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.