End of Life Care- A Consumer Issue We Need To Talk About

Americans don’t like to talk about death.

When the Affordable Care Act was created we had a heated discussion about the provision that provided doctors with compensation for discussing the end-of-life care for their patients. Those opposing the law (and everything else about it) introduced “death panels” and “pushing grandma off the cliff” into the discourse. The public fell for it, and the section was eliminated from the law. We didn’t want to talk about it anymore.

Well, the Institute of Medicine has resurrected the discussion with its release of the 500 page report “Dying in America.” In it, the IOM attempts to highlight how our existing health care system is woefully unprepared to address the influx of deaths we should expect with an aging population and why it’s only going to add unnecessary costs to an already bloated health care system.

Here’s some facts to think about:

·         In 2011 we spent over $550 billion on Medicare. Of that amount, approximately 28% was spent during the last 6 months of life and 32% was spent during the last two years of life.

·         A study of patient inpatient hospital costs during the last two years of life found huge variations in costs between hospitals. At Mayo Clinic the inpatient costs were $53,000 while UCLA spent $93,000 and New York University spent $105,000. There was no difference in quality of life or outcome (all patients ultimately died.)

·         According to research at Dartmouth, while most patients would prefer to die at home, nearly 55% ended up dying in the hospital.

·         While most Americans believe it is important to talk to their families about their end-of-life preferences, only 30% have written instructions (Advanced Directives) on what they are.

Bottom-line: Health care costs are greatest at the end of our lives (which is no surprise). While we know it is important to document our end-of-life preferences, very few have actually followed-through and outlined what we want. While most would prefer to die at home (or a setting other than a hospital), the majority of us will end-up dying in the hospital- and the costs to Medicare or our families will be dependent upon which hospital we go to.

Even though we may not want to talk about it- death is a reality. Our health care system is not equipped to predict our preferences when we are no longer able to communicate what they are. Health care will throw all its resources to prolonging a life no matter what we would have wanted. This only adds to the emotional and financial costs associated with the event.

Talking with family and executing an Advanced Directive is part of the role the new health care consumer will need to play. It’s about accountability and direction for ourselves and for our family members who will be making difficult decisions on our behalf.

This isn’t “pushing grandma off the cliff.”  This is making easier for those we care about. We need to talk about it.

 

Obamacare: Not the Time to Spike the Ball

There was a lot of news coming out of the Obama Administration last week related to the Affordable Care Act (ACA). The Administration could certainly use some positive news about it and they did their best to capitalize and strategically coordinate the messages to the public. Quite honestly, I’m not sure how much was real news and how much was just an attempt to re-position their overall strategy with the general public. They have a lot of work to do.

First, was the announcement that over 7.5 million individuals used the different health insurance exchanges to purchase health insurance for themselves or their families.  This number miraculously exceeded the moving

target established to define the success of the implementation.  After the disastrous launch and rollout in October last year, this is certainly some positive news. Despite many questioning what the numbers actually mean, the Administration used the opportunity to spike the ball a few times while announcing it.

Second was the announcement that Kathleen Sebelius was going to leave her post as Cabinet Secretary at the Department of Health of Human Services. This wasn’t any surprise to most as she had stayed on much longer than many expected and as an added benefit she could now be used as the fall-guy/gal to blame future Obamacare problems and missteps.

As an added benefit, the Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) updated their numbers regarding the potential impact the ACA is having (will have) on the number of uninsured and the deficit. Despite all the changes in the law and the economy since it was enacted in 2010, the CBO/JCT estimate over 12 million individuals are financially protected with health insurance today that wouldn’t have been otherwise. By 2017 that number will rise to over 26 million. Additionally, while they can’t specifically quantify the number, they still believe the ACA will continue to have a positive impact on the deficit over the next 10 years.

I’m still not as sold on the Obamacare idea as I once was and you can certainly debate the meaning of some of the numbers being thrown around.  But, it’s the only defined strategy we have to work with right now. Until we have another real option (and just repealing the law with no replacement is not a real option) we’re going to need to fix what needs to be fixed and move on while we sort through the meaning of the numbers to see what they are telling us.

In the meantime, the Obama Administration should probably hold off from spiking the ball in victory any time soon. We still don’t know if this thing is going to work.

The Mandate for Contraception- Going Too Far and It Must Be Fixed

One of the things I liked about the Affordable Care Act when it was first introduced was that it tried to put more of an emphasis on prevention in the health care system. We all know our current system has evolved into a “sickness system” trying to fix an illness only after it develops. If we could begin to focus more of our time taking care of ourselves and preventing illness and disease before it happened, the costs would surely decline. It made sense.

And, it also made sense to put a special emphasis on “women’s health” as women tend to suffer disproportionately from chronic disease and for certain conditions adding to the overall cost of health care for everyone.

But there are limits as to how far the law should go.

In 2011, the Institutes of Medicine provided recommendations to the Department of Health and Human

Services of the types of services they believed could improve the health and wellness of women in the population through prevention and ultimately lower the costs over the longer-term. Their recommendations included:

1.       Improved screening for cervical cancer, counseling for sexually transmitted infections, and counseling and screening for HIV

2.       A fuller range of contraceptive education, counseling, methods, and services so that women can better avoid unwanted pregnancies and space their pregnancies to promote optimal birth outcomes

3.       Services for pregnant women including screening for gestational diabetes and lactation counseling and equipment to help women who choose to breastfeed do so successfully

4.       At least one well-woman preventive care visit annually for women to receive comprehensive services

5.       Screening and counseling for all women and adolescent girls for interpersonal and domestic violence in a culturally sensitive and supportive manner

In most cases, the recommendations made sense from a strictly economic/cost perspective. But they must be balanced with the rights established by our Constitution.

Only two weeks after the IOM made their recommendations (remarkably fast for any government decision or anything related to the Affordable Care Act) the Department of Health and Human Services accepted all recommendations and required the recommendations to be included in all health plans beginning in 2012 as part of the Affordable Care Act implementation- no exceptions.

Recommendation #2 (related to contraception) moved the discussion away from addressing the cost of health care- to a debate between a woman’s right to choose for some and the right for religious freedom for others. The issue will be settled legally by the United States Supreme Court later this year.

In a Senate debate a few weeks ago, Senator Patty Murray (D-Washington) stated, “What’s at stake in this case before the Supreme Court is whether a CEO’s personal beliefs can trump a woman’s right to access free or low-cost contraception under the Affordable Care Act.”

This is not a right to choose issue- but it remains a health care cost issue ad most certainly a religious freedom issue.

Since the personal beliefs in all of the challenged cases are, in-fact, based on the fundamental religious beliefs of those challenging this requirement, the answer to Senator Murray’s question should be a no-brainer, even to her. If the implementation of this law begins to infringe on the religious freedom and rights of the individuals it has gone too far and it’s time to put it in check.

And we have reached that point- at least for this part of it.

Reforming Health Care is a Supply-Side Problem

Anyone who read the Affordable Care Act (ACA) when it was first enacted, has a basic understanding of how health care works, and comprehends the reality of the political world we live in isn’t surprised with how the implementation of the law has turned out so far. Unfortunately there aren’t many who possess all three traits.

From the beginning, the law was too big, too overreaching, tried to accommodate too many special interests and placed implementation responsibility in the control of a government not capable of its execution. The law has tried to create a universal health care environment with private market incentives in a private market that has little interest in creating a universal health care system in the first place. The pieces were just not going to fit together.

To be fair, the ACA has accomplished some good things by getting rid of some of the insurance underwriting practices that prevented the sick from having a means to pay for health care expenses and provides access

to health insurance to those who have not been able to afford it in the past. However, when you compare it to the number of people in the individual market who have been negatively impacted by this implementation you have to wonder if there might have been a better way to achieve better results. Unfortunately, things are not likely to get much better in the year ahead when employers are thrown into the mix.

The ACA is going to end up costing much more than originally anticipated and it still doesn’t even address the primary issue facing the country- increasing health care costs. The only way we’re going to address the cost problem is by creating a real health care system in this country that focuses on efficiency, collaboration, outcomes, and prevention. Reforming health care is a supply-side problem and the ACA focuses primarily on the demand.

There are alternatives to the ACA being discussed. These ideas (the main ones being the Empowering Patients First Act and the American Health Care Reform Act- you can find them by clicking here) also focus on the demand-side of the equation and will require market changes that aren’t going to be any easier to implement than the ACA. But they still don’t address the cost and inefficiency issue we are facing.

Numerous studies have indicated that anywhere from twenty-percent to over half of what we spend on health care is wasted in the delivery system we have today. We see it every day (the wasted money on web sites for the ACA is just another example.) By improving the way doctors, hospitals, and patients work together, changing payment and incentives, improving technology and communication, and eliminating the ungodly waste that exists we could easily pay for access to health insurance for those who need it while addressing the fundamental cost issue we face today.

While our politics and general public continue to focus on the availability of health insurance (demand) we’re continuing to focus on the wrong side of the equation. We need supply-side reform to make it work. 

Reducing Provider Networks- Not All the Fault of Obamacare

With all the distractions concerning the appalling Obamacare marketplace roll-out taking center-stage it would be wise for the country to try to keep in mind the bigger picture. It would be wise to remember that the economic/business model of our current health care system is simply unsustainable for the future. This current model spends more, wastes more, and takes up a larger percentage of our economic output than any other country in the world. The model simply has to change or it is going to collapse under its own weight.

Obamacare can (and should) be justifiably criticized for many deficiencies. However, we also need to keep in mind there are many other culprits that have put us in the position we’re in today. Obamacare is not the only cause. There is enough blame to go around for everyone.

United Healthcare recently announced it would be cutting loose between 10 and 20% of its Medicare Advantage provider network across the country. As is the normal plan of action in health care today, there was little communication or dialogue between stakeholders and the action has already resulted in lawsuits, further mistrust, and confusion for seniors as to whether their doctor was going to be part of the Medicare Advantage network in 2014 (especially during the Medicare open enrollment currently underway). The timing sucked for the consumers but it was easy to place the blame on Obamacare with all the other media hype going on today. A spokesman for United Healthcare stated (from the Wall Street Journal),” It’s no secret we are under substantial funding pressure from the federal government.” The message? Blame Obamacare.

Yes, Obamacare did cut funding for the Medicare Advantage plans to the health plans providing them. Numerous studies point to the fact that these became a profit center for health insurance plans and cost 10-15% more than traditional Medicare- and these costs are being funded by the taxpayers. The reduced funding was justified to address the costs of the program.

And yes, in order to address the cost of health care health plans will need to focus on the significant cost differences existing between physicians and hospitals across the country. Remember the Atul Gawande article that showed some areas of the country spend twice the Medicare dollars on health care for no particular reason. Some doctors cost more depending on where they live (see the Dartmouth Atlas if you want proof)

So, while United Healthcare is justified in creating a more cost-effective and efficient provider network they are not justified in blaming Obamacare for the reason. Reducing the provider network is something that could have been done many months ago to avoid putting consumers in the middle. Obamacare simply provided good cover.

Consumers need to be prepared. This won't be the last health insurance organization to make some significant changes to their network. This isn't just about Obamacare- this how a primarily for-profit insurance system is going to react when they finally have to focus on reducing costs. And, that's the ultimate goal.

Obamacare- The Next Hurdle? The Shortage of Doctors

It’s interesting. The country has been debating the pros and cons of the Affordable Care Act since it began in 2010. Unfortunately, until the discussion became relevant to the broader population the general public had remained largely detached.  Yes, some good things have come out of the law to help some of those with pre-existing conditions and to help the system finally start to work on prevention. But many questions about how all the pieces are going to fit together remain.

The debate about health care has been primarily political instead of looking out for what is good for the country and its citizens. Neither side has been willing to try to fix the cumbersome, complex, and expensive law that was enacted. It’s been all or nothing for both and we’re now living with the consequences.

I’ve been following the ACA since the beginning and I’m not all that surprised with the failure of the www.Healthcare.gov web site to work. The processes we are using to manage our government systems are dysfunctional- and the website rollout is a product of that dysfunction.

The country is now focused on www.Healthcare.gov because of the poor implementation and execution of a fundamental feature of the legislation. This rollout was very visible to most, and health care suddenly became more relevant to many.

But, www.Healthcare.gov is only the beginning. Once the site is fixed and running, more individuals will be participating in the broader health care system than before. The website is simply the pipeline for access into the delivery system.

What then?

The most likely answer lies in Massachusetts. After a similarly difficult rollout in the beginning, over 96% of all Massachusetts residents now have health insurance.  But they are facing other problems.

The Massachusetts Medical Society released two reports (2013MMS Patient Access to Care Study; and 2013 Workforce Study) that are likely indicative of what will happen nationally once more individuals enter the health care market.

In 2013, wait times in Massachusetts to schedule appointments with providers ranged from 22 days to 50 days for more routine services. Only 45% of internal medicine practitioners and 51% of family medicine practitioners are now accepting new patients. And a quote from one study states, “With no intervention, health care spending in Massachusetts will double by 2020.”

Even before the ACA was implemented, the country was projected to experience a significant shortage of primary care physicians by 2020. With more people entering the system, that shortage may occur much sooner. Obamacare will certainly be blamed- some of it justified for not addressing the problem before adding to it, some of it not because the problem existed anyway.

Consumers need to be prepared to wait longer and may have to spend more time finding a physician. In some cases (and regardless of the sales pitch) you may not be able to keep your doctor due to the realities of the market. It’s a simple matter of supply and demand.

Be prepared. And don’t be surprised or shocked when it happens. The politics of Obamacare is one thing, the reality is another.

Obamacare- Neither Side Has The Right Answer

In June, 2013 the Government Accountability Office presented a report regarding the overall status of the federally facilitated health insurance exchanges. This report covered the overall project status for the 34 states that were going to rely exclusively or partially on the federal government (CMS) to establish and maintain their health insurance marketplaces. The GAO was somewhat concerned back then. The report stated, “. . . and the many activities yet to be performed- some close to the start of enrollment, suggest a potential for challenges going forward.” We’re certainly going to have challenges going forward and nobody should really be surprised what has happened.

For the past 3 years we have heard the Republicans vowing to repeal the Affordable Care Act (Obamacare) with no vision or plan for replacement. Today, we heard President Obama and those on the left communicating that with the exception of the federal exchange (Healthcare.gov) everything is great in Obamacareland. Neither side is facing reality.

I was actually a supporter of the Affordable Care Act when it was passed in 2010. Finally, the country was going to do something to address the unsustainable health care costs in our country. Finally, the country was going to do something to help prevent individuals from losing everything because of the devastation created by a health care event. Finally, the country created a path to do something that would begin to get rid of the waste and inefficiency that everyone knows exists in the health care system today. I didn’t agree with the approach (getting everyone into an already broken system and then fix the system later) but at least the potential existed to make the changes that needed to be made. I was willing to give it some time.

Yes, the Affordable Care Act is the “law of the land,” yes, the ACA has survived Constitutional scrutiny from the Supreme Court, and yes, Romney wasn’t able to produce an alternative approach during the election last year. But it’s difficult to support an idea that has been communicated and implemented so poorly, fails to acknowledge its deficiencies, and doesn’t sound like its open to new ideas to help improve how it works for Americans.

Obama finally held a press conference that (I thought) was going to acknowledge the existing flaws, address the real misperceptions existing with and about the ACA, and the steps that were going to be taken to get it back on track. I thought he would certainly recognize the deficiencies existing with the federal Healthcare.gov web site, the challenges some employers are facing to implement the law, the disagreements many have with some of the requirements of the law, the reasons some individuals are experiencing “sticker shock” attributed to some of the features of the law, and the general confusion surrounding the intent of the law itself.  I thought he would finally be selling the broader purpose- the need to reform our health care delivery system for the good of the country and our economy- as opposed to simply selling health insurance.  He opted to just sell health insurance and trash the opposition.

The president was right when he stated the Affordable Care Act is more than just a web site. Some of the early features of the law have already helped many individuals (uninsured and those with pre-existing medical conditions). However, to get the general public engaged is going to require a providing a broader understanding of the steps that are needed to fix the mess that exists in our health care system today. It’s time we faced reality and acknowledge some things need to be fixed in the ACA and it should require collaboration and ideas from all sides. Health care reform should be about working together with all stakeholders to achieve a common goal for the country.  In 2010, I naively thought there would be some collaboration to fix what needed to be fixed in the ACA. That is obviously not where this is heading.

Reforming health care is not just trying to get people to go to a web site that does not work to buy health insurance. Unfortunately, that’s the message President Obama sent today and the flaws of the ACA are going to remain. The country will end-up paying for it.