Hospices: Delayed Death and Payment Consequences

“Doing this for 40-something years. Every time I think someone is going to die tomorrow, damned if they don’t live for a year and a half.”


Sumpter Blackmon, MD, Camden, Alabama
Medical Director, Hometown Hospice, a hospice Medicare is dunning because its patients live too long


On November 25 a New York Times front page article, “In Hospice Care, Longer Lives Mean Money Lost,” reported,


“Over the last eight years, the refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices exceeding reimbursement limits repay hundreds of millions of dollars to Medicare.”


Sometimes, in its desperation to save money, Medicare does something silly. No one, not even the most esteemed among us, knows with certainty how long it will take patients to die. It depends on the underlying disease, on what organ will shut down first and the organ failure cascade that follows, on the will to live, on the desire to die, and maybe even on something or some one greater than one’s self.


The only thing we know with certainty is that Medicare hospice care, started in 1983, is growing more expensive. Medicare payments tripled from 2000 to 2005, to $8.2 billion, and 40% of Medicare recipients now use the service, often for routine care in the home, where Medicare pays $135 a day. Duke University researchers say hospice care saves money, if one takes into account alternative forms of care in other settings, such as hospitals, nursing homes, or Medicaid home care.


Hospice care was originally designed for cancer patients, who are assumed to run a predictable course at a certain point in their illness. But in recent years, patients with Alzeimer’s , amyotrophic lateral sclerosis, strokes, and Parkinson’s disease are being admitted to hospice. The average stays for these patients is 86 days versus 44 days for cancer. To be admitted, two doctors must certify that the patient has less than 6 months to live.


Medicare and others have determined that 1 of 13 hospices, some 220 to 250 of them, are somehow gaming the system – mismanaging the disease or misestimating the time to die – to the tune of $166 million to $200 million a year. According to Congress, a hospice’s total annual reimbursement can’t exceed the product of the number of patients it serves and the per patient allowance set by Congress ($21, 410 in 2007). If a hospice has exceeded its reimbursement limit over the last five years, it must structure a plan to pay back Medicare a high interest rate, 12.5% in the case of the Camden, Alabama hospice.


Somehow this all seems wrong. Has Medicare seriously considered the cost of alternative forms of care, which often involve continuing chemotherapy or other fruitless pursuits for cure? Has Medicare polled its constituents, whom they serve, to ask their level of satisfaction with hospice care? What will be the human consequences of putting out of business hospices in rural areas, where no alternative care for the dying is available? Has Medicare considered patients die individually, rather than statistically?

Blogging Doggerel - Never Say Die

Old Internists never die, they just lose their differentials.


Old Family Physicians never die, they just keep it in the family.


Old Orthopedic Surgeons never die, they’re just get cast aside.


Old Cardiologists never die, they just lose heart.


Old Heart Surgeons never die, they just get bypassed.


Old Urologists never die, they just get stoned.


Old Pathologists never die, they just get disembodied.


Old Anatomists never die, they just become disorganized.


Old Endocrinologists never die, they just make their Last Gland Stand.


Old Hospitalists never die, they just walk down their last corridor.


Old Pulmonologists never die, they just breathe their last.


Old Fertility Experts never die, they just breed their last.


Old Obstetricians never die, they just can’t deliver anymore.


Old Surgeons never die, they just can’t cut it anymore.


Old Plastic Surgeons never die, they just do a final lifo-suction.


Old Gastroenterologists never die, they just disappear up their own fundamental aperture.


Old Neurologists never die, they just lose their nerve.


Old Psychiatrists never die, they just lose their minds.


Old Physiatrists never die, they just can’t rehab themselves anymore.


Old Radiologists never die, they just disappear into the shadows and lose their body image.


Old Dermatologists never die, they just shed their skins.


Old Ophthalmologists never die, they just make spectacles of themselves.


Old Allergists never die, their immune systems reject them.


Old Nephrologists never die, their machines fail and they lose their metabolic balance.


Old Physician Executives never die, they just cross the Great Divide to the Other Side.


Old Anesthesiologists never die, they just pass their final gas.


Old Critical Care physicians never die, they just reach critical mass.


Old Emergency Room Physicians never die, they just triage themselves.


Old Oncologists never die, they just lose their sense of tumor.


Old Otolaryngologists never die, they just close their ears, noses, and throats.


Old Osteopaths never die, they just get the credit they deserve.


Old Veterinarians never die, they just go to the dogs.

Clinical Innovation - Simplicity and Innovation: The Case (and the Multiple Cases) of Gatorade

Robert Cade, MD, the nephrologist who invented Gatorade in 1965, to rehydrate dehydrated University of Florida football players, died in Gainesville, Florida, on November 26 of end stage kidney disease.


He died a wealthy man because of a profoundly simple idea: that you could replace electrolytes lost through sweating by replacing lost electrolytes with electrolytes in a sweet drink. The drink, Gatorade, named after the Florida athletic team’s mascot and Cade's last name, was made up of water, sucrose, glucose, salt, lemon juice, and a cunning dash of whatever.


This year people drink 12 million bottles of Gatorade each day. Athletes drink it on the practice field and during games, dehydrated patients receive it, and the rest of us drink it because we’re thirsty. Gatorade commands 81% of the sports drink market, and it has generated more than $150 million of royalties for the University of Florida (and for the Cade family), which agreed to split the royalties after a 31 month legal battle in the 1960s.


Gatorade is a huge success because its concept is simple, it fills a need, and it’s name is memorable. Its genesis was simple. Cade created it after the University of Florida football coach, Dwayne Douglas, asked Cade<” Why don’t my players urinate after a game?” Even its taste is simple. Athletes rejected the first Gatorade because it was tasteless. Cade’s wife, Mary, said, “Why don’t you add a little lemon juice?”


In the end Gatorade works because it fills the late Peter F. Drucker’s first postulate for a successful innovation;


“Innovation has to be simple and focused. If it does morethan one thing, it confuses. If it isn’t simple, it won’t work. The greatest praise of Innovation is, ‘This is obvious. Why didn’t I think of it?”


Gatorade does one thing: It replaces what’s lost.

Government Reform - 365 Blogs, 365 Days; Still No Reform in Sight

A year ago, I struck out to write a blog a day over the course of a year. Today ends that trek. Here are the changes of import I am witnessing.

Fading hopes for single-payer (even in Massachusetts, it’s clear that will not happen).


Moves towards “convenience care, “ retail, worksite clinics, ambulatory and urgent care centers, as employers search for answers to cost problems (These developments collectively may be the innovation of the year)


Embrace by the public, doctors, CMS, and health plans of generics to take edge off brand name expense ( An example of this is the rush of seniors to fill the Medicare “donut hole” with generic equivalents).


Wary gains of consumer –driven care as more and more small and mid-sized employers replace HMOs and PPOs with high-deductible/HSA fueled plans and Medicare makes HSAs universally available for the first time).


Growing empowerment among physicians as they sense that they’re central to any reform and that 70% of health costs sluice through hospitals, other health institutions, health plans, and administration structures (doctors are expressing this empowerment through Sermo.com, the AMA, and the Physicians Foundation for Health Systems Excellence, an organization of state medical societies representing 500,000 physicians)


I see no prospects for sweeping reforms. I’m no fan of the New York Times editorial page, but it’s lead editorial in today’s Sunday Times gets it about right on many counts ( “ The High Cost of Health Care, November 25)


Here’s what the editorial had to say.


The Problems


High health costs causes vary and are rooted deep – our wealth and willingness to spend more, our reliance on specialists and technologies, our fragmented array of providers and insurers (one man's fragmentation is another man's personal doctor). The fundamental question is: what can be done to lower costs and rate of increases, and does it matter?


The Solutions


Cut 30% cost variance by regions (to me this is wishful thinking. Every region expense priorities and beliefs in what constitutes "quality care" differs and will never be the same). Identify what care works, inform consumers what works, reward doctors that make it work (what works, unfotunately, often falls into “gray” areas, and comparative effectiveness studies are in their infancy). Managed care is creeping back into health plans in the form of protocols and P4P (but there are signs a backlash is growing ). Implement information technologies on a grand scale ( I differ with the Times assessment that “There is little doubt” widespread computerization could greatly reduce the paperwork burden, head off drug errors, and reduce replication of diagnostic tests). Preventive measures – controlling weight, exercising, stopping smoking, checkups and screening and judicious use certain drugs – will slash costs (fat chance in individualist and misbehaving America). Carefully coordinating care and managing chronic disease ( I believe this is sound approach). Have the government negotiate Medicare drug prices and import drugs from abroad (I’m not optimistic beat the pharmaceutical and device manufacturer lobbies).


Who Picks Up the Tab?


Pay doctors less ( The Times doesn’t favor this, and neither do I). Stress Primary Care ( The Times says this will be a long term-project, requiring changes in reimbursement formulas and medical education reform. I agree). Give consumers skin in the game ( The Times cites 1972-1982 Rand studies showing consumers spending own money spent 30% less, but doubts consumers have competence to second guess doctors, and says consumer-driven care will apply to the poor and the sick. Single payer whereby government pays for all care and dictate prices (The Times says such a system might cut costs but has limited political support.


The Times conclusions? No silver bullet exists to slash costs; there is not enough information to cut costs without impairing quality, and maybe, just maybe, some hope for cost lwoering lies in “cascading knowledge’ flowing from human genome project, nanotechnologies, tailor-made personal treatments. I’m dubious about the latter, but hope springs eternal, and I may be wrong.

Book Review - A Novel for Dialysis Patients

That Damn Dialysis – A Book Review

For patients undergoing dialysis and waiting for a possible kidney transplant, That Damn Dialysis, a dramatic, sometimes comical, account of the emotional gauntlet through which a dialysis patient passes, offers a shared experience for those suffering from the disease. . Nephrologists may want to recommend That Damn Dialysis for patients seeking information, empathy, and hope.


The author is Cindy Barclay. She is a RN and critical care nurse with 20 years in the dialysis field and 14 years as owner and CEO of Quality Dialysis, Inc, a Houston, Texas based company with 50 employees. She noted early on the nephrology industry tended to treat patients in a vacuum, leaving patients and families in a dark and confused state about their disease’s implications.


To clear up the confusion, she first wrote a manual for dialysis patients. The manual evolved into That Damn Dialysis (Claybar Publishing, Inc, 2007, $19.95, $10 for dialysis patients). It took two years to write. It’s a tale about the trials and tribulations of Cledus Washington, a 50 year cabinet maker after he learns he has chronic kidney disease and needs dialysis. Mrs. Barclay is now at work on a sequel to That Damn Dialysis about Cledus’ life once he receives a kidney transplant.


I asked Ms. Barclay, “Why a novel?” And she responded, “ Because people like drama, and it’s an effective way to explore relationships and tell a story.” In the story, Cletus loses his girl friend and fears he will lose his job because of the time required for three times a week dialysis treatment.

In writing the book, Ms. Barclay realized 20.6 million Americans diagnosed with chronic kidney disease had little access to understandable information about their disease. Most information on bookshelves is written for medical professionals, rather than patients. This leaves a void for patients trying to understand their own debilitating illness.
This novel describes one man’s struggle with kidney disease and dialysis. It carefully explains the medical terms, options, and what Medicare for dialysis patients is all about.


When the news is broken to Cledus that he will need a machine to keep him alive, his life turns upside down. Not only does he lose his kidney function, he loses his girl friend, too. He feels his job may be in jeopardy. He contemplates the possibility of a kidney transplant. Ultimately, Cledus reaches into his soul and survives.

In the book . patients will find new hope and understanding about this devastating disease. After reading it, dialysis patients will learn that can live with their disease and still enjoy life without letting dialysis completely control their destiny.

According to Charles Crumb, MD, a Houston nephologist with 35 years experience. “I look forward to finding out how Cledus deals with his kidney transplant. Excellent reading material; a great story, combined with easy to read medical knowledge.”

That Damn Dialysis is available at: www.claybarpublishing.com, www.amazon.com.

Transparency - In a Clash All By Myself

Health Care Transparency and Returns on Social and Personal Investments

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.

Francis Scott Fitzgerald, 1896-1940, The Crack-up, 1936

Let me be perfectly clear.


I am for transparency, clarity, openness, honesty, integrity, accountability, data measurement and management, sunshine laws, collaboration, joint ventures, the common good, adequate returns of social investments, public disclosure of outcomes and ties to pharmaceutical companies, and physician teamwork to improve care.


I am against rigid, arcane laws requiring armies of attorneys to interpret and which stifle physician-physician and physician-hospital collaboration and joint ownership.


I am for physician individualism, competition, economic freedom, adequate compensation, innovation, personal creativity, self-interest, wealth creation, inherent human nature tendencies, doing well by doing good and reasonable returns on personal investments.


I am against unbridled and unfettered greed, monopolies, and oligopathies.


I am, in short, in a clash all by myself. To be clear, and that’s what this discursive essay is all about, I believe more health care transparency is a good thing, and, at the same time, I believe total transparency has inherent limitations.


Consider:


Revenue-producing ancillary services in doctors’ offices. In theory, physicians ought to make all their money for time spent with patients, not on side investments. . But as every doctor knows, given falling reimbursements for time spent, those who preach transparency delude themselves. Besides health consumers like one-stop shopping, even if a doctor’s business interests are involved. It’s about convenience, not conflict of interests.

Referral to services in which you have part-time ownership – such as joint ownership of MRI or CT scanners. Pete Stark not withstanding, to whom should you refer – to local hospitals, to competitors, to academic institutions, to others who profit from your referrals? Should you reward yourself – or others? To many, self-reward is more commonsensical.



Use of medical devices in which you have a financial interest, you believe in, have developed, have a patent on, or receive royalties from. Suppose you think your device is best thing on the market, which is why you conceived it. . Personally I believe doctors should tell your patients of financial interests, royalties, and self-interests. The proposal before Congress, the Physician Payment Sunshine Act of 2007, requiring companies to publicly disclose payments of $25 or more to physicians may be a good thing.


Wide deployment and diffusion of data of factual information, i.e., data, from multiple sources funneling into a common data tank so government, payers, and consumers can objectively judge for themselves the best value, the best providers, the best outcomes, and the best deal. In some circles, this is known as Health 2.0 – or management by data –reformulating algorithms in an open and transparent market. I applaud data diffusion, but doubt its practicality.


Universal communication through electronic medical records systems between hospitals and doctors so everybody can coordinate care and everybody can know what everybody else is doing with standards and controls to continuo sally improve quality, outcomes, and safety. Good idea, hard to do, given costs, privacy and security returns, and dubious returns on hospital and physician investments.


I trust I have been clear I’m for common social ends lofty goals can bring and against the realistic barriers human nature brings.


For doctors, transparency poses nettlesome problems – interference with improving the bottom line, keeping up a leg up on your competition, attracting patients, and concealing secrets of your success.


Then, on the part of doctors, there are other problems as well – expense of data input, loss of productivity during the transition to computers, use of your own data against you, lack of capital resources to install systems, the huge amount of work to get a system up and running, start-up costs of $25,000 to $50,000 per doctor to get EMRs off the ground, and maintenance costs of $5000 to $10,000 to maintain.

Good will, trust, and desire for the common good and better health care may overcome barriers to transparency – such as privacy, common terminologies, security, and cost. Maybe we’ll find a way to pay. But convincing doctors there’s a business and clinical case to be made for transparency will be formidable – with attractive but uncertain long term social gains but intractable and certain short term problems.