Diane Meier: Palliative Care Improves Quality Of Life, Reduces Medical Spending
Posted on Thursday, December 5th, 2013 at 5:21 pm by lifemediamatters
Half of older Americans visit emergency departments in their last month of life; 75 percent in last six months of life
Palliative medicine helps improve quality of life and reduces unnecessary spending on emergency care for the chronically ill, said Dr. Diane Meier, director of the Center to Advance Palliative Care and a professor of medical ethics at the Icahn School of Medicine at Mount Sinai. Meier was the keynote speaker for “Palliative Care: A Major Paradigm for Care Coordination,” a conference presented by the Illinois Hospital Association in Naperville Thursday.
Meier opened her lecture with the true story of an elderly couple struggling without palliative support:
Mr. B is an 88-year-old man suffering mild dementia and admitted to the hospital via the emergency department for management of back pain due to spinal stenosis and arthritis. His pain is an 8 on a scale of 10 upon admission– he receives 5 grams of acetaminophen (Tylenol) each day. He has been admitted three times in two months for pain, weight loss, falls and altered mental status due to constipation. His 83-year-old wife is overwhelmed.
“He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do,” Mrs. B told Meier.
Meier pointed out to an audience of palliative care nurses and other medical professionals that among Medicare enrollees in the top spending quintile, nearly half have chronic conditions and functional limitations, just like Mr. B. Most of the costliest 5 percent of Medicare enrollees (61 percent) suffer from similar conditions. Nationally, spending on dementia-related services totaled nearly $215 billion in 2010.
“The emergency department has become the modern death ritual in the U.S.,” Meier added, because half of older Americans visit the emergency department in their last month of life, and 75 percent do so in their last six months.
According to Meier, a palliative care strategy with geriatric support could have helped Mr. and Mrs. B manage symptoms more adequately, and it could even have helped them avoid some unnecessary hospitalizations. “What we need to do is get out of our taxonomy silos, specialty driven silos,” Meier said. “Because of the concentration of risk and spending, palliative care principles and practices are central to improving quality and reducing cost.” The costs of Mr. B’s four most recent hospital visits totaled several hundred thousand dollars. But the Bs did not do anything wrong, Meier said, because the medical system encouraged their situation. What else could they do?
Meier suggested more home and community-based services to help reduce the number of seniors who find themselves in situations like the the couple– lacking an able-bodied caregiver and without an easily accessible medical provider. “Staying home is concordant with people’s goals, she said. “Based on 25 state reports, costs of home and community-based long term care services are less than one-third the cost of nursing home care.” For example, in a study published in the journal Health Affairs, researchers determined that simply having meals delivered to a senior’s home significantly reduced the need for a nursing home.
As HealthDay News reported: “If all 48 contiguous states increased by 1 percent the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care.” Still, the U.S. lags behind every other industrialized nation when it comes to the ratio of social to health service expenditures.
Hope Brown, a nurse with the Carle Foundation Hospital in Urbana, IL, said she appreciated Meier’s attention to the costs of care and the need for social support. “It happens every day, situations like the Bs. We definitely need to get people into social services earlier, even meal delivery,” she added.
Overall, Meier urged medical professionals to “treat the person, not the disease.” Since most patients prefer to live at home and remain independent, (76 percent rank “independence” as most important, followed by pain and symptom relief, and staying alive last) palliative medicine should reflect those wishes.
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Short Hospice Stays May Mean Lack Of Awareness, As NHPCO Launches First National Campaign
Posted on Tuesday, December 3rd, 2013 at 10:16 am by lifemediamatters
Despite the growing number of Americans seeking end of life care, the number of short stays in hospice is troublesome, and a sign that caregivers and the hospice industry see as a major lack of awareness about a key service for the dying.
A new report from the National Hospice and Palliative Care Organization (NHPCO) shows that more than one in three hospice patients (35.5 percent) died or were discharged within seven days of admission last year. That rate was largely the same as in 2011.
NHPCO’s analysis comes as usage of hospice, however, is on the rise. More than 1.5 million patients with a “life-limiting illness” were admitted to hospice last year, at a time of greater need- with an aging population of baby boomers eligible for the Medicare health insurance program for the elderly.
“Many physicians and hospitals don’t refer those patients until the end. Some don’t refer because it interrupts their own reimbursement or the physician’s.”
“There’s an awareness problem,” said Donald Schumacher, president and chief executive officer of National Hospice and Palliative Care Organization (NHPCO) in an interview with Life Matters Media. “People are always struggling when it is going to be the end of life.”
Hospice is generally care provided in a patient’s home, but can also be provided in a center, hospital, nursing home or other long-term care facility for people facing illness near the end of life. The number of hospice patients served has risen more than 25 percent over the last five years from 1.25 million in 2008, according to NHPCO figures published in the organization’s 2013 annual publication “Facts and Figures: Hospice Care in America”
Caregivers say the industry needs to do a better job at outreach and education to medical professionals and the public at large, particularly given the benefit is adequately funded by the Medicare health insurance program for the elderly and disabled, which offers access to hospice to potentially millions of Americans.
Schumacher said there can be many reasons for the lack of service and related knowledge about a benefit designed for patients with a prognosis of six months or less, assuming their disease follows its normal progression. Patients can remain in hospice if they live longer, pending a physician’s analysis for continued eligibility, hospice providers say.
“Many physicians and hospitals don’t refer those patients until the end,” Schumacher said. “Some don’t refer because it interrupts their own reimbursement or the physician’s.”
Though the number of patients with short lengths of service is a concern, the average length of service, or length of stay, continues to rise. In 2012, the average length of service was 71.8 days compared to 69.1 days in 2011.
“As hospice and palliative care professionals, we need to continue reaching out to patients and family caregivers to help them understand all the benefits that hospice care brings,” Schumacher said in a statement NHPCO released to accompany its report. “And as part of our ongoing engagement efforts, we must continue our efforts to reach communities that are under-utilizing hospice care.”
To improve awareness about hospice and the services it provides, NHPCO is launching a first-ever national campaign. Though NHPCO executives are not ready to disclose details, they did confirm the campaign will be a “multi-million-dollar” effort launching in January.
Certainly, hospice facilities have a financial interest in making patients and their families aware of this benefit.
But meanwhile in Washington, the sequester has already slashed Medicare and other government spending on an array of programs – including hospice – and providers don’t want to give Congress another reason to reduce spending on a service studies show is needed. This year, hospice had Medicare reimbursement of nearly $160 per day reduced to $156, a payment that covers professional staffing such as nurses, therapists and social workers.
Still, Schumacher said Congress is supportive of the hospice benefit and said it fits the push by the Affordable Care Act and government health insurance programs to keep patients in high quality, low cost settings rather than in more expensive inpatient hospital settings.
“There is Medicare funding for hospice,” Schumacher said.
“We are a huge savings,” he said of hospice care. “Hospice saves on average about $2,300 in comparison to other patients who are admitted for similar illness” to other facilities like hospitals.
The Medicare hospice benefit is the primary source of coverage for hospice care. In 2012, 83.7 percent of hospice patients were covered by Medicare, the NHPCO study showed.
Schumacher said hospice programs are becoming more integrated in newer healthcare delivery models designed to help save Medicare dollars, while at the same time improving quality such as accountable care organizations (ACOs) that have contracts with Medicare to coordinate treatment in hopes of improving outcomes while lowering the cost of medical care.
This fall in Detroit, for example, Hospice of Michigan partnered with Genesys Physician Hospital Organization’s ACO.
The ACO model differs from the predominant fee-for-service medicine in which medical providers are paid for each service for each patient in a system. Fee-for-service medicine can lead to potentially excessive treatment. When it comes to end of life care, patients are known to get a lot of care, but it is often not coordinated.
Genesys Physician Hospital Organization’s ACO was one of the original 32 so-called “pioneer ACOs” that were launched by Medicare’s administrator, the Centers for Medicare & Medicaid Services.
“By offering additional support early on to those suffering from serious illness, we are able to better manage symptoms and relieve pain,” Dottie Deremo, president and chief executive officer of Hospice of Michigan, said in a statement announcing the new partnership. “This type of care provides the patient with comfort, helps relieve stress and anxiety and extends the patient’s quality of life.”
Hospice Use: New Facts and Figures
Posted on Tuesday, November 12th, 2013 at 9:36 am by lifemediamatters
In 2012, 1.6 million Americans received hospice care; 36 percent died or were discharged within seven days of admission.
New findings published in the annual hospice facts and figures report show nearly 80 percent of hospice patients receive care for less than 90 days before dying. The median length of a hospice stay is only about 19 days, and the findings are both consistent with those of 2011 and troubling to study researchers.
The report, “Facts and Figures: Hospice Care in America,” was conducted by National Hospice and Palliative Care Organization. It provides data on hospice trends and updated information on the growth, delivery and quality of hospice care throughout the U.S.
“As hospice and palliative care professionals, we need to continue reaching out to patients and family caregivers to help them understand all the benefits that hospice care brings,” said NHPCO President and CEO J. Donald Schumacher, Psy.D in a press release. “As part of our ongoing engagement efforts, we must continue our efforts to reach communities that are under-utilizing hospice care.”
Hospice is care that aims to provide comfort and pain management rather than aggressive treatments– usually only for terminally ill patients with six months or less to live. It is most often used when curative treatments are no longer effective. Cancer remains the most common diagnosis for patients seeking hospice; 37 percent of enrollees are cancer patients.
Sixty-six percent of patients who receive hospice benefits remain in the place they call home, whether it be a private residence or nursing home, unchanged from 2011. The gender divide between hospice patients also remains unchanged; 56 percent of hospice patients are female.
Since the founding of the first American hospice in 1974, more than five thousand hospice programs have opened throughout the U.S. The Medicare hospice benefit, enacted by Congress in 1982, remains the predominant source of payment. Eighty-four percent of patients receive coverage through the benefit.
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Managing Conflicts When End Of Life Treatments Are Futile
Posted on Thursday, August 29th, 2013 at 2:53 pm by lifemediamatters
Communication between patient, doctor and family is vital when aggressive end of life treatments become futile, said Dr. Robert Taylor, associate professor of medicine at The Ohio State University Wexner Medical Center, during a presentation entitled “Managing Conflicts Around Medical Futility.” Taylor addressed medical professionals at Advocate Illinois Masonic Medical Center in Chicago Wednesday. After his talk, Taylor spoke with Life Matters Media about how to foster better doctor-patient communication. He also shared his thoughts about the impacts of race, religion and culture on end of life care.
How early should seriously ill patients consider hospice care?
The rule is that patients have to be within six months of death for Medicaid or other insurance coverage of hospice. But it is worth bringing the topic up earlier and making people aware if we think they are headed in that direction. So much of it is listening to people. I think doctors neglect to bring up end of life conversations because it is part of the human condition. And we aren’t always fair to doctors. It is all of us. Death is a scary thing, and most people are not accepting of death. Physicians do have this sense, this burden, to be a cheerleader for their patients. They try to cheer them on, make them stronger. Then the patients don’t want to go to hospice, because they think it’s their fault they can’t get stronger– I’ve never met a doctor who didn’t have good intentions, though.
During your presentation you spoke about how many African-Americans have a distrust of medical professionals, especially when end of life issues are discussed, because of their history of receiving less care than whites and the atrocities of the Tuskegee experiments. How can doctors better care for African-Americans?
To some degree, it can be best done by African-American doctors and nurses. Richard Payne, a neurologist with Duke, has worked through the black churches, because his argument is that they are not getting access to these services, because they are not aware of them. But the biggest thing is listening to people and reassuring them. Listening to how they are suffering and what is causing their pain.
Many Christians, especially fundamentalists, opt for more aggressive end of life treatments than others, even when such treatments are deemed futile. How can this be addressed my doctors?
It is a well-documented reality. The Catholic bishops are generally pretty reasonable about not recommending aggressive treatments. I don’t find that so much in Catholics. I think the Protestant evangelicals and fundamentalists, and certain Orthodox Jews and devout Muslims are more concerned with keeping people alive. I think getting chaplains and religious leaders involved and explaining treatments to them is important. There are two goals for a dying patient: controlling symptoms and comforting the patient and family. It’s not reasonable to keep people alive if they are not comfortable, but you can’t change everybody.
Much has been said about the implementation of the Affordable Care Act and ‘death panels,’ even though measures encouraging end of life conversations have been taken out of the law. Now a bipartisan push for Medicare coverage of such doctor-patient dialogue is making waves. What do you think about such measures?
I think end of life discussions are helpful, although they can be done badly. I think people graduating from medical school today will be better at these conversations. Not paying for end of life conversations is wrong. They absolutely should be in the Affordable Care Act. Advance care planning doesn’t have to be scary. ”Ye shall know the truth and the truth shall make ye free.”
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Long-term Care: The Crisis Nobody Talks About
Posted on Thursday, July 11th, 2013 at 5:42 am by lifemediamatters
The U.S. is running out of time to remedy its long-term health care crisis, Dr. Bruce Chernof, chairman of the Federal Commission on Long-term Care, told Chicago’s NPR affiliate. As long-term care insurance dries up and becomes more expensive, millions of baby boomers must begin planning now for uncertain futures.
“It’s important to recognize that we are going to age differently than our grandparents did,” Chernof said, “because 70 percent of folks over the age of 65 will need, on average, about three years of long-term services and support.” Twenty percent will need five years or more. Planning is vital because federal benefits will most likely be scarce; such care is not covered through standard health insurance and is not a prominent portion of Medicare or Medicaid.
But while planning for long-term care is essential, the few available options are expensive. Current long-term care insurance has a price, dependent on when one buys it, one’s medical history and how much care one wants. “We have products that aren’t available to the majority of people who might want them, and we have challenges getting people to understand and to make a choice to plan,” Chernof said.
Even though long-term care insurance has been available for more than 20 years, the industry has faced challenges from conservative investments and historically low interest rates, contributing to higher premiums. “I don’t think anybody would have predicted this if we had this discussion in 2006,” Chernof said. Reuters reports that policyholders have faced double-digit rate hikes. Policy prices are about 20 percent higher this year than in 2012, according to the American Association for Long-term Care Insurance.
Adults should be aiming for long-term care insurance by age 40, he said, since premiums are likely to become much more expensive. Nationally, Chernof suggests building the private long-term care insurance market.
While the biological clock ticks, so does the time Chernof’s commission has to come up with solutions to fix long-term care: 80 days. The commission came about as a result of the January deal that averted the controversial “fiscal cliff,” a combination of tax hikes and spending cuts. The commission is composed of only 15 members (9 Democrats and 6 Republicans) with fundamental differences in opinion.
The commission first convened in late June and is operating with severe limitations– they can only meet during the next four months, there is no permanent staff and the commission will be disbanded after final recommendations are sent to Congress. Congress has no obligation to consider any of the commission’s recommendations.
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