One Nation… Without Healthcare Justice for All
Posted on Tuesday, June 16th, 2015 at 9:05 am by lifemediamatters
Though every state in this nation struggles with escalating and unmanageable healthcare costs, only Oregon has established a rationing policy for the care needs of those on Medicaid.
Oregon’s overt rationing plan has suffered the bumps and bruises of being a pioneer, but it set the stage for other states to follow.
Oregon’s Medicaid costs were so high, it proved impossible to cover the needs of the poor. So in 1990, the state calculated what it could afford to spend collectively, and it then developed a list of diseases and disorders to rank the cost-of-treatment against the benefit. A red line was drawn. If treatments were above the line, they were covered. If a treatment fell below, it was not. So far, no other state has followed suit. Neither has the federal government when it comes to another taxpayer responsibility, Medicare.
Our country faces a moral dilemma. How do taxpayers picking up the tab for Medicare and Medicaid equitably support those most vulnerable? First and foremost, the government and providers have a moral responsibility to be efficient. In his essay, “Setting Priorities for a Basic Minimum of Accessible Healthcare,” Paul T. Menzel, Professor of Philosophy Emeritus, Pacific Lutheran University argues that “efficiency is not a moral luxury, it is a moral obligation.”
Rather than looking inward at its mushrooming inefficiencies, the government has shifted the burden to the individual citizen- with the likes of greater premium sharing, higher deductibles and larger co-pays. When bloated bureaucracies fail to self-adjust, and financial resources are so strained- they move into the category of extreme scarcity. There is another way to allocate financial resources: rationing.
Oregon’s Medicaid program is the nation’s bellwether. Individual states are grappling with how to address cradle-to-grave healthcare demands, but not one has taken the controversial step that Oregon did long ago. The common good is not served when Medicare spends more than 128 billion dollars annually on end of life care, or when Medicaid spends 45 thousand dollars for each neonatal intensive care unit admission. The basic minimum of healthcare needs for the poor and elderly go unmet in this broken system. Overt rationing decides systematically in proportion to the common good. With rationing, limited resources are more equitably distributed to all.
Our country faces a moral dilemma. How do taxpayers picking up the tab for Medicare and Medicaid equitably support those most vulnerable?
As Charles Camosy offers in his book, Too Expensive to Treat, “All one is entitled to [in society] is equal consideration with others in proportion with the common good of all…this may mean that lifesaving treatment may be justifiably withheld from some persons.” With billions of dollars collectively spent on the art of rescue at both the beginning of life and life’s end, the principle of equal consideration is lost.
This lack of rationing seems grossly unfair. Social justice exists when all share a common humanity and a right to equitable treatment. Assuming we are in solidarity, why are the poor in Oregon the only individuals afforded a policy of rationing?
As Pope Francis explained, “solidarity…is a firm and persevering determination to commit oneself to the common good; that is to say to the good of all and of each individual, because we are all really responsible for all.”
We say we are “one nation, under God, with liberty and justice for all,” but such justice is not reflected in our public health care policies. Rationing is unjust when only one small subset of Oregon’s population bears the consequences of a ubiquitous societal crisis. If we are truly one nation and delivering on our Pledge, we should all be sharing in the fair allocation of extremely scarce resources and rationing for the common good.
Rare Bipartisan Health Legislation Pushes Advance Care Planning
Posted on Monday, June 15th, 2015 at 1:16 pm by lifemediamatters
Rare bipartisan health care legislation is gaining momentum in Washington that would reimburse doctors and teams of providers to help patients suffering serious illness with advanced care planning.
The legislation, called The Care Planning Act of 2015, was introduced in the U.S. Senate by Mark Warner, a Virginia Democrat, and Johnny Isakson, a Georgia Republican. The bill would for the first time provide reimbursement under Medicare to health professionals to consult with patients about end of life care, including advanced directives.
“This (legislation) is not intended for the advanced care planning process to be static,” said the National Hospice and Palliative Care Organization’s Jonathan Keyserling in an interview with Life Matters Media. “It should be dynamic. This should help the patient and family to better understand the disease trajectory about their health care goals and convey those goals to all of the relevant medical care providers.”
It is believed to be the first major push in Congress behind legislation to reimburse medical providers for consultations since Sarah Palin, the former 2008 Vice Presidential candidate, contributed an avalanche of demagoguery on an effort to include payment for advanced care planning early in President Obama’s first term.
Amid the health reform debate of 2009, Palin accused the Obama administration and Democratic proponents of creating “death panels.” Meanwhile, John Boehner, then the House Republican leader, said Medicare coverage of advanced care planning would lead to “government encouraged euthanasia.”
Though neither Boehner nor Palin were accurate in their allegations, Medicare reimbursement for consultations was stripped from the legislation.
This time, there is bipartisan support and momentum for what lawmakers are calling a “voluntary and structured discussion about the goals and treatment options for individuals with serious illness, resulting in a documented care plan that reflects informed choices,” a memo from Warner’s office describes.
Sens. Warner and Isakson already have several Republican and Democratic sponsors to the legislation. Supporters include Democratic Sens. Tammy Baldwin of Wisconsin and Amy Klobuchar of Minnesota, as well as Republican Sens. Shelley Moore Capito of West Virginia and Susan Collins of Maine.
“In the last several years, some have deliberately chosen to misrepresent the purpose of care planning services to frighten people to score cheap political points,” Sen. Warner said in a statement. “It’s about making sure that your doctors, your hospital, and your family know what choices you have made about your care. If a patient prefers to explore every possible treatment option, that choice will be respected.”
Under current law, doctors can receive Medicare reimbursement for “medically necessary” care during their annual wellness visit. This care can include discussions about end of life care or advanced care planning and directives. However, consultations about end of life care cannot be the only reason for reimbursement to physicians, according to the Centers for Medicare and Medicaid Services.
The proposed legislation would create a new benefit under Medicare for “planning services” for those with advanced illnesses that would not only reimburse doctors, but include payment to an entire team of providers such as nurses, social workers and spiritual counselors.
“This (legislation) doesn’t create an opportunity for a physician alone to bill for advanced care planning,” Keyserling told Life Matters Media. “The Senators have taken a different tack, envisioning an interdisciplinary approach. It brings more accountability, better care coordination and better alignment of what the family desires being delivered to them.”
To be sure, the legislation calls on the U.S. Department of Health and Human Services to develop a set of quality metrics that will measure, among other things, whether the patient’s stated goals are in sync with the documented care plan. Also measured will be the treatment that is delivered and what the outcome of the treatment was on the patient.
Providers of medical care say the reimbursement and related aspects of the legislation will fill a void in patient care.
“This legislation closes a gap in the health care system, and will strengthen our ability to comprehensively and appropriately address complex care needs that are core to our mission: to care for the whole person,” said Dr. David DiLoreto, chief executive officer of Presence Health Partners, a large network of Chicago area doctors and other providers. “We want to enhance the patient experience by truly allowing their voices to be heard in a way that is meaningful for them and for their loved ones.”
Medicare, like most private health insurers, is increasingly moving from a fee-for-service model of health care that rewards volume of care delivered to a value-based approach. This shift is designed to better ensure that patients are getting the right care, in the right place and at the right time.
“If an individual prefers a different approach after informed consultations with their health team, their families and others, those choices should be documented and honored too,” Warner said. “The important thing is being able to make that decision and trust that it will be respected.”
Several Senators backing the legislation have issued a parade of statements in the last week talking about their personal stories. Those stories come with a common thread about how lost they were when it came to advanced care planning.
“Having recently lost both of my parents, I speak from personal experience when I say how important it is for families, loved ones and medical care providers to have clear direction when making decisions about treatment in their final days,” Senator Capito said. “Sadly, Medicare will not currently pay doctors to have this conversation.”
The legislation provides five million dollars in fiscal 2016, beginning Oct. 1 of this year. The funding directs the Center for Medicare and Medicaid Innovation to create an “Advanced Illness Coordination Services” pilot program to reimburse “wrap-around, home-based services” to Medicare beneficiaries and for testing other care-coordination models.
There is also a consumer outreach portion of the legislation that will involve launching a national campaign designed to encourage advanced care planning as well as funds for a web site with information about advanced care planning, palliative care and hospice. The information will also be included in the popular “Medicare & You” handbook, sent annually to millions of seniors and considered a senior citizen’s Bible to Medicare benefits.
More than 40 groups in recent weeks have touted their support for the program.
“This legislation would help respect individuals’ goals, values and preferences for care and treatment,” Joyce Rogers, senior vice president of government affairs for AARP said in a statement. “This legislation recognizes and supports the critical role that family caregivers often play in providing and coordinating care or their loved ones.”
I’ve Waited So Long, I Could Die
Posted on Friday, May 22nd, 2015 at 10:13 am by lifemediamatters
It has been a year since waiting lists at VA hospitals made international headlines, as our American veterans struggled to access timely health care. In the months since, The Associated Press has found that the number of medical appointments delayed 30 to 90 days has largely stayed flat. Appointments taking longer than 90 days to complete have nearly doubled in number, and patients typically get sicker during the wait.
However, our veterans’ waiting list isn’t our only worrisome one. Another is just as onerous- the list of those patients with End Stage Renal Disease (ESRD) awaiting donation of a kidney for transplant. Congress approved an exclusive benefit for citizens with ESRD in 1972, authorizing Medicare to fully fund patient dialysis- the only treatment that can prolong their lives. This technology and the benefit making it affordable resulted in a 260 percent growth in the number of those awaiting kidney transplants. Meanwhile, there was only a 16 percent growth in kidney supply. This explosive demand parallels such at the VA. In a country of enormous abundance, these waiting lists are killing our citizens.
There is a way to attack this waiting list, just as the VA is working to better serve its veterans. It takes a to-do list- not a waiting list- to achieve a creative solution. That solution is one supported by ethicists, scholars and the medical community; there has been wide consensus that now is the time to test the model for a regulated market for the sale of kidneys for transplant.
The current problem with such a proposal is that it’s against the law. Congress approved the National Organ Transplant Act (NOTA) in 1984, prohibiting the sale of organs and criminalizing such action with a prison term and fine. With no other scalable solution proposed, Congress explicitly outlawed organ sales.
In the 30 years since NOTA’s passage, the transplant waiting list has come to be known as a “waiting list to die,” ballooning to more 100,000 candidates who hope to receive one of 13,000 available kidneys each year. On average, between seven and 12 people awaiting a kidney die each day. In a country with such abundance, this reality is unconscionable.
In a country of enormous abundance, these waiting lists are killing our citizens.
Congress must authorize a pilot program for a regulated market in which live and deceased donors can be compensated to provide kidneys to unrelated candidates. We don’t need to categorically rescind portions of NOTA, but we do need to allow a test to determine whether providing payment for kidneys could ethically reduce the waiting list so that thousands won’t die due to a wait each year.
Altruistic donation is a selfless act and has been the only source of kidney supply. As wonderful as it is, altruism will never meet the demand. It is outrageous that our ESRD patients are regularly allowed to die while highly regarded ethicists, transplant surgeons and scholars are poised to support a proposal for such a regulated market test.
To be sure, there could be abuses in a system of financial incentives. However, these potential abuses are no morally worse than not trying financial incentives in a regulated market. A policy of financial incentives will produce fewer unfortunate results than the current system. Our veterans are heroes, and those who provide organs are, too. Let’s try on their behalf.
Video Urges Hospice Providers To Treat Patients’ Terminal Prognosis
Posted on Sunday, April 12th, 2015 at 9:03 am by lifemediamatters
The National Hospice and Palliative Care Organization (NHPCO) is circulating a video that encourages hospice providers to think in terms of terminal prognosis and not only principal diagnosis when caring for dying patients.
“Determining what aspects of care hospice providers are responsible for has become an issue of growing importance in recent months,” according to a NHPCO statement sent to Life Matters Media. “There is significant concern from regulators on Capitol Hill that some providers may be relying on a single diagnosis, thereby defining their scope of responsibility too narrowly, ultimately failing to provide and coordinate all the care and services that they should.”
The Centers for Medicare and Medicaid Services (CMS) requires a principal diagnosis on reimbursement forms for patients using the Medicare hospice benefit. However, “principal diagnosis” is often only part of what should be reported to provide more comprehensive reasoning for a patient’s short life expectancy. In 2013, 67 percent of claims listed only one diagnosis.
Hospice care aims to provide comfort and pain management for terminally ill patients with a life expectancy of six months or less. It is most often used when curative treatments are no longer effective.
“As providers of hospice care, we must properly frame the way we think about and characterize our patients and the scope of our responsibility in providing care to them,” said J. Donald Schumacher, NHPCO president and CEO, in a statement. “The question can be asked, ‘Does this diagnosis or condition contribute to or influence the patient’s terminal prognosis?’ If so, then it is our responsibility.”
The NHPCO, the nation’s largest nonprofit organization representing hospice and palliative care programs, created the 10-minute video for use during hospice staff meetings and training. Jonathan Keyserling, senior vice president of health policy, said a series of complex issues needed clarification among providers, including a congressional mandate to reform payment methodology..
“An effective tool is to look at all those items that are connected to the prognosis that qualifies a patient and their family for hospice services under Medicare,” Keyserling said. “It’s really a reiteration of the existing statute. The Affordable Care Act has nothing to do with this affirmation.”
Although the video is not targeted to patients and families, Keyserling hopes it encourages them to have a conversation about their end of life care wishes, even if it does not involve hospice.
“We think it’s critically important that families sit down and have a conversation about their goals and objectives at the end of life,” he added. “It’s therapeutically neutral, but we encourage families to have that conversation so that there are no surprises, so that when a patient is not able to speak, then their loved ones have a good idea about what that patient would have wished.”
Reimburse Doctors For Helping Patients Plan End Of Life Care, Experts Say
Posted on Monday, March 23rd, 2015 at 6:44 pm by lifemediamatters
This piece was first published in Reuters Health. President Randi Belisomo is a contributor.
Physician incentives are needed to improve end of life care in the U.S., health experts said Friday at an Institute of Medicine (IOM) forum.
The forum convened at the National Academy of Sciences to discuss action on the recommendations of the IOM’s seminal fall report, Dying in America.
“Our current system is not equipped to deal with these challenges,” said IOM President Victor Dzau, citing a rising number of elderly with multiple chronic illnesses, too few palliative care services to keep pace with demand, and time pressures that keep providers from having conversations with patients about end of life preferences and values.
“We need to make sure that healthcare providers do not shy away from these discussions,” said Senate Aging Committee Chairman Susan Collins (R-Maine). “Until we solve the reimbursement issue, I don’t think we are going to make true progress.”
Senator Mark Warner (D-Virginia) said he regretted his failure to talk with his mother, an Alzheimer’s patient, about the end of life care she desired. He lost the opportunity to have this conversation when she lost her ability to communicate, nine years before her death.
“I was an informed citizen at the time, the governor of Virginia, and yet my family and I didn’t have a full understanding of everything that was before us,” said Warner, indicating that he will reintroduce a measure to create a Medicare and Medicaid benefit for end of life planning.
When people fail to plan for end of life care, they may suffer through ultimately futile, invasive and often unwanted treatments, advocates say. Surgeon and author Atul Gawande detailed the “medicalization of mortality” occurring over the past several decades, noting that the most likely time for Americans to undergo surgery is the last week of life.
“We fail to recognize that people have goals and priorities in their lives we need to serve besides just living longer,” Gawande said. “The way you learn what people’s priorities are is by asking.”
Last year, the Centers for Medicare and Medicaid Services rejected an American Medical Association request to create a billing code for doctors to use when they spend time helping patients plan for future care. Patrick Conway, chief CMS medical officer, said the coding would be considered this year.
If physicians will be reimbursed, work remains to ensure the quality of care patients receive. “Metrics in this area are not easy to develop, but they’re not impossible,” said Christine Cassel, president of the National Quality Forum. “Payers need to know they are paying for the right kind of care.”
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