurance companies. The American multi-payer system, far from driving down costs through competition, adds costs to the system in the form of marketing, sales, and management overhead. Even Medicare, which until recently had far lower administrative costs than the private sector, has experienced a rise in costs since 2003 because of payments it makes to private plans to administer the Medicare Advantage Plans and the Part D drug benefit.

Investments in health are also higher than in peer countries after adjusting for per capita wealth. This means the US invests more in public health and basic research than other countries. This is one area where the excess, relative to other nations, may well be beneficial and not wasteful. Whether NIH and state public health departments are spending their money in the most effective way—whether they are getting maximum value for their investment—should be carefully examined.

At the bottom of the list, but still a major source of waste, is inpatient care. What’s fascinating here is that both the number and length of hospitalizations are shorter in the U.S. than anywhere else. The waste stems from the cost per hospital day, which is roughly twice the OECD average. This in turn reflects more spending on high tech equipment and subspecialty care.

At least as interesting as the breakdown of the types of waste is the way the distribution has changed in the last few years. The identical analysis by McKinsey using 2003 data found that by far the largest source of waste was inpatient care, accounting for slightly under half of all the waste. Why has the contribution of hospitalization gone from first to last? The mechanism of reimbursement for hospital care by diagnosis related groups, which gives hospitals a fixed amount of money depending on the reason the patient was admitted rather than a per diem rate, has been in effect for older patients since 1983. What has changed is the availability of a more lucrative alternative—day surgery and treatment in ambulatory surgical centers—for the treatment of conditions such as hernias and cataracts. The move from one site of care to another dramatically demonstrates the tremendous adaptability of the health care eco-system.

The implications for health care reform of this type of analysis are profound. If we truly want to decrease wasteful spending, both short term and long term interventions will be required. If we want to manage the flow of procedures from the hospital to the outpatient setting wisely, we need to regulate the proliferation of ambulatory surgical centers and diagnostic imaging centers and to control what they charge for their services. If we want to affect the balance of specialty and generalist care, it will not be enough to provide incentives to medical students to go into primary care: we will need to markedly decrease the phenomenal rate of reimbursement for specialists. If we hope to decrease waste in the medication arena, we will need to determine whether new drugs are better than old ones and if so how much better. We will need to institute some sort of price control over the pharmaceutical industry, at least by negotiating prices (not currently an option under Medicare Part D). And if we truly want to get rid of wasteful administrative costs, we need to consider a single payer system, something that is currently not even on the table as Congress debates health care reform. Finally, we need to recognize that some of what other countries deem wasteful, such as high tech care near the end of life in exchange for a minute chance of life-prolongation, Americans seem to value. If we want to get rid of this type of expenditure, we will need to change the culture that supports this approach, not merely the economic incentives that further facilitate it.

Is Death Optional?

2009-06-02T08:57:00.001-04:00

Just how far attitudes and expectations about aging have changed in the last 60 years hit home on reading an article from the NY Times Magazine from 1950 called “Recharting Life for an Aging America.” The author, a physician, wrote that “To lead a long and happy life falls, for the average citizen, into the same category of irrational wishes as to be a millionaire or a movie star.” The reality, he said, is that most old people are “lonely, poor, ailing, crippled, ugly, [and] mentally and physically deteriorated.” Today, by contrast, older people take the possibility of ever increasing longevity for granted.

The change in perspective is dramatic and it’s very new: while Americans born in 1950could expect to live far longer than their grandfathers did, most of the improvement in life expectancy was due to decreases in infant mortality. It was only in 1970—5 years after the introduction of Medicare—that 65-year-olds could look forward to a longer period of retirement than any previous generation. By 2005, white men could anticipate another 17.2 years of life and white women 20 years.

Is the result really that Americans today fail to accept that death is inevitable? Or do patients appear to believe that death is optional because physicians seldom discuss life’s final stage and continue to offer treatments, even if they are of little or no benefit?

For all the lip service paid to informed consent and joint physician-patient decision making, older patients seldom understand their likely trajectory with and without a particular treatment. I recently saw a dramatic example of this problem in the course of palliative care consultation at a major teaching hospital in Boston.

The patient was a man in his late 70’s who had been hospitalized with a devastating stroke due to massive bleeding in his brain. He was being kept alive in the ICU with a variety of high tech interventions. The attending neurologist told the patient’s wife that the likelihood of any recovery was very small but that the full extent of his improvement might not be known for months. The doctor held out no hope of a full recovery and expected that if the patient did survive, he would require total care and would have little if any language capacity.

The patient’s wife didn’t think her husband would have wanted life-prolonging treatment if he would be left with profound limitations on his functioning, but she wasn’t absolutely sure. She wondered if she should authorize further vigorous treatment to “give him a chance.”

What quickly became clear to me was that the wife’s conception of what it would be like for her husband over the next two months if she opted for attempted rehabilitation and life-prolonging treatment bore little relationship to reality. She imagined that “going to rehab” would be as benign as taking a daily vitamin pill. I explained to her that after transfer to a rehab facility, he would likely suffer multiple complications such as pressure ulcers or pneumonia. He would probably be shuttled back and forth between the rehab facility and the hospital—and after all that, he would either die or be left extremely debilitated. Once she understood both what treatment would entail and how unlikely meaningful recovery was, she had no further hesitation: the right course of action for her husband was to focus exclusively on his comfort.

In today’s medical world, this kind of discussion is rare. If Medicare patients are to get appropriate care, and if costs are to be controlled, physicians must have such conversations. But since the focus is on life-prolongation throughout a physician’s training, with little attention to maximizing quality of life or to deciding when to stop, medical education will need to change.

Medicare and Medicaid pay just under $10 billion per year to hospitals in the form of General Medical Education funds to train residents. But as the Council on Graduate Medical Education observed in a letter to the Secretary of Health and Human Services in May, 2009, hospitals are not held accountable for how they spend the money. Their concern is with their own labor needs, not with training the next generation of physicians to manage chronic disease. It is time to monitor and regulate the way the federal government’s money is spent and require proficiency in end-of-life discussions along with disease management and care coordination.

Some experts believe that telling patients about the trajectory of illness with different treatment options won’t suffice because patients engage in magical thinking: physicians can lay out the various possible scenarios but patients will gamble that they will be the lucky ones who have the best outcomes. My experience suggests that most patients do respond to realistic discussions about their future, but the way to deal with the minority of patients who might want to try a treatment that has a vanishingly small chance of working is simply not to offer such interventions.

Decisions to take certain kinds of treatment in certain situations off the table should be made at the policy level. This will require holding National Institute of Health consensus conferences to determine a new standard of care for patients with a variety of chronic conditions such as dementia or heart failure in the last phase of life. The Centers for Medicare and Medicaid Services (CMS) will then need to give teeth to the practice guidelines that emerge from such conferences by agreeing to reimburse only for treatment that is consistent with those guidelines.

Perhaps the greatest challenge is that policy makers, who will need to endorse the kinds of changes I am suggesting, share the same expectations of ever increasing longevity as other Americans. A good starting point is therefore to limit treatments that are burdensome, unlikely to be effective, and expensive.

The next step will be to dispassionately analyze interventions that offer only a slight chance of benefit and that are expensive but that are not burdensome to patients. Some devices such as pacemakers have become increasingly acceptable as they have become smaller and implanting them has become safer and less invasive. Likewise, some cancers have become chronic illnesses because of the development of relatively non-toxic, targeted therapy. Patients naturally want potentially life-extending treatment if it comes in the form of a pill, without the nausea, vomiting, hair loss, and bone marrow depression associated with conventional chemotherapy.

Ultimately, policy-makers will have to take into consideration cost-effectiveness in deciding whether CMS will cover such treatments. Far less politically charged are the steps that should be taken immediately: regulating spending on graduate medical education and limiting reimbursement for treatment that comes at a high price to both patients and society without conferring any appreciable benefit.

A modified version of this piece appeared on the Health Care Cost Monitor, a blog of the Hastings Center.

Fixing Medicare

2009-05-27T12:21:00.004-04:00

The Medicare Modernization Act of 2003 was supposed to bring the Medicare program into the 21st century. It was going to ensure that good health care was a reality for both America’s elderly and its disabled citizens. It didn’t succeed.

The 45 million Americans who are enrolled in Medicare are certainly far better off than the 47 million Americans who have no health insurance at all. Some of them are better off today than they were before the MMA was passed since they now have a prescription drug benefit. In fact, for those elders who are in good health, Medicare is a model program: designed in 1965 to cover acute, time-limited illness, it does that very well. The problem is what Medicare does not do so well. It does not provide coordinated and preventive care for those with chronic illness; it favors institutional over home care; and it offers excellent end of life care only to the minority of patients willing to forgo hospitalization and palliative treatment and to enroll in hospice. And Medicare has no good way to control costs.

When the first of the baby boomers turns 65 in 2010, Medicare costs are expected to reach 3.3% of GDP; they will jump to 6.3% of GDP in 2030 and reach a staggering 8.4% in 2050. Forget all the concern about Social Security—it’s the Hospital Trust Fund, which pays for Medicare Part A, that is on track to go bankrupt. The latest report from the Trustees, hot off the press, projects this will happen by 2017.

What Medicare is best at is treating a disease like pneumonia: the patient gets sick quickly, is hospitalized for at most a week, and then goes home with a prescription for a few days’ worth of oral antibiotics. But Medicare patients today have multiple chronic conditions: the 21% of Medicare beneficiaries with 5 or more chronic diseases account for 68% of all Medicare spending.

Patients with chronic medical problems need a very different model of care. They need a coordinated, integrated approach. Right now one of the few ways to get this kind of treatment is through the Program for All Inclusive Care for the Elderly (PACE), a program for the frailest of the frail--elders who are dually enrolled in Medicare and Medicaid and who are impaired enough to qualify to live in a nursing home to boot. PACE has been very successful not only in keeping such patients out of the nursing home but also at keeping them out of the hospital, while providing high quality care. But the model for addressing chronic disease in the MMA was not the capitated PACE program, but rather “case management,” typically provided by an outside agency that does the medical equivalent of trying to direct traffic by phone rather than through the physician’s office. Not surprisingly, these programs have in general been a disappointment.

Because Medicare is geared towards treatment of acute illness, it is built on hospital-based care, not community care. In 2007, 30% of Medicare spending went to hospital treatment. Much smaller chunks went to skilled nursing facility (SNF) care (5%) and to home care (4%). And there are incentives for patients to be treated in institutions rather than at home. For example, patients must spend three nights in a hospital before going to a SNF, even though some simple problems such as pneumonia could easily be treated in the SNF. Similarly, there is an incentive for patients to move into a nursing home—and be covered by Medicaid—rather than to receive care at home.

One of the jewels in the Medicare crown is its hospice benefit. Enacted in 1982, the hospice benefit allows patients with a prognosis of 6 months or less to receive intensive services focusing on their comfort, care which in 95% of cases is delivered at home. The program has gotten excellent marks from families in satisfaction surveys and in formal research studies.

Hospice grown dramatically: between 2000 and 2007, the number of Medicare certified hospices increased by 41%, and the number of hospice patients doubled from 513,000 to one million. But the problem with Medicare hospice is that it forces patients to make a diabolical choice. In order to qualify for the home care services most patients want at the end of life, they have to agree to forgo treatments that can offer significant palliation. Contemporary medicine can enhance the quality of life for many patients with advanced disease through relatively non-invasive treatments such as oral chemotherapy or blood transfusions. But the reimbursement structure of the Medicare hospice benefit—a fixed per diem rate—simply does not allow for these treatments.

How can Medicare do all these things—and continue to provide acute medical care? Providing additional benefits seems like the last thing the Medicare program should do: the costs of the Medicare program have already been skyrocketing, partly due to the growing number of older individuals, but to a much larger extent due to the insatiable American appetite for health care and the introduction of new, expensive technology. Fortunately, the reality is that while Medicare is failing to provide a variety of services that are critically important for older patients, it is simultaneously providing an enormous amount of care that is useless and in many cases even harmful. In fact, when Medicare patients with a heart attack, hip fracture, or colorectal cancer were followed over a five year period, those living in parts of the country with higher spending on medical care experienced higher mortality.

Medicare routinely pays for burdensome, expensive treatments for patients at the end of life. Similarly, it reimburses physicians and hospitals generously for diagnostic tests and procedures of dubious benefit. And it pays for costly medications and treatments when cheaper, equally effective treatments exist. How can Medicare move from today’s reality, in which it fails to provide all kinds of care it should offer and systematically encourages the use of all kinds of care it should not?

In terms of chronic disease, the secret to success lies within the PACE program, which provides coordinated care within a capitated system. HMOs got a bad name in the 1990s, but the truth is that only when an integrated health care system operates within a fixed budget that we can expect to see appropriate allocation of resources. With respect to new technology, which is the principal driver behind escalating costs in the Medicare program, the trick will be to stimulate innovation without allowing technology to diffuse unchecked.

One solution is to allow cost effectiveness analysis to enter into CMS reimbursement decisions, not as the sole criterion, but along with other ethical principles such as preferential treatment for the most vulnerable. Finally, to provide good end of life care to all Medicare patients who die, not just those who currently opt for hospice, many of whom enroll in the program within days or even hours of death, we need to create a new benefit. This would provide much of what is currently available through hospice but allow for some hospital care and many palliative treatments in exchange for forgoing the most expensive types of care such as major surgery and ICU care.

The current discussions of health care reform have appropriately emphasized the importance of universal access. And right now those over 65 do have access through Medicare—though median out-of-pocket health spending as a percent of income has been rising for older individuals, going from 11.9% in 1997 to 16.1% in 2005, potentially jeopardizing access. But Medicare deserves significant attention as well, both to quality and costs, two goals that are sometimes in conflict. The good news is that truly modernizing Medicare—paying attention to the most important health needs of older individuals and focusing on care that works—can actually improve quality while constraining cost.

This article also appeared in the new Hastings Center Blog, the Health Care Cost Monitor.

Follow the Money?

2009-04-20T15:42:00.005-04:00

Most Americans have probably never heard of it, but MedPAC is arguably one of the most influential organizations in the health care arena. The Medical Payments Advisory Commission is a non-partisan, independent Congressional agency established by Congress in 1997 to advise on issues relating to the Medicare program. That translates mainly into advice on reimbursement policies, but MedPAC’s mandate also includes addressing access and quality of care.

What is MedPAC and just what does it do? It is comprised of 17 commissioners, including a chairman, who serve staggered 3-year terms. They are appointed by the Comptroller General—another important position that most of us have never heard of. While the 17 members of MedPAC are a distinguished group of professionals who come from diverse fields including medicine, nursing, health policy, and economics, they all have other jobs and could not possibly carry out their mission without a strong staff to do the heavy lifting. In fact, MedPAC’s website lists an executive director, an associate director, a deputy directory, 8 principal policy analysts, 9 senior analysts, 2 analysts, and 2 research assistants, along with miscellaneous other aides and consultants. Based on my experience as a member of the Massachusetts Public Health Council, the supposed seat of health care policy in the state, it is the staff that does most of the work and holds the real power.

The work of MedPAC is evident in its “Reports to Congress,” which appear in March and June of each year, as well as in an annual Data Book. The most recent Report, released in March 2009, all 424 pages of which are available on the web, gives some indication of the breadth and depth of MedPAC’s work. The introduction by Chairman Glen Hackbarth (who incidentally is a founding member of the multi-specialty group practice where I work, Harvard Vanguard Medical Associates), sets the scene. Hackbarth identifies 5 major imperatives for Medicare reform: redesigning and rebuilding primary care, moving beyond fee for service to a more integrated and coordinated model of care, revamping the Medicare Advantage program to reward excellent performance, working to constrain costs by modifying the reimbursement system, and investing in comparative effectiveness research.

To get a flavor of just how far MedPAC goes in its recommendations, consider just 3 of its specific suggestions, those dealing with updating the payment system, revising the Medicare Advantage Program, and modifying the reimbursement system for hospice. Every year, MedPAC tells Congress what changes to make in how much Medicare pays for a variety of services. One of the areas the report addresses this year is payments for expensive imaging services—payments for MRI and CT and PET scan studies. Hidden behind its very dry language, MedPAC does something quite radical: The Commission recognizes that its system for deciding how much to pay for such procedures has been based on the assumption that the equipment is operated 25 hours/week. As a result, providers have an incentive to purchase expensive machinery, even if they have only modest needs, but then to use it as much as possible. The latest report advises modifying the reimbursement formula by assuming that equipment is in operation many more hours each week, thus decreasing the per scan reimbursement and potentially slowing the rapidly rising number of imaging studies ordered each year.

A second area tackled by MedPAC is the Medicare Advantage program. To encourage older individuals to sign up for a private plan rather than the government program, third party payers have been encouraged to come up with capitated plans as alternatives to conventional fee for service Medicare. Some of these plans offer coordination of care and a truly integrated model of health care, which are widely held to be desirable for older patients. Others don’t offer such a comprehensive program but nonetheless receive roughly 14% more from Medicare than do fee-for-service plans providing comparable care. MedPAC wants to make sure that it’s getting value for its money by eliminating what it sees as the windfall offered to capitated programs.

Finally, the report discusses Medicare hospice reimbursement, which has been essentially unchanged since the hospice benefit was introduced in 1982. Between 2000 and 2007, about 1000 new hospice providers entered the market, almost all of them for-profit agencies. The Commission recognizes that many of these hospices are making a sizable profit by enrolling lots of long stay patients: Hospices are paid a fixed per diem rate, so if they care for many low-maintenance patients over an extended period of time, they make money. The new proposal is to pay hospices a higher daily fee initially, when the hospice spends a disproportionate amount of time and effort evaluating a patient and providing whatever medications and equipment the patient needs, then pay a lower fee for intermediate days, and pay a higher fee for the last few days of life, when resource utilization goes up. While this approach is entirely rational as a way to prevent hospices from bilking Medicare by, for example, enrolling nursing home patients with dementia for long periods of time, it has the potential to further discourage hospices from enrolling cancer patients who are interested in pursuing palliative but expensive treatments such as radiation therapy or oral chemotherapy.

MedPAC’s suggestions are based on an extensive analysis of Medicare data—data which are published in its annual data book. They are often very reasonable strategies to improve the existing system of care. But while the Commission has an excellent grasp of the context within which reimbursement occurs and professes interest in developing a correspondingly broad set of recommendations, its concrete proposals tend to deal fairly narrowly with payment issues. The main job of the Commission, after all, is to advise on Medicare payment.

Proposals for reforming America’s health care system are multiplying faster than any other type of innovation in medicine—in fact, I haven’t had written a blog posting in some time because each time I prepare to respond to one plan, another one appears. The New England Journal of Medicine, Health Affairs, and the Annals of Internal Medicine have all featured numerous articles on health care reform. One piece just published this month, emanating from something called the FRESH-Thinking Project, boasts a record 50 authors. Most of these articles, like MedPAC, focus on reforming the reimbursement system. They assume that financial incentives drive medical practice. And they are of course right to follow the money, as Deep Throat famously told journalist Bob Woodward. But important as finances are, and insightful and pragmatic as MedPAC is, there is more to health care reform than modifying the payment system. The payment system is essentially the same throughout the country and yet there is enormous variation in the way medicine is practiced. Very little of that variation is due to differences in how sick people are in New Jersey (the highest spending area of the country) and North Dakota (the lowest spending area). The root cause of variation is differences in the culture of medicine. It is the sociology of medicine that we must understand before turning to MedPAC to implement change in the reimbursement system.

A Tale of Two Patients

2009-02-12T14:56:00.002-05:00

The primary caregiver for her three grandchildren, 59-year-old Lola Sanchez tried unsuccessfully to go to the kitchen to prepare a snack for the four-year-old and found something was terribly wrong with her right leg. She managed to call an ambulance, but by the time the paramedics arrived, Mrs. Sanchez could no longer speak distinctly and her entire right side was paralyzed. Her blood pressure and her blood sugar were sky high. When she reached the hospital emergency room, she was in a coma. Two days later she was dead, a victim of a massive intracerebral hemorrhage, caused by untreated high blood pressure and inadequately controlled diabetes. Mrs. Sanchez had no health insurance.

In the intensive care unit of the same hospital, Samuel Wang, a 92-year old man with advanced dementia, lay curled up in an ICU bed, dependent on a ventilator to breathe. He had been brought in from a nursing home two weeks earlier with pneumonia. Mr. Wang, who could no longer speak or recognize his family, had aspirated—his food had gone into his lungs, a common occurrence in the final stage of Alzheimer’s disease. Because his family asked the physicians to “do everything” to prolong his life, he remained attached to the ventilator, receiving artificial nutrition through a feeding tube in his stomach. A pacemaker helped keep his heart going. One month after admission, he died after an unsuccessful attempt at cardiopulmonary resuscitation. Mr. Wang was enrolled in Medicare, which together with his supplementary medical insurance, paid the entire $125,000 cost of his hospital stay.

These two scenarios are far from uncommon. According to a recent Urban Institute report, 27,000 Americans died of preventable causes because they lacked medical insurance in 2006. Since most people like Mrs. Sanchez with high blood pressure are asymptomatic, they often do not visit the doctor if they are uninsured. But over the long run, untreated hypertension predisposes to stroke. In the same year, according to researchers at the Dartmouth Institute for Health Policy and Clinical Practice, Medicare spent $10 billion on non-beneficial care for elderly individuals with chronic disease such as Mr. Wang. Expenditures on diagnostic tests, physician visits, and hospitalization are three times higher in some areas of the U.S. than in others, without resulting in any better outcomes.

The current administration hopes to help people like Lola Sanchez by increasing access to care. Access is critical: fully 75 million adult Americans are uninsured or under-insured, resulting in the U.S. coming in last among 19 industrialized nations in the rate of preventable deaths, according to a new analysis by the Commonwealth Fund. But it is irresponsible to improve access, adding to the total government expenditure on medical care, without simultaneously addressing its cost. Currently, Medicare and Medicaid alone account for nearly 5% of GDP and Peter Orszag, Director of the Office of Management and Budget, has projected this will rise to 20% by 2050 unless we take dramatic steps to curb escalating growth.

In the move toward health care reform, cost has received short shrift except to stimulate exhortations to limit waste and inefficiency. Waste—ordering duplicate diagnostic tests because of a lack of an electronic medical record, or prescribing expensive brand name medications instead of far cheaper generic equivalents—makes a modest contribution to spiraling medical costs. The main culprit, according to most medical economists, is the American obsession with high tech medicine. Physicians, patients, and families believe that more is better. The faith in technology is further fueled by device-manufacturers, pharmaceutical companies and the media, as well as by our health care reimbursement system. As health care reform proceeds, we should focus on access, quality, and cost. That will mean using our technology selectively in those who have a reasonable chance of benefiting. It will mean changing the medical culture to ensure that patients nearing the end of life do not routinely undergo pacemaker insertion and are not regularly admitted to the ICU, but instead receive competent and compassionate palliative care.

Movies, Restaurants, Hotels—and Now Nursing Homes

2009-01-02T09:06:00.005-05:00

With considerable fanfare, the Centers for Medicare and Medicaid Services (CMS) released a new rating system for nursing homes in mid-December. Depending on your perspective, the state where I live, Massachusetts, either did very well—it was among the top 10 states in the US—or not so well—it has a lower percentage of five-star and a higher percentage of one-star nursing homes than neighboring New Hampshire, Connecticut or Maine.

All rating systems are subject to criticism and this latest one is no exception. For some time, CMS has published Nursing Home Compare, which allows consumers to see how a particular nursing home scores using a variety of indicators. The new approach tries to boil down all the assessments to a single summary statistic. That statistic (the number of stars) in turn depends on just three measures: the result of health inspections, the staffing ratio, and a quality measure. Arguably the most important—and controversial—of these is the quality measure. For long stay nursing homes, the rating system uses 7 different measures to come up with its rating, ranging from the percent of residents who report untreated pain (a good measure but dependent on self-reporting by the facility) to the frequency of urinary tract infections (of dubious importance as many nursing home residents have bacteria in their urine that is of no significance). For short stay facilities (rehab or post-acute care), the rating system uses only 3 different measures to derive its composite quality rating: the presence of acute confusion (delirium), pain, and pressure ulcers. None of the three is corrected for the severity of illness of the patients in the facility. It’s not clear to me that this simplified rating system is an improvement over the previous more nuanced reports. But what is indisputable is that nursing homes in Massachusetts vary enormously. Facilities awarded five stars are probably pretty good and those with one star are probably pretty poor. What, then, should the state do to promote better quality?

The prevailing approach to ensuring quality relies on an extensive system of federal regulations that are enforced by the state Department of Public Health. Teams of surveyors make unscheduled inspections to determine whether facilities are in compliance with the regulations and issue citations for any “deficiencies.” The results of these surveys are public and may result in penalties ranging from fines to loss of Medicaid and Medicare certification. Nursing home quality has improved over the past 10 years, and the regulations probably played a role in stimulating change, particularly when combined with a mandatory resident assessment system, but clearly there is more work to be done.

How should Massachusetts promote further improvement? Perhaps it is time to move from a punitive system to one that offers incentives for achieving quality. An interesting experiment that bears watching is underway in Minnesota, which has introduced pay-for-performance into nursing homes. But pay-for-performance tends to encourage institutions to concentrate only on those areas in which they know they will be measured, to the detriment of other areas. And by rewarding facilities for outcomes rather than for improvement, they decrease reimbursement to precisely those sites that need an infusion of funds to improve.

Over the long run, Massachusetts can hope to improve nursing homes by making a career in long-term care attractive. Physician interest in nursing home care has grown, though modestly: medical directors of nursing homes now have their own professional society and an academic journal. Nurse practitioners are playing an increasing role as primary care clinicians in the nursing home, where they have contributed to better medical care and decreased hospitalization rates along with a high degree of family satisfaction.
The last frontier is the nursing assistant, who continues to be poorly paid, to have limited opportunities for advancement, and to suffer from high rates of job-related injury.

The Massachusetts Act to Promote Cost Containment, signed into law in August, 2008, commits the state to a major effort to attract primary care physicians and nurses through enhanced educational opportunities and loan forgiveness programs. We need to broaden that initiative by developing a career ladder for nursing assistants, creating a variety of positions between the Certified Nursing Assistant (who typically receives 75 hours of classroom training and 100 hours of on-the-job training) and the Registered Nurse (who may have spent 4-5 years getting a Bachelor of Science in Nursing). Only when all those caring for nursing home residents take pride in their work, when they receive respect for what they do and have autonomy in their jobs, can we expect both quality of care and quality of life to improve in nursing facilities.

A shorter version of this posting appeared on Commonhealth

Don't Just Do Something, Sit There

2008-12-04T16:28:00.004-05:00

All over the country, hospitals are setting up “rapid response teams.” The idea is to intervene quickly when a patient looks as though he might be going downhill—for example if his blood pressure is falling or he’s breathing very rapidly. The expectation is that this preventive approach will avoid cardiac arrests, emergencies in which a patient’s heart stops and respiration ceases. Massachusetts recently passed a law that requires hospitals to put rapid response teams in place (The Act to Promote Cost Containment, Transparency, and Efficiency in the Delivery of Quality Health Care). The only problem is that there is now pretty good evidence that the teams don’t save lives.

A study in this week’s Journal of the American Medical Association is the first large, carefully conducted study of the effect of a rapid response team, taking into consideration normal seasonal variability in the rate of cardiac arrest and death. Carried out at a medium sized tertiary care hospital in Kansas City, Missouri, the investigators found there was no decrease in the frequency of cardiac arrest after the intervention was introduced and no change in the mortality rate at the hospital.

What was particularly striking about the study is that at first glance, it looked as though the rapid response teams were effective: the crude code rate (number of cardiac arrests per 1000 hospital admissions) fell from 11.2/1000 to 7.5/1000. But when the physicians carrying out the study adjusted for normal month-to-month changes in the frequency of cardiac arrests, the differences vanished. Failure to look at the consequences of rapid response teams over a long enough period of time and to calculate the effect of seasonal changes may have accounted for the positive results in earlier, preliminary studies.

The other startling finding in this study is that of the 70 patients who died despite the rapid response team interventions, fully 46 decided on a do-not-resuscitate status after their evaluation. In other words, the rapid response team stimulated a discussion among physicians, patients, and families about the fact that the patient was very ill and doing poorly. The result of this discussion, in many cases, was an explicit decision to limit invasive and painful interventions that had only a small chance of success.

What can we learn from this provocative study? The first is that it’s a bad idea to institute sweeping changes in medicine without good evidence that the changes will have the desired effect. Several physicians expressed skepticism about rapid response teams when they were becoming the vogue (for example, "Rapid Response Teams—Walk Don’t Run," JAMA 2006). A review of the subject done by the Cochrane Collaborative, a group that undertakes systematic reviews of all kinds of questions in medicine to determine whether the preponderance of evidence support their use, found no evidence of benefit from rapid response teams. But despite these calls for caution, the Institute for Healthcare Improvement recommended that all hospitals adopt rapid response teams. The intervention may turn out to be more effective than the current study suggests—the JAMA study was at a single hospital and used a particular combination of two ICU nurses and a respiratory therapist with ICU physician backup; other institutions using other types of clinicians may achieve different results. But what is clear is that sweeping policy changes in medicine, changes that involve many resources and great expense, should be preceded by correspondingly extensive evaluation.

The second conclusion to be drawn is that the best time to engage patients and families in advance care planning—talking about what approach to medical care they want if they are extremely ill—may not be when they are doing well and may not be when they are in the middle of a crisis. Rather, the best time to consider what they hope treatment will accomplish for them, and what treatments are consistent with their goals, may be when they have just come through a serious illness. We know, for example, that patients are particularly susceptible to advice to stop smoking right after they had had a heart attack. That, of course, is a bit late, but a recent study found that after any hospitalization, whatever the medical problem, patients are good candidates for giving up smoking (Rigotti et al, “Smoking Cessation Intervention for Hospitalized Smokers," Archives of Internal Medicine, October 2008). While it would be premature to conclude that advance care planning is best done right after a close call—just as it was premature to conclude that rapid response teams are the way to go based on very preliminary data—it’s an area to explore further.

Medicare for More

2008-10-28T16:10:00.001-04:00

The next administration will have an historic opportunity to reform the American health care system. The federal government might actually do something about the fact that 45 million Americans are uninsured, that health care costs are soaring (with spending on Medicare and Medicaid alone now accounting for 4.6% of GDP and on track to reach 20% by 2050), and that despite our extraordinary level of expenditure on health care, the U.S. ranks in last place among 19 industrialized nations in terms of quality of care (see my posting ‘F’ is for Failure on 7/22/08). Unfortunately, neither Obama nor McCain has put forward a plan that is likely to solve our problems.

What would fix the situation would be to expand Medicare to cover all Americans, as proposed by Senator Edward Kennedy (see “Kennedy and Dingell Fight for Medicare for All,” http:/kennedy.senate.gov/newsroom/press). This approach has the potential to insure everyone while reducing costs and enhancing quality. And it would finally bring the U.S. in line with all other developed nations: countries such as Australia, England, France, Germany, and Canada all provide some form of mandatory universal health insurance for their citizens. They also all have lower infant mortality rates, lower rates of preventable death in people under 75—at a per capita cost half that of the U.S.

When Congress created the Medicare program in 1965, it acted in the belief that older people were somehow exceptional—they were sicker, they lived on fixed incomes, and they did not have employer-based health insurance. While some physicians, politicians, and economists hoped that Medicare would be the wedge opening the door to health insurance for all, Medicare was passed precisely because it did not promise mandatory health insurance (see the chapter, “Medicare for the Middle Class” in David Rothman’s insightful book, Beginnings Count: The Technological Imperative in American Health Care, NY: Oxford University Press, 1997). Single payer insurance was touted then and continues to be seen today as “socialized medicine,” but the expansion of Medicare does not imply a government-run system. While Medicare is publicly financed, it is a private health care system administered by private intermediaries that gives patients an extensive array of choices of physicians and hospitals.

Ironically, there is one part of the health care system in which government is actually in the business of providing medical care, and it’s a part of U.S. health care that McCain vigorously supports. That’s the Veterans Health Administration. The VHA operates the largest integrated health care system in America, which includes hospitals, outpatient clinics, nursing homes, and rehabilitation facilities. A uniform medical benefits package is available to all veterans and covers primary care, outpatient and inpatient services, and prescription drugs. Additional benefits, such as nursing home care and dental care, are available to some vets, depending on their “priority level.” The VA system is known for its pioneering work in managing chronic conditions, for its comprehensive electronic medical record, and for other quality improvement measures.

No one is recommending expansion of the VA system—it’s just not a politically tenable solution. But expanding Medicare, while clearly a difficult sell, would make a great deal of sense. Medicare is far more efficient than private health insurance plans: Medicare’s overhead is about 2%, whereas private insurers take an average of 13% of premium dollars for overhead and profit, with large managed care plans taking as much as 30% (see David Himmelstein and Steffie Woollhandler, “Why the US Needs a Single Payer Health System,” www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_systemphp). Not only would it be simple and efficient, but paradoxically, the existing Medicare program would do a better job serving the non-elderly than it does with those it currently covers.

Medicare was established to cover acute, time-limited illness. By far the largest component of Medicare expenses continues to be for hospitalization. Of the $402 billion spent by Medicare in 2006, 29% went to inpatient care, compared to 15% for physicians, 12% for outpatient drugs, and 3% for home health care (see the MedPac report, www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf). Medicare was designed to address a disease such as pneumonia in which the patient rapidly develops a significant illness, is hospitalized for a week or so (covered after a deductible), and is then discharged home to complete his treatment by taking a few days’ worth of oral antibiotics. By contrast, the typical Medicare patient today has multiple chronic conditions, which are best cared for using a model of chronic disease management: 75% of the elderly have at least one chronic disease and 50% have two or more chronic illnesses. While the Medicare Modernization Act of 2003 addressed some of the needs of today’s older patients, principally by offering a prescription drug plan, the program is still heavily weighted toward the treatment of acute illness. Its incentives, for example, promote hospital care rather than treatment in the home or the nursing home (see chapter 4, “The Trouble with Medicare,” in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, Cambridge, MA: Harvard University Press, 2006). But this focus on acute care is precisely what most younger, healthier patients need. Some middle aged individuals have congestive heart failure or chronic obstructive pulmonary disease and similarly, some children suffer from chronic conditions such as asthma or diabetes; the majority do not.

The most rational approach to American health care reform is to offer Medicare to everyone, perhaps the existing plan for younger Americans and a modified version for the elderly and the disabled. The U.S. should guarantee health insurance by providing a basic insurance plan (Medicare) paid for out of tax revenues. Patients could choose to exchange their Medicare benefit for a private plan or to supplement their basic plan with a more comprehensive plan for which they would pay directly. A new, expanded Medicare program would be ideally positioned to address the other pressing issue that both Congress and the presidential candidates have largely ignored—the soaring costs of care (see my blog posting, “Going for Broke” on 12/28/2007) by controlling what medical interventions it is willing to cover and how much it will pay for them.

Massachusetts Health Care Reform--Act 2

2008-09-04T09:38:00.001-04:00

Why isn’t everyone talking about the new Massachusetts Health Care Reform law? Is it that the Governor signed the legislation into law during the dog days of summer? Is it that the act, which introduces cost containment measures and quality improvement measures, isn’t a single issue bill like the first health care reform law, which expanded coverage to almost all Massachusetts residents?
The “Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care,” (S2863) is an important piece of legislation which should be getting a great deal more local and national attention than it has. But for all its virtues, it also has some major flaws—and it won’t make much of a dent in the skyrocketing cost of health care.
The law calls for two new programs: a pharmacy drug detailing program and a health care workforce center. The detailing program is modeled on an intervention proposed by Harvard researchers Jerry Avorn and Stephen Soumerai 25 years ago: they wondered whether the same kind of clever strategies used by drug companies to promote their wares could be used to provide physicians with accurate information about the safety and cost-effectiveness of drugs by using trained pharmacists as “un-sales reps.” Their 4-state randomized trial found that academic detail men were accepted by the overwhelming majority of physicians—and that the program saved $2 for every $1 in costs (Jerome Avorn and Stephen Soumerai, “Improving Drug-Therapy Decisions Through Educational Outreach. A Randomized Controlled Trial of Academically Based ‘Detailing,” New England Journal of Medicine 1983; 308: 1457-63). With the new health reform law, the Massachusetts Department of Public Health has been charged with arranging face to face visits to “inform prescribers about drug marketing intended to circumvent competition from generics.” How effective this strategy will be in 2008 is unclear, now that drug companies are not only targeting physicians but are also pouring money into direct-to-consumer advertising.
The law also calls for the establishment of a Health Care Workforce Center whose main purpose is to increase the number of primary care physicians in the state. Specifically, the program will set up a loan repayment program for doctors who go into primary care. A related part of the bill requires the University of Massachusetts Medical School to increase its enrollment, to add residency slots for primary care, and to waive tuition for applicants who agree to practice in under-served areas. Taking steps to enhance primary care is laudable, but as demonstrated in the recent Institute of Medicine Report, Retooling for An Aging America: Building the Health Care Workforce (see my blog entry, “the Boomers are Coming, the Boomers are Coming,” from May 9, 2008), what we desperately need is not just primary care physicians and nurses, but also a diverse array of individuals equipped to care for our growing geriatric population.
One of the few provisions of the new law that did garner quite a bit of attention is the “gift ban,” which requires health care providers to publicly report any gifts they receive from pharmaceutical or medical device manufacturing companies and which bans certain kinds of gifts altogether. Drug companies protested loudly, but as Dr. Jerome Kassirer argued in his book, On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Life ( NY: Oxford University Press, 2005), the standards promulgated under the law constitute are not radical or draconian: they simply represent a basic, ethically justifiable set of guidelines for corporate and professional conduct.
Massachusetts Health Reform, Act 2 contains a hodgepodge of other provisions designed to improve quality and efficiency of care. It requires hospitals to develop rapid response teams for “deteriorating patients,” a measure that could lead to the installation of “panic buttons” in every patient room—not necessarily a good idea. The concerns of families need to be respected and addressed, but surely it should be professional judgment and not anxious families that dictate the summoning of an emergency response team. The act will require hospitals to implement computerized physician order entry systems by 2012 and electronic medical records by 2005—which is probably a good thing, but not as well-supported by hard evidence as I would like. As Drs. Pamela Hartzband and Jerome Groopman argue in their essay, “Off the Record: Avoiding the Pitfalls of Going Electronic” (New England Journal of Medicine 2008; 358: 1656-8), electronic medical records can “constrain creative clinical thinking” and computers can “become a barrier between patients and physicians.” And the act calls for new initiatives in end of life care and in home care—laudable but at this point vague and without substance.
All these components of the new law focus on improving the efficiency and quality of medical care. The only measure that seeks to control costs by actually changing the way we do things in medicine, not merely by ensuring that we do what we have been doing but with greater efficiency, is the requirement that physicians wishing to build ambulatory surgery centers apply for and receive a “Determination of Need” certificate. The engine that drives costs is technology and right now hospitals and medical groups can build new outpatient centers for doing procedures with essentially no restrictions. And in medicine, if you build a new machine, it will be used, regardless of whether one more scanner or surgical suite actually improves the population’s health. Dr. John Wennberg of Dartmouth, who has devoted his career to the exploration of regional variations in American health care, has found repeatedly that the number of elective procedures in various parts of the country depends not on need but on the capacity to perform those procedures (see for example John Wennberg and Alan Gittlesohn, “Small Area Variation in Health Care Delivery,” Science 1973; 182: 1102-8). Controlling the untrammeled growth of technology by evaluating the need for the centers that house that technology has the potential to have an enormous effect on the future cost of medical care. The caveat is that the legislation needs to have teeth, and it is unclear how the requirement that ambulatory surgical centers demonstrate “need” will play out: how is “need” to be defined and measured? Will the cost of the center be a consideration or if there is “need” (read “demand”), is any cost acceptable? Unfortunately, current Massachusetts Determination of Need regulations for hospitals include no such considerations.
Massachusetts Health Care Reform—Act 2 is an important step in the right direction. But if we want to truly change the way health care is delivered and provide high quality care at an affordable cost, we better start working on Massachusetts Health Care Reform—Act 3.

"F" is for Failure

2008-07-22T09:11:00.002-04:00

Federal Reserve president Ben Bernanke stood in front of the Senate Finance Committee a month ago and delivered some bad news: the cost of health care is spiraling out of control. And costs will continue to “rise relentlessly,” he said, unless Congress substantially overhauls the health care system (Robert Pear, “Fed Chief Addresses Health Care and Its Cost,” New York Times, June 17, 2008), which it has shown no inclination to do.

At the same time, Bernanke pointed to two other problems with U.S. health care: access and quality. It is these two areas that get most of the attention from lawmakers. Just how poorly the U.S. is doing in these two domains was emphasized yet again in a report released last week by the Commonwealth Fund. The results of the “National Scorecard on U.S. Health System Performance, 2008” are shockingly poor. Lumping all 37 indicators of quality devised by the Fund into one measure, the U.S. scored a 65 out of 100 (down from 67 in 2006). (“Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008,” available at www.commonwealthfund.org.) I'd call that a failing grade.

In terms of access, the average score was 58, with 75 million working age adults—42% of the population—either uninsured or underinsured, up from 61 million (35%) in 2003. The direct consequence of lack of coverage is that the U.S. is now in last place among 19 industrialized nations in terms of deaths that could have been prevented with timely and effective care. In terms of quality, only 41% of adults with hypertension were adequately treated—and only 21% of those with hypertension who had no health insurance.

What continues to get relatively little attention is Bernanke’s first point, the high cost of health care. The Commonwealth report notes that the U.S. spends twice as much per capita as other major industrialized countries on health care, though it fares worse on virtually all outcome measures. Even within the U.S., higher levels of spending often translate paradoxically into lower quality care: among Medicare patients treated for heart attacks, hip fractures, or colorectal cancer, the regions of the country with the lowest mortality rates also had lower total costs.

The presidential candidates say laughably little about health care costs. A side-by-side comparison of their statements on health care reveals only a few points about cost. The democratic and republican proposals are limited, unimaginative—and remarkably similar (see the analysis by the Henry J. Kaiser Family Foundation, “2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary,” at www.health08.org.)

Both Obama and McCain advocate malpractice reform and greater competition among insurance plans. Both candidates allude to the high cost of prescription drugs and favor encouraging the use of generics, and both talk in general terms about the need for increased attention to preventive care and the treatment of chronic conditions. These are all important issues but they will not solve the problem of the high cost of care. Obama specifically advocates investing in electronic medical records and health information technology (to improve efficiency) and McCain wants to give consumers more information about treatment options (in the naïve hope that they will choose less expensive care). But neither talks about the real culprit—the excessive use of high cost technology, even when it is of little or no benefit (see for example Kenneth Thorpe et al, “Which Medical Conditions Account for the Rise in Health Care Spending? Health Affairs, August 25, 2004).

The New York Times, by contrast, is finally beginning to understand the role of technology in driving up the cost of medical care. Over the last month, the Times has featured an article about the use of Avastin (Bevacizumab), a form of chemotherapy costing as much as $100,000/patient/year (Gina Kolata and Andrew Pollack, “Costly Cancer Drug Offers Hope, But Also a Dilemma,” New York Times, July 6, 2008) and another article about the use of an implantable defibrillator in a 99 year old woman (Anemona Hartcollis, “Rise Seen in Medical Effort to Treat the Very Old,” New York Times, July 18, 2008). But both articles wistfully conclude that we are facing a heart-rending dilemma, what the journalists view as an insoluble conflict between the legitimate wish of sick patients to get better and the societal need to constrain costs.

In fact, there is a perfectly reasonable solution: physicians should be restricted in their use of expensive technology to situations in which it has been demonstrated to be beneficial; and Medicare should set reimbursement for high tech interventions at a level reflecting their cost-effectiveness. In the case of Avastin, for example, it may be rational to prescribe the drug for those forms of cancer for which it has been shown to be beneficial, even when the benefit is the prolongation of life by only several months, but not for other forms of cancer for which efficacy is entirely speculative. Moreover, Medicare should set reimbursement at a rate commensurate with benefit, as is done in Australia. When this has been done in the U.S., as when the Centers for Medicare and Medicaid set the reimbursement rate for the left ventricular assist device (an invasive, expensive, but occasionally modestly effective means of treating advanced heart failure) well below the manufacturer’s charges, the rate of use stayed very low. In the case of the defibrillator/pacemaker, which in the Times example was inserted to prevent symptoms of dizziness and weakness, it would have sufficed to implant a pacemaker (cost $11,712 in FY 2005). There is no need to deprive a patient of an effective treatment that will ameliorate symptoms simply to control costs. The problem is that the patient was given a combination defibrillator/pacemaker, a sophisticated device intended to prevent sudden death as well as to counteract a low heart rate—more than doubling the cost ($28,442 in FY 2005) without conferring any advantage in terms of quality of life. The total annual spending on implantable defibrillators in the U.S. is over $1 billion/year, some of which is clearly beneficial, but some of which is not.

Improving access and quality, while tremendously important, will just exacerbate the cost issue if we tackle them without simultaneously addressing cost. It is time for Congress, the Administration, the presidential candidates, and the American people to stop burying their heads in the sand. U.S. health care just got a failing grade: if you sent your child to an expensive private school and he came home with F’s and D’s on his report card, would you blithely and unquestioningly continue to fork out exorbitant tuition payments because the headmaster assured you the school was the best in the world?

The Boomers are Coming, the Boomers are Coming

2008-05-09T17:20:00.002-04:00

I often wonder just how many billions of dollars Americans spend every year on producing reports. Think tanks, government agencies, and academic departments, not to mention corporations, are forever releasing reports. Most of them are filed away, largely unread, certainly unheeded. Every so often a report actually has a major impact—on policy, on behavior, or on public understanding. The Surgeon General’s Report, The Health Consequences of Smoking, first released in 1971, led to a campaign to promote health by quitting smoking. As a result, per capita cigarette consumption is down in the U.S., as are the incidence of lung cancer and the death rate from heart disease, the primary diseases attributable to smoking.

Several weeks ago, the Institute of Medicine released a new report, Retooling for an Aging America: Building the Health Care Workforce. With luck, this will be one of those reports that triggers a response, but given its low key presentation, unsexy topic, and unpopular message, I fear it will be ignored.

Written in the non-inflammatory, academic style of the IOM, Retooling quietly argues that if we are to provide high quality care for the baby boomers in their old age, we need to geriatricize both health care professionals and personal caregivers. In an equally subdued voice, the report’s writers also conclude that we need to overhaul our entire approach to medical care. They’re right. I hope someone is listening.

The first of the 78 million baby boomers will turn age 65 in 2011. When the last baby boomer turns 65 in 2030, “older adults” will make up 20% of the population, up from the current 12%. Unless we find a cure for Alzheimer’s disease in the immediate future, which is extremely unlikely, and unless we can prevent or cure osteoarthritis, diabetes, and vascular disease, the boomers will develop all these problems in phenomenal numbers. Although they will be healthier than their counterparts a decade ago, many will eventually develop multiple medical problems and will need both health care and personal care if they are to hope to have a reasonable quality of life.

What the new IOM report tells us is that we do not have enough physicians, nurses, social workers, and physical therapists with special expertise in taking care of older adults to handle this enormous wave. We do not have enough home health aides and other personal care attendants to assist older people with basic “activities of daily living” such as dressing, bathing, and eating, given that we can expect that in 2030, over 9 million people will need this kind of help (that’s based on another important report, this one by Robert Friedland, writing for the Georgetown University Long-Term Care Financing Project in 2004: Caregivers and Long-term Care Needs in the 21st Century: Will Public Policy Meet the Challenge?) And informal caregivers—the family members and friends who provide the bulk of the care to frail older Americans—are already overwhelmed physically, emotionally, and financially by their responsibilities.

Retooling for an Aging America tells us very clearly what steps we need to take to begin to fix this problem. It uses the bland language of “increasing recruitment and retention” of personnel, but quickly gets to the central issue: few people are going to jump at the chance to take care of the elderly, whether they be physicians, nurses, or home health aides, unless they receive appropriate recognition, social and financial, for their work. That means compensation needs to go up—a lot. Currently, geriatricians earn on average less than the primary care physicians who see a more diverse population of adults, who in turn earn far less than gastroenterologists or cardiologists. Taking care of frail older people takes extra time, it requires coordination of multiple services, and it necessitates discussions with family members, all of which are reimbursed poorly or not at all. The suggestion that public and private payers provide financial incentives to increase the number of geriatric specialists in all health professions is key. So too is the recommendation that professionals with special expertise in geriatrics receive enhanced reimbursement, though given budgetary constraints, it seems more plausible that physician incomes will need to be redistributed than that payment to those on the bottom end of the totem pole will rise. Similarly, aides who provide hands on care for older people are among the most poorly paid workers in our society, they have the highest rates of on the job injury, and they have few opportunities for advancement. Without better wages, adequate fringe benefits, and an attractive career ladder, it’s hard to imagine the situation will change. The recommendation that state Medicaid programs increase pay and fringe benefits for direct care workers and establish wage floors is an important first step. It does not, however, go nearly far enough, and is not as sweeping as another report that is probably already collecting dust—the study prepared by the much maligned President’s Council on Bioethics in 2005, Taking Care: Ethical Caregiving in Our Aging Society.

It is in the arena of “redesigning models of care” that the report is at its most radical. It begins with the tepid comment that “care that is currently provided to older adults often falls short of acceptable levels of quality.” Then it heats up a bit, acknowledging that the vision of health care services it proposes represents “a major departure from the current system” that will require changes in the ways services are “organized, financed, and delivered.” The report recommends three fundamental changes: care must be comprehensive, it must be efficient, and it must rely on the active participation of older adults.

By comprehensive care, the report means that our current fragmented system has to go. Right now, Medicare doesn’t have an incentive to provide home care because it would be cheaper for patients to go into a nursing home (paid by Medicaid or private funds) than it is for patients to stay at home and have a visiting nurse and physical therapist (paid by Medicare). Today, physician practices shy away from using multidisciplinary teams, the backbone of good geriatric care, because this kind of care is inadequately compensated. Comprehensive care means including both acute care and long term care (at home, in assisted living, and in nursing homes--currently the stepchild of the American health care system) under one umbrella.

By efficient care, the report means that we need to create seamless transitions between the sites where older people receive health care such as the office, the hospital, the skilled nursing facility, and the home setting. This will require better systems of communication and widespread adoption of a single electronic medical record.

By active participation, the report implies that effective management of chronic diseases—and almost a quarter of Medicare beneficiaries have at least 4 chronic diseases—requires self-management. Given that many older patients cannot, by themselves, engage in self-management, a more realistic recommendation would be the involvement of families in all aspects of health care.

So far, Retooling has been written up in the Wall Street Journal and the LA Times but not, as best I can determine, in the New York Times or the Washington Post. This mild-mannered report, which makes reasonable suggestions but says little about how its recommendations might be implemented (or paid for) could well be destined for the dustbin. Let’s hope not. We really need to do something to prepare for the baby boomers, and we need to start now. Write your congressman. Whisper in the ear of the presidential candidates, who have said little or nothing about long term care. Act now.

Don't Look Back

2008-04-16T15:48:00.003-04:00

For 35 years, the Dartmouth Atlas of Health Care has been publishing startling data on regional variation in the amount of money spent on medical care in the U.S. It has consistently shown—and the newest version of the Atlas, released this month, is no exception—that Medicare spending on chronically ill patients during the last 2 years of life varies enormously across states (Dartmouth Atlas of Health Care 2008, www.dartmouthatlas.org.) . In recent years, for example, California spent $57,914/patient compared to Iowa, which spent $33,864/patient in the 2 years before death. When the brains behind the Atlas looked at what all the extra money is spent on in “high expenditure” states like California, they found that it’s not spent on effective care (interventions that have been shown unambiguously to be beneficial) and it’s not spent on preference-sensitive care (treatments that some patients select while other patients choose other equally effective treatments with a different side effect profile). Rather, it is lavished on supply-sensitive care: services whose supply determines utilization, without any clear-cut benefit. In states like Massachusetts, for example, with a disproportionately high number of specialists and lots of technology, patients have correspondingly more doctor visits with specialists and receive more high tech diagnostic tests.

It’s not that some areas have more specialists and fancy equipment per capita because they have a higher percentage of sick people in the population. When age and gender are taken into consideration, the rates of illness in California and Iowa are remarkably similar. California just has more medical resources per person, so it devotes more resources to the care of Californians. As a result, patients with chronic illness in some parts of the country spent 6 days in the hospital during their last 6 months of life, while patients in other regions spent 22 days.

The critical question is whether there is any added value to the extra expenditures, and if so, is it worth the additional cost? The creators of the Dartmouth Atlas say there is no additional value, since all the patients they studied died, regardless of what was spent on them.

But this analysis looks only at chronically ill patients who died and then asks what kind of care they received in the 2 years before their deaths. There’s a problem with looking back in this way. The problem is that 2 years before they died, their physicians did not know they were going to die. The real question is, did those chronically ill patients who lived benefit from all the extra medical care they got? What we need to do to answer this question is to study a group of chronically ill patients in a high roller state like New York and the same number of comparable patients in a low spending state like North Dakota. Some of these people, if followed for the next two years, will live and some will die, no matter how much is expended on them. After two years have passed, we can determine not only what fraction lived in each of the two states, but also what happened to the ones who lived. Did they live longer in New York than their counterparts in North Dakota? Was their quality of life any better? If neither those who lived nor those who died benefited from all the additional resources devoted to their care, then clearly New York was spending too much. But if some people benefited, even if others did not, then the issue is more complex. It’s complicated further if those who lived benefited but those who died were made worse off because of the resources spent on them—if they underwent painful procedures and spent a great deal of time in the Intensive Care Unit. In either case, we need to come up with a way—cost-effectiveness analysis is an example—to decide whether we derive sufficient value from the added money spent to make it worthwhile.

To be fair, the creators of the Dartmouth Atlas perfectly well recognize the desirability of looking forward instead of backwards. An important study carried out by this group based on data from 1993-1995 and published in 2003 did exactly that. Elliott Fisher, David Wennberg, and their colleagues studied a group of patient hospitalized for either a hip fracture, colon cancer, or a heart attack, as well as a large representative sample of other Medicare patients. They then asked what happened over the next 5 years: within each group, was there any difference in mortality, in functional status (the ability to care for oneself), or in patient satisfaction, depending on how much money was spent on medical care? What they found was that those people who lived in regions with the highest spending received 60% more medical care than those with the lowest level of spending, with no differences in outcomes (Elliott Fisher, David Wennberg, Therese Stukel et al, “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 2003; 138: 288-298). But this study relies on data that’s 15 years old, and it’s just one study. I think it’s very likely that the regional differences in expenditures uncovered in the 2008 Dartmouth Atlas similarly do not translate into benefit for patients—neither for those who lived nor for those who died. But we could be far more confident in this result if we conducted more studies that looked forward instead of back.

If the conclusions of the Dartmouth Atlas are correct, we need to put a stop to the endless proliferation of sub-specialists, of expensive diagnostic equipment such as PET scanners, and of facilities such as outpatient surgical centers. We should instead identify what medical interventions truly make a difference and limit the supply of those that do not.

Do No Harm: New Data on Dementia

2008-03-27T09:37:00.001-04:00

At 43 pages, the newly released report from the Alzheimer’s Association, “Alzheimer’s Disease Facts and Figures.” is 50% longer than last year’s report and every bit as alarming ( www.alz.org/national/documents/report_alzfactsfigures2008.pdf). Today, 5.2 million Americans have Alzheimer’s disease. By 2050, between 11 million and 16 million people will be afflicted unless medical science finds a way to prevent or treat this progressive, ultimately fatal brain disease.

To its credit, the report shies away from hyperbole. Under the heading of treatment and prevention, the authors state unequivocally: “No treatment is available to delay or stop the deterioration of brain cells in Alzheimer’s disease.” They add that while the FDA has approved five drugs for the treatment of Alzheimer’s, these drugs “temporarily slow worsening symptoms for about six to 12 months, on average, for about half of the individuals who take them,” hardly a ringing endorsement for pharmacologic treatment.

Recognizing that one of the major challenges in providing for individuals with dementia is who will take care of them, the report features a major section on family caregiving. Close to 10 million family members, friends, and neighbors provide unpaid care for a person with dementia in the U.S. today. All told, they contribute an estimated 8.4 billion hours of care per year. The impact on the caregivers’ emotional well-being, health, employment, and financial security is considerable. The need for caregivers—paid and unpaid, family and professional—is reaching crisis proportions. The report only hints at the magnitude of the problem (see the President’s Council on Bioethics, Taking Care: Ethical Caregiving in Our Aging Society, 2005, www.bioethics.gov/reports/taking_care/taking_care.pdf)

But the most striking statistics in this number-laden report are those relating to hospitalization rates—and costs—for individuals with dementia. Medicare beneficiaries over age 65 with dementia are 3.4 times more likely to be hospitalized each year than are their non-demented counterparts. Looked at differently, this means that 25% of older patients in American hospitals at any point in time have dementia. Not surprisingly, annual Medicare costs for those with dementia are high: $13,207 per person compared to $4,454 per non-demented person. This discrepancy is directly attributable to the disproportionately high rate of hospitalization. But not only are people with dementia at high risk of hospitalization, once they’re in the hospital, they cost Medicare 3.2 times more than other patients: they have more complex diseases, undergo more procedures, and stay in the hospital longer.

The data on hospitalization rates are extraordinary because it is far from clear that it makes sense to subject individuals with dementia to frequent and lengthy hospitalizations. The more advanced their dementia, the more frightening the experience of being in a strange place, cared for by a new and unfamiliar nurse every eight hours—and the less they have to gain. In one study of survival after hospitalization, for example, 55% of patients with dementia and a hip fracture were dead in six months, compared to 12% without dementia treated for a hip fracture, and 53% of patients with dementia and pneumonia were dead in six months, compared to 13% of those without dementia treated for pneumonia (RS Morrison, A Siu, “Survival in End-Stage Dementia Following Acute Illness,” Journal of the American Medical Association 2000; 284: 47-52). These uncomprehending patients who are near the end of their lives endure intravenous injections, nasogastric tubes and other uncomfortable and scary procedures in exchange for a small chance of living ever so slightly longer in their demented state (S Mitchell, D Kiely, and MB Hamel, “Dying with Advanced Dementia in the Nursing Home,” Archives of Internal Medicine 2004; 164:321-6). Surely the burdens of invasive treatment outweigh the benefits. A palliative approach to care, focusing on comfort rather than a misguided attempt to increase longevity, makes sense.

The report concludes by noting that the lifetime risk of developing dementia is 21% for women and 14% for men, assuming they live to be at least 55. A low fat diet, rich in fruits and vegetables, may attenuate these stark numbers slightly, as may a vigorous social network. Research into drugs and vaccines to delay the onset of dementia or treat the disease once it develops is thriving and may yet produce a magic bullet that dramatically alters the odds of dying of dementia. But in the mean time, we need to overhaul the prevailing approach to the care of individuals who have this devastating disease. It’s one of the few areas of medicine in which doing the right thing actually has the potential to save money.

MiniClinics on the March: Politics, Policy, and the Public's Health

2008-01-24T15:30:00.000-05:00

In the ten months that I have served on the Massachusetts Public Health Council, no issue has been more contentious than “limited service clinics,” quickie drop-in offices offering treatment of minor illnesses that will be located primarily in pharmacies and staffed by nurse practitioners. The 15-member council, which is empowered to help shape health care policy in Massachusetts, has approved expensive new scanners, multi-million dollar outpatient buildings, and the creation of additional hospital beds with scarcely a whimper of protest. Many of these capital expenditures will predictably drive up health care costs in the state of Massachusetts, potentially threatening outlays for services essential to the health and well-being of the citizens of the Commonwealth. The benefit accruing from these capital investments is not subject to scrutiny.

The regulations that will permit the introduction of limited service clinics in Massachusetts, by contrast, provoked a storm of protest. Council members were deluged with petitions from interested parties—primarily physician groups arguing against this form of medical practice. The Council spent the better part of two of its monthly meetings debating the issue. But was the issue really the regulations—the Department of Public Health did an admirable job of developing detailed regulations that conformed to the proposed regulations developed by the American Academy of Family Physicians—or rather the belief of a variety of interest groups that mini-clinics are dangerous because they offer episodic care rather than coordinated care, they will be staffed by nurse practitioners rather than physicians, they will tend to be for-profit, and many will be located in drug stores, which sell cigarettes. Do any of these concerns hold up?

Nothing but the best…
Ideally, if you live in Massachusetts, you have your own primary care physician. Not only that, but you have ready access to that physician—no week-long waits for an appointment, no 2-hour waits to be seen even if you have an appointment. In the best all of all worlds, if you are elderly and have multiple chronic illnesses, you have coordinated care, facilitated by a case manager (see R. Bernabei et al, “Randomised Trial of Impact of Model of Integrated Care and Case Management for Older People Living in Community,” British Medical Journal 1998; 316: 1348-1352). You also have health insurance coverage to pay for your visit to the physician. And if you happen not to be a resident, but merely visiting the state, you are able to find a primary care practice ready and willing to accommodate you if you happen to get sick while you’re here.

The reality is very different. Massachusetts has a shortage of primary care doctors. Generalists don’t want to move to the state, where salaries are below the national average and the cost of living is well above the national average. Despite the recent initiative to require health insurance for all residents, not everyone has coverage. “Coverage” may include substantial co-payments and deductibles. Thousands of patients throng to emergency rooms for care every day—where the wait to be seen is usually measured in hours, not minutes.

The fix for these problems is complex. And it’s not a problem that Massachusetts can solve alone—nation-wide, primary care is in a slump. The number of young physicians going into primary care is declining every year, and the reasons range from high student loans to fear of litigation, with a dozen other factors in between that adversely affect physicians’ willingness to practice general medicine.

Over the short term, limited service clinics can help. They provide an alternative way for patients to get treatment for straightforward problems such as sore throats and sprained ankles. They can administer flu shots and help tourists with a rash or a stomach bug. With suitable regulatory oversight, mini-clinics can improve the public’s health.

The NP/Physician Wars
Physicians have been suspicious of the care provided by nurse practitioners for years. But the evidence is that in the arenas where NPs work, they often do at least as good a job as physicians. A study by Mary Mundinger et al (“Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial,” Journal of the American Medical Association 2000; 283: 59-68), found no differences in outcomes or satisfaction among over 3000 adults, some of whom received care from NPs and some from MDs—except in the case of management of high blood pressure, where NPs performed better. In data specifically on limited service clinics released as part of the Minnesota Health Care Quality Report, the NP-run clinics received a 100% rating for the treatment of sore throat in the pediatric population in 2006. When I randomly chose a not-for-profit clinic operating in the same Minnesota county to compare to Minute Clinic, I found it had a 72% rating on the sore throat treatment indicator (see mnhealthcare.org).

NPs always have MD back-up and supervision. It’s a condition of their licensure. But that doesn’t mean a doctor must be on the premises. NPs have been providing high quality care in nursing homes (where doctors often fear to tread) for years, as well as in hospices and in patients’ homes. There is no reason to worry they will misdiagnose or mistreat the routine ailments that will come to their attention in mini-clinics.

Big bad for-profit health care…
Many health care institutions throughout the United States are for-profit. There are for-profit HMOs, for-profit hospitals, and for-profit physician group practices, among others. The data on the effect of for-profit status on the quality of care is mixed. A National Bureau of Economic Research Conference Report comparing for-profit hospitals to not-for-profit hospitals found evidence that in some situations, for-profit hospitals are higher quality than not for profit hospitals (David Cutler, ed, The Changing Hospital Industry: Comparing Not-for-Profit and For-Profit Institutions, Chicago: University of Chicago Press, 2000). On the other hand, a study comparing health plans found for-profit plans performed less well than not-for-profit plans on 3 out of 4 quality indicators (EL Schneider et al, “Quality of Care in For-Profit and Not-for-Profit Health Plans Enrolling Medicare Beneficiaries,” American Journal of Medicine 2005; 118: 1392-1400).

For-profit health care is no stranger to Massachusetts. We have for-profit nursing homes. We have for-profit hospices. There is no justification for dismissing limited service clinics simply because many of them will be owned and operated by CVS.

It’s an outrage to have a health care clinic within a facility that sells cigarettes…
Cigarettes are one of the leading causes of some of the major killers: coronary heart disease, emphysema, and lung cancer. Clearly, the Massachusetts Department of Public Health needs to be concerned with strategies to decrease cigarette smoking and to prevent young people from starting to smoke in the first place. But we do not ban the sale of cigarettes outright. We do not tax cigarettes enough to make them unaffordable to all but the very rich. And we do not prevent drug stores that sell prescription drugs for the treatment of coronary heart disease, emphysema, and lung cancer from also selling cigarettes. I fail to see why we should prevent those same drug stores from housing a health clinic.

The bottom line
I hope that some day all patients in Massachusetts have access to top notch primary care. In particular, I hope that frail geriatric patients will have the kind of integrated care that I believe is best achieved through a case-managed, capitated health plan. In fact, I hope that there will be so little demand for mini-clinics that they disappear. But for the moment, I suspect they will provide a valuable service for many sick people in Massachusetts.

It is time for policy makers to pay at least as much attention to the rising cost of health care and its potentially dire consequences as to mini-clinics. Just this morning the Boston Globe reported that Governor Patrick has proposed a $28.2 billion budget that includes a 1.3 billion dollar budget gap, “created mainly by rising health care costs and decreased revenues.” The Congressional Budget Office recently released statistics indicating that barring any changes in policy, total spending on health care, which currently accounts for 16% of the Gross Domestic Project, will rise to 25% in 2025 and 37% in 2050. Federal spending on Medicare and Medicaid alone (net of beneficiaries’ premiums) is now 4% of GDP and will rise to 7% in 2025 and 12% in 2050 (see www.cbo.gov). Medicaid is a joint federal/state program: for every dollar spent by the federal government on Medicaid in Massachusetts, the state spends another dollar. And over the long run, as Medicare costs soar, the federal government will have less and less to spend on other programs that affect everyone, including Massachusetts residents.

The leading engine behind this unsustainable growth in spending is technology (See James Lubitz, “Health, Technology, and Medical Care Spending,” Health Affairs 2005; W5: R81-R85). While some forms of technology contribute much to health, others simply contribute to costs. Hospital beds, once built, will be used. But more is not always better. In a major study, Medicare enrollees living in high spending regions of the country received more care but did not have better health outcomes or greater satisfaction with their care (Elliott Fisher et al, “The Implications of Regional Variations in Medicare Spending: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 2003; 138: 288-298).

The Public Health Council can do little more than rubber-stamp most of the requests it receives for substantial capital expansion. Massachusetts Determination of Need law does not permit the Public Health Council to do much other than review whether health care facilities submitting requests for substantial capital expenditures have engaged in the recommended planning process, whether they have developed the requisite community health services initiatives, and whether the proposed construction complies with existing standards. Ostensibly, the law is intended to “promote availability and accessibility of cost effective quality health care.” But the current statute promotes the evaluation of cost effectiveness without the ability to consider effectiveness. If Massachusetts is to have sound health policies, and if the PHC is to devote its time to the critical issues facing the state, the legislature will have to revamp the Determination of Need law of the Commonwealth.

Going for Broke

2007-12-19T17:53:00.000-05:00

It’s official: combined federal spending on Medicare and Medicaid has reached 4.6% of the Gross Domestic Product (GDP), up from 4.2% in 2005, and on track to reach 5.9% in 2017 and a whopping 20% in 2050. These sobering estimates come from the Congressional Budget Office, not from a fringe radical group or an ultra-conservative think tank (see Peter Orszag and Philip Elis, “The Challenge of Rising Health Care Costs—A View from the Congressional Budget Office,” New England Journal of Medicine 2007; 357: 1793-5). At this rate, just about half of every tax dollar will go to fund these two programs by mid-century. This rate of expenditure is simply unsustainable—it would drive out support for education, roads, and parks, not to mention national security. Expenditures on Medicare will have to be cut and cut substantially. The biggest challenge for the future health of the baby boomers is how to restructure Medicare to provide good care at an affordable price.

The trick will be to put the brakes on technology, because it is the development and diffusion of new medical technology that has repeatedly been shown to be the engine fueling the growth in costs (for example, see L. Lubitz, “Health, Technology, and Medical Care Spending,” Health Affairs 2005; W5: R81-R85). To control technology without stifling progress, we will need to figure out to a far greater extent than we do today just how much benefit an innovation provides and to whom. Right now physicians and patients embrace technology—and Medicare pays for it—if the intervention has been shown to be beneficial, regardless of how small the benefit relative to either its cost or to alternative treatments. The effect of this strategy is that some regions of the country spend three times as much per Medicare enrollee as other areas with no discernible benefit in any health outcome (see the Dartmouth Atlas of Health Care, www.dartmouthatlas.org).

We will also have to recognize that older people are not a homogeneous population, and technology that is beneficial for one person may not help—or may even hurt—another. Accepting that different people benefit from different approaches to care, not just because they have different values and preferences but because of their underlying health status, will require a shift in our thinking. What we will need to do is to design different “pathways of care” for older individuals depending on whether they are robust, frail, or dying. The robust should receive something like today’s Medicare program; the frail, whether suffering from physical or cognitive frailty, should get less high tech and more disease management and home care; and the dying should all have palliative care resembling today’s hospice program.

Designing new approaches to care that are tailored to meet the needs of particular patients will enable the baby boomers to have a good old age: they will be offered technology when it can make a substantial contribution to health and well-being but will not subjected to invasive and painful technology when it is of little or no benefit. This is precisely the strategy we need in order to save ourselves from financial ruin. It also happens to be a compassionate and appropriate way to provide medical care to the elderly.

The Truth About Hospitals

2007-11-01T09:22:00.000-04:00

In a bold move intended to foster quality care, the Massachusetts Hospital Association has begun posting data on its web site about the risks patients face if they are hospitalized,. Specifically, it reports on falls, on falls which cause injury, on surgical infections, and on the care for several conditions, including pneumonia, heart failure, and a heart attack. The new site is called Patients First (www.patientsfirstma.org) and it is intended to “educate people so they can make better decisions,” accorded to the senior vice president of the Institute for Health Improvement, which helped develop the new approach. Will this strategy in fact help patients decide where to seek their care? Is it a good idea?

It’s hard to imagine a patient in the throes of a heart attack checking out the web site to see which hospital in his area performs best. Odds are that the ambulance will take him to the nearest facility, regardless of his preferences. Moreover, most patients choose a physician, not a hospital, and accept that they will be hospitalized at whatever facility their physician practices.

Even if an individual patient did consult the web site to learn more about the hospital where his doctor worked, he would be hard pressed to draw any useful conclusions from the data presented. Take falls as an example. If you look up the hospital where I care for patients, the Brigham and Women’s Hospital, (BWH) you will find two different graphs, one showing the number of falls per 1000 patient-days, the other showing the number of falls with injuries per 1000 patient-days. In each category, you will find a rate for the medical floors, one for the intensive care units, another for combined medical-surgical units, a rate for step-down units, and still another rate for exclusively surgical floors. And for each location, you will see the BWH rate over a 6-month period compared to the “peer group average.”

I wanted to know how likely my patients are to fall and get hurt if they are on a medical floor at the BWH. What I learned is that the hospital has 0.96 injurious falls/1000 patient-days compared to the peer group average of 0.76. Presumably this means that the BWH is worse than average. But how much worse? Are the rates significantly different? Are the patients at the BWH comparable to the patients cared for in the “peer group” hospitals? What is the peer group anyway?

To get the answers to all these questions, you need to go to the Appendix, a 67 page document (also available on line) that describes the methodology on which the numbers are based. Hospitals are grouped according to size, so the BWH is lumped with all hospitals in Massachusetts having over 500 beds. That means Boston Medical Center, Massachusetts General Hospital, the Beth Israel Deaconess Medical Center, and the University of Massachusetts Medical Center. You can also find the confidence intervals for the rates reported, the statistical measure you need in order to figure out whether a given facility’s rate is significantly different from the rates at the other facilities. What you learn is that in fact, there is no significant difference between the BWH rate and the peer group average. In fact, if you look up the data for each of the hospitals with more than 500 beds, you will find that they all have equivalent rates, except Boston Medical Center, which does a bit less well.

What is also buried in the appendix is that that the fall rate of 0.96/1000 patient-days on the medical units at the BWH is based on a grand total of 2 falls that occurred in 2084 patient days. I wouldn’t want to draw any inferences based on 2 cases.

You might conclude that I don’t think much of this idea of publicly displaying data relating to quality of care. Actually, I think it’s an excellent idea, but not because it will help patients make choices. It’s a good idea because hospitals compete with each other and knowing how your neighbor is doing will stimulate you to do better. Above all, it’s a good idea because it helps hold hospitals accountable for the care they give and it encourages each facility to compete with itself to do better.

Of all the hospitals whose performance data is reported, I noticed only one that posted a comment about its own statistics. The Beth Israel Deaconess Hospital in Boston went beyond the numbers to say that starting in May, 2007 they developed and implemented an enhanced program for identifying patients at risk of falling. Their study teams discovered that the middle of the night is a particularly risky time. They responded to this observation by instituting a program of frequent checks at night. They also found that patients often fall when left unattended in the bathroom and have made efforts to ensure that high risk patients are not unsupervised in the bathroom.

This is exactly how hospitals should be responding to data. The BIDMC, it turns out, is way ahead of the curve. Spearheaded by its president, Paul Levy, the hospital has its own web site for reporting data. Called “Putting Ourselves Under a Microscope,” this site reports data on many of the same indicators as the Massachusetts Hospital Association. (www.bidmc.harvard.edu/thefacts)

The BIDMC compares its performance to a national average and to its own previous performance. And it sets targets for improvement, with a plan for how to achieve the targets. Now that’s impressive.

Don't Fall for It

2007-10-25T13:06:00.000-04:00

In an earlier posting, “Break a Leg,” I recommended that frail older people use hip protectors to prevent hip fractures. The data, at that time, were suggestive but not conclusive. A recent study, unfortunately, definitively argues against the benefits of hip pads. In an article published in the Journal of the American Medical Association, Dr. Douglas Kiel and his colleagues reported on a large randomized trial that used a very elegant approach to answer a difficult and important question (D Kiel, J Magaziner, S Zimmerman et al, “Efficacy of a Hip Protector to Prevent Hip Fracture in Nursing Home Residents,” Journal of the American Medical Association 2007; 298: 413-422).

Earlier studies were plagued by all sorts of problems: people didn’t like wearing the hip pads, leading to what was called “poor compliance,” making it hard to analyze the results. The hip pads studied were made of differing materials and some of the pads may actually have increased the chance that a fall would cause an injury to the hip bone itself rather than merely to the surrounding soft tissue. This new study used a hip protector that had been shown to have the desired biomechanical properties. It was conducted in nursing homes, where the frailest elders live, the people with the highest risk of falling and fracturing a hip. And the investigators did something very ingenious: they used each nursing home resident as his own control. Every individual in the study wore a one-sided hip pad on either the right or left hip. The researchers would then observe all the residents over time to see whether the protected hip was any less likely to be fractured than the unprotected hip.

The study was carried out in 1042 individuals with a mean age of 85 who lived in one of 37 nursing homes located in Massachusetts, Missouri, or Maryland. What the authors found was that the nursing home residents were just as likely to fracture the protected hip as the unprotected one. In fact, the study was stopped early because preliminary evidence was so overwhelming that the hip pads, contrary to everyone’s hopes and expectations, simply did not work. Even when the analysis was restricted to the 334 nursing home residents who wore the pad more than 80% of the time, there was still no difference in fracture rates between the protected and the unprotected hip.

It would have been great to be able to say, at last, that hip pads really work. But at least we now have the necessary information with which to conclude that they don’t. Now we know that we shouldn’t spend money on hip pads. I have to retract my earlier recommendation. It’s time to look for other strategies.

A New Test for Alzheimer's Disease: Hype or Hope?

2007-10-15T11:07:00.000-04:00

The New York Times reported today on “a blood test” for Alzheimer’s disease (Andrew Pollack, “Progress Cited in Alzheimer’s Diagnosis,” NYT October 15, 2007). Is there actually such a test? If not, is one imminent?

Don’t hold your breath. I’m old enough to remember the eye drop test for Alzheimer’s and the skin biopsy for Alzheimer’s, neither of which panned out, not to mention the serum beta amyloid test and a few spinal fluid tests. What the news media are reporting appeared in the on-line edition of Nature Medicine yesterday in a letter-to-the-editor, not in a peer-reviewed article (Sandip Ray, Markus Britschgi, Charles Herbert et al, “Classification and Prediction of Clinical Alzheimer’s Diagnosis Based on Plasma Signaling Proteins,” Nature Medicine online, October 14, 2007). This means the findings have not been written up in an article and subjected to careful scrutiny by other scientists who are experts in the field. The letter, penned by 25 scientists, notes that the group has been studying over 100 different proteins found in the blood of patients with a diagnosis of Alzheimer’s disease to see if some combination of them might serve as a diagnostic test. They have found that a particular pattern involving 18 different proteins successfully classified 8 out of 9 patients with Alzheimer’s disease (confirmed at autopsy) as having the condition. The results, while interesting, are far too preliminary to be of interest to the general public.

If we did have a test that could accurately diagnose Alzheimer’s disease, would it matter to the millions of people with cognitive impairment and their families? Probably not. Right now, physicians can already diagnose Alzheimer’s disease with 90% accuracy, based on a careful history and physical examination together with existing laboratory tests. Even more crucial, while it is useful to diagnose dementia (whatever the cause) so as to begin planning for the future, it’s only important to distinguish Alzheimer’s disease from other forms of dementia to the extent that we have good treatments specific to Alzheimer’s. Today, the only “treatment” we have for early Alzheimer’s disease is a group of drugs known as cholinesterase inhibitors—drugs such as Donepezil (Aricept). This medicine can temporarily improve cognitive function a very modest amount. Its effectiveness is so questionable that the British NICE (National Institute for Health and Clinical Excellence) recommends against its use in patients with mild dementia (see my earlier blog posting, “Americans, Alzheimer’s, and Aricept,” February, 2006). It doesn’t cause any harm if it’s administered to patients who prove to have a non-Alzheimer’s dementia, such as vascular dementia.

One day, when we have good treatments for early Alzheimer’s disease, it will be important to make the diagnosis early and accurately. Today, what a good doctor can do is good enough.

"The Denial of Aging" is Available in Paperback

2007-10-03T08:34:00.000-04:00