Apr 4, 2013

The Rising Costs of Dementia Care

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Research published today in the New England Journal of Medicine – Monetary Costs of Dementia in the United States – describes the projected economic consequences of caring for an aging population afflicted with various forms of dementia, including Alzheimer’s disease.

Separating the caregiving related costs attributable to dementia is challenging, if not impossible, because of the prevalence of comorbidity in individuals having dementia and because of the lack of quantifiable data reflecting the financial burden associated with informal caregiving. Using data from the University of Michigan’s Health and Retirement Study, the study’s authors sought to adjust for such phenomena by parsing out data that is believed to reflect the marginal costs associated with dementia.

Their methodology looked at how these costs could vary over the spectrum of probability within a given population that an individual would be afflicted with dementia. Costs were stratified according to:
     Out of Pocket Spending
     Spending by Medicare
     Net Nursing Home Spending
     Formal and Informal Homecare

If the intuitive concern that the economic impact of an aging society will be dramatic, the aggregate cost projections from this research certainly reinforces that concern. With a prevalence rate of 14.7% of the US over the age of 70 having dementia, the current (2010) cost of care (not including the valuation of informal caregiving) is $109 billion. By 2040, if prevalence rates and utilization of non-informal services and care are held constant, that amount is projected to more than double.

The authors note that dementia is one of the most costliest diseases to society, yet 75% to 84% of attributable costs of dementia are related to institutional care (e.g., a nursing care facility) or home-based long-term care – i.e., as opposed to medical care. Healthcare providers in that space should recognize the challenges and opportunities of that consequence.

I think it is important to remember that the inherent subjectivity of the dataset – and the data elements represented – is a reality that cannot be overlooked. In addition, even if there wasn’t the inherent subjectivity, I’m not really sure of the article’s value, nor whether it is deserving of the attention received in the press. Perhaps there’s something there I missed.

Counting the number of teeth a shark has and noting their regenerative capabilities is a fascinating exercise, but it’s the shark that can kill you – not its teeth.

Cheers,
  Sparky

Special Note: last summer I shared with Pub visitors a webinar, Emerging Trends and Drivers in Dementia Care, presented by my Artower colleague, Lori Stevic-Rust, PhD ABPP, Board Certified Clinical Health Psychologist and nationally recognized authority on Alzheimer’s disease. Another plug here seems appropriate.

Filed Under: Alzheimer's/Dementia Care, In the News · Tagged: , , ,
Mar 31, 2013

Readmission Realities

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The topic of Hospital Readmissions has evolved into a primary point of discussion and debate within the nation’s lexicon of Healthcare Reform, most notably through broadly accessed media outlets not typically associated with in-depth reporting on medicine and healthcare. As often happens, by the time such a topic traverses the tipping point of being newsworthy it will have actually been around for quite a while in  smaller though certainly no less important academic circles.

As an example, Dr. Elliott Fisher and colleagues were sharing their research findings on hospital readmissions back in 1994 in the New England Journal of Medicine. Using Medicare claims data they studied discharge patterns in Boston and New Haven between October 1987 and September 1989. What they found was that, “hospital-specific readmission rates varied substantially …” and that “no relation was found between mortality (during the first 30 days after discharge or over the entire study period) and <sic> either community or hospital-specific readmission rates.”

In their conclusions they noted that, “regardless of the initial cause of admission, Medicare beneficiaries who were initially hospitalized in Boston had consistently higher rates of readmission than did Medicare beneficiaries hospitalized in New Haven. Differences in the severity of illness are unlikely to explain these findings. One possible explanation is a threshold effect of hospital-bed availability on decisions to admit patients.”

In other words, despite what is  understandably a popular media association, identification, concern and debate over whether and how reducing hospital readmissions represents a prudent means of lowering healthcare expenditures without impacting quality or outcomes is not a phenomenon borne of the Affordable Care Act. More importantly for my purpose here, understanding the history of hospital readmissions as a policy topic is to understand and accept the challenges associated with developing public policy intended to incent reductions.  And of course, the primary case in point here is Section 3025 of the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP).

I believe there is justifiable concern with the HRRP, particularly in the realm of unintended consequences. But I also believe those concerns have thus far tended to be self-serving and inflated when compared to the potential benefits. I addressed these points just about a year ago in the post, Is Focus on Hospital Readmissions Misguided? That was in reaction to another article published in NEJM, Thirty-Day Readmissions – Truth and Consequence. Now fast forward to an article published this past week in the NEJM, A Path Forward on Medicare Readmissions. Are you getting the sense that the hospital readmissions topic is nothing if not complex and contentious?

In this latest contribution to the subject, authors Drs. Karen Joynt and Ashish Jha identify two recent developments that provide insights into how HRRP implementation appears to be playing out.  The first was a MedPAC report evidencing a decrease in national rates of readmission for all causes, from 15.6% in 2009 to 15.3% in 2011. The second is an emerging recognition, based on CMS reports, that hospitals most susceptible to financial penalties under the HRRP are also those most likely to provide care for individuals with complex and/or expensive healthcare needs. In other words, this suggests that HRRP implementation has the potential to provide a financial disincentive leading to disparities in care availability.

Rather than chucking the HRRP as a policy failure, however, the authors suggest an approach that is quite admittedly conceptually foreign to a government characterized by intransigence and stubbornness: they suggest modifying the program in reaction to what is learned during implementation. Specifically, they first suggest adjusting readmission rates for socioeconomic status. Second, they suggest weighting the HRRP penalties according to the timing of the readmission to better recognize the potential causes of that readmission. And finally, they suggest an offsetting credit be given for comparatively lower mortality rates in recognition of hospitals – e.g., large teaching hospitals – where readmission rates are more likely to be an expected consequence of keeping their sickest patients alive.

The authors correctly point out that, “no policy is ever perfectly designed at inception, and policies should be changed as new evidence emerges.” At the same time, we should be cognizant where policies reach too far or are impractical in their design. For example, the UK’s National Health System (NHS) Medical Director, Bruce Keogh, announced this past Friday that hospitals there will face future reduction in fees for failing to follow the latest clinical guidance (i.e., quality standards).

In my thinking, there is both a philosophical as well as practical difference between policies that provide financial incentive through measuring health outcomes versus measuring the means and methods of achieving those outcomes. But if our aim is to develop a healthcare system that leverages the productivity and efficiency advantages of market-based solutions, while guarding against the market failures inherent to healthcare, we will need to be vigilant in avoiding the slippery slope of policy dysfunction.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Hospital Readmissions · Tagged: , ,
Mar 14, 2013

While Rome Burns . . .

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This post was intended to be written and shared on Sunday, March 17th, while much of the rest of America will be either celebrating being (or pretending to be) Irish. Such foolishness was always strongly discouraged in my family: the reason I spell my name with one “t” is because that was my father’s way of reminding me that I am Scottish. And I’m pretty sure the only day my grandfather seriously frowned upon drinking was St. Patrick’s Day.

But the real reason I am sharing this today instead is that I watched Escape Fire: The Fight to Rescue American Healthcare last night. I had planned on giving myself a few days to get through it, but  I stayed up much later than I wanted – or should – because I found it compelling, disheartening and yet, incredibly inspiring. The feature film’s title has an interesting foundation, and I share that at the bottom of this post.

The one-hour-and-forty-minute documentary, produced and directed by Matthew Heineman and Academy Award-nominee Susan Froemke, provides candid and balanced insights into the inherent structural and systemic elements of our country’s healthcare challenges. For those intimately involved in healthcare delivery there is nothing here that will necessarily surprise you – though I personally found coverage of healthcare delivery in the military to be both enlightening and very concerning from the perspective of national defense.

The storyline organizes and weaves together a root cause analysis from first hand perspectives of various industry stakeholders, e.g., patients, caregivers, industry executives and journalists. It features commentary from holistic health experts Dr. Andrew Weil and Dr. Dean Ornish, Safeway grocery chain CEO Steve Burd, medical journalist Shannon Brownlee, Cleveland Clinic cardiovascular chairman Dr. Steven Nissen, and former Director of CMS, Dr. Donald Berwick.

Unlike Michael Moore’s documentary, Sicko, in which balanced research and evidence were largely supplanted by rhetoric and well-positioned emotion, this film is not an effort to indict, lay blame or point fingers. As Dr. Berwick offers, “between the healthcare we have and the healthcare we could have lies not just a gap but a chasm … I don’t blame anybody – they’re just doing what makes sense – and we have to change what makes sense.” The film does a wonderful job of fairly explaining without getting technical how we got into this situation – and how if we do not make fundamental changes the system will ultimately collapse under its own weight. A lot of lives are going to be lost in the rubble of that collapse.

From a healthcare policy perspective our debate should be focusing on who gets to define what makes sense and who is responsible for making the changes necessary to create individual incentives that align with desired systemic outcomes. A consistent theme in the film is the incredibly impactful power that individual action and accountability can have in healthcare. While at the same time, the inbred allegiance between industrial and political powers in this country are culturally embedded in our social psyche and represent enormous obstacles to change.

If you are even a little concerned about the future of healthcare delivery in the United States, I strongly encourage you to watch this film. And then I encourage you to share your thoughts and insights with us in the HCPolicy Discussion Group (see the picture icon at the top of this blog).

Escape Fire can be seen this weekend on CNN @ 8pm and 11pm EDT (and again at 2am on the 17th – in case you’re already up getting ready for the parade).

Cheers,
  Sparky

On the Film’s Title
In an interview with Sundance Film Festival’s Nate von Zumwal,  Matthew Heineman explains how the movie received its title:

For over a year, we struggled to find a title for the film. How could we synthesize this complex problem and potential solutions under one label? We were stumped. Then we came across Dr. Don Berwick’s healthcare manifesto, “Escape Fire: Lessons for the Future of Healthcare,” delivered years before he became head of Medicare/Medicaid.

Dr. Berwick draws a striking parallel between our broken healthcare system and a forest fire that ignited in Mann Gulch, Montana in 1949. Just as the healthcare system lies perilously on the brink of combustion, the forest fire began to burn out of control, threatening the lives of 15 smokejumpers.

On the spot, the leader Wag Dodge came up with an ingenious solution: he lit a small fire that consumed the fuel around him. He urged his men to join him, but they ignored him, clinging to what they had been taught. The fire overtook the crew, killing 13 and burning 3,200 acres. Dodge survived, nearly unharmed. He had invented what is now called an “escape fire,” and soon after it became standard fire-fighting practice.

Dr. Berwick applies the “escape fire” analogy to healthcare, exploring how our system is “burning,” while there are solutions right in front of us. Upon reading the manifesto for the first time, we realized how perfectly it fit our subject matter. We knew we had our title, and soon after we contacted him about taking part in our film.

As Dr. Berwick says in the film, “We’re in Mann Gulch. Healthcare, it’s in really bad trouble. The answer is among us. Can we please stop and think and make sense of the situation and get our way out of it?”\

Filed Under: Good to Know, Healthcare Reform · Tagged: , ,
Why Can’t We Be Friends?
Mar 6, 2013

Why Can’t We Be Friends?

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Partisanship is as ingrained into the political fabric of this country as are the imported core ideologies from whence it sprang. The history of our domestic partisanship can be traced to the days of George Washington’s presidency with the establishment of the Federalist Party (led by Alexander Hamilton – being in favor of a strong federal government) and the Jeffersonian Republicans, which under Thomas Jefferson’s leadership advocated for strong state governments.

And our history is replete with examples where the individual and collective passions of partisanship have led to bitter conflict, even being manifested in physical assaults on the floors of both houses of Congress.

Shown below is a cartoon depicting a fight in the House of Representatives between Republican Matthew Lyon and Federalist Roger Griswold as depicted in this 1798 engraving. Lyon was the first member of Congress to have an ethics violation charged filed against him when he was accused of “gross indecency” for spitting in Griswold’s face (Griswold had called Lyon a scoundrel, considered profanity at the time).qAnd in 1856, at the heyday of debate over slavery, South Carolina Senator Preston Brooks – deeply agitated at what he considered Massachusetts Senator Charles Sumner’s libelous characterization of Brooks three days earlier in his infamous, “Crime Against Kansas” speech (at which Brooks was not present to protest) – used a metal cane to pummel Sumner, who had to be carried off the Senate floor.
So perhaps, in retrospect, the challenges of partisan politics standing in the way of addressing the nation’s fiscal crisis need to be taken in context. Or do they?

This morning, the Bipartisan Policy Center hosted a town hall meeting facilitated by USA Today’s Washington Bureau Chief Susan Page at the Ronald Reagan Presidential Foundation and Library to launch the Commission on Political Reform. Beginning today, the 30-member commission will be holding forums across the country in the hope of engaging a body politic unwittingly caught up in the maelstrom of political polarization that has been exacerbated and capitalized upon by a Media that serves a profit motive first and civic responsibilities somewhere south of fifth.

Take this, for example. In advance of the new Commission’s launch USA Today recently conducted a clever – albeit devious – poll in which it surveyed 1,000 individuals who were asked to assess two education polices: the first plan would reduce class sizes and make sure schools teach the basics; the second plan would increase teacher pay while making it easier to remove underperforming teachers.

Half of the respondents were told the first plan was a Democratic plan and the second a Republican plan. For the other half of respondents, the labels were reversed. In both instances, respondents overwhelmingly (by a margin of 3 to 1) favored the plan that was associated with their party affiliation. In fact, both sets of respondents were inclined to describe their support as being “strongly” in favor, regardless of which policy was represented.

The BPC’s President, Jason Grumet, in introducing this morning’s town hall panel was deliberate in noting the Commission’s purpose is not to create Kumbaya symmetry wherein political discourse becomes an effort to go along in order to get along. To the contrary, robust debate is needed now more than ever – because the complexity and urgency of the challenges facing our nation demand it.

But today, intelligent, productive discourse and debate is buried in sound bite rhetoric designed to be easily digested by a society in transit, always seeking first to be entertained – and then thoughtful and concerned. Along with that the tribal instincts of our modern social conscience have made the concept of political compromise tantamount to failure.  Since today’s town hall meeting was held at the Reagan Library, I thought it would be fitting to end this post with a quote from President Reagan’s autobiography.

“When I began entering into the give and take of legislative bargaining in Sacramento a lot of the most radical conservatives who had supported me during the election didn’t like it.  ‘Compromise’ was a dirty word to them and they wouldn’t face the fact that we couldn’t get all of what we wanted today. They wanted all or nothing and they wanted it all at once. If you don’t get it all, some said, don’t take anything. I’d learned while negotiating union contracts that you seldom got everything you asked for. And I agreed with FDR, who said in 1933: ‘I have no expectations of making a hit every time I come to bat. What I seek is the highest possible batting average.’ If you got seventy-five or eighty percent of what you were asking for, I say, you take it and fight for the rest later, and that’s what I told these radical conservatives who never got used to it.”

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Public Policy · Tagged: , , , ,
Mar 3, 2013

Shades of Grey

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Charlie Ornstein is a senior reporter at ProPublica and board president of the Association of Health Care Journalists. More importantly, he is the son of Harriet Ornstein, who passed away peacefully on January 18th of this year following a short stay in hospital. Last week, Charlie published an article relating his experience – How Mom’s Death Changed My Thinking About End-of-Life Care.

Reading Charlie’s article reminded me of the insights of Dr. John Henning Schumann, which I shared in my post, The Politics of Dying in America. Charlie’s experience is no different than that of hundreds of thousands of families every year. His perspective, however, is uniquely different because he is now in the unfortunate camp of having looked at end-of-life care from both an objective and deeply subjective vantage.

From a public policy perspective, the vulnerabilities of the American healthcare dragon are so easy to identify that you have to marvel at our inability to effectively exploit them. As Charlie points out in his article, about one-fourth of all Medicare expenditures are made during the last year of a beneficiary’s life. We are paying millions and millions of dollars to buy a few extra days. Doesn’t seem objectively reasonable does it?

What would you pay for one more day? Seeing as the day after one more day the collection agencies wouldn’t be able to reach me, I guess I’d pay whatever my credit would allow. That might get me through Good Morning America. On the other hand, my dad always told me that a noble goal was to leave the world indebted to no one while being the poorest soul in the cemetery. So I got that going for me . . .

Without any intention of being disrespectful to the cherished memory of Mrs. Ornstein, I make light of a scary and depressing topic simply because there isn’t much else to do with it that seems logical. And that’s where very often rational discussions of healthcare public policy breakdown: because one person’s calm, objective logic is another person’s emotional reality. I think this is at least partially what Charlie was getting at in his article.

The elasticity of demand for medical care is one of the most capricious concepts we face in analyzing and assessing healthcare public policy. What I would pay to stay alive another day is necessarily going to be different than what I would pay to keep someone I have never met alive. But the reality is that through public healthcare programs supported by taxation (e.g., Medicare and Medicaid) I do help pay to keep someone alive another hour, day – or hopefully, much longer. Fortunately, I’m not directly involved in that decision making because I cannot imagine what it would be like if I had to choose how my tax contributions should be used – or not – on a case-by-case basis.

The point of all this is while some folks involved in healthcare policy debate would have us believe the world is black and white – with clearly delineated focal points for determining what’s right and what’s wrong – it obviously is not. The real world is a thousand shades of grey between black and white and nowhere is that more evident than when the topic is end-of-life care.

Cheers,
  Sparky

 

Filed Under: Editorials & Opinions, End-of-Life Care · Tagged: , , , ,
The Political Realities of Sequestration
Feb 28, 2013

The Political Realities of Sequestration

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imageNow be honest, before last summer had you ever heard the term, sequestration? Though I’m sure I did, I can’t recall when, and I am quite certain I wouldn’t have known the correct Jeopardy question, “What is the term used to describe the legal confiscation and possession of a defendant’s property in lieu of a judgment or court order?” And that’s not even the popular meaning now embedded into our political lexicon.

I have come to understand that Congress’ use of that term dates back to the 1985 Gramm-Rudman-Hollings Balanced Budget and Emergency Deficit Control Act in which it was used as a means of reforming Congressional voting procedures and intended to raise that body’s consciousness that budgeting should be a process of allocation from funds available – rather than an exercise in arithmetic reflecting the outcome of decentralized appropriations (insert favorite form of sardonic humor here).

The idea was that if the combined totals of appropriation bills passed separately by Congress resulted in spending in excess of the limits agreed to by Congress in the annual Budget Resolution, and then if Congress could not agree on ways to reduce that spending (or did not pass a higher Budget Resolution), then there would be an automatic reduction in spending: the aforementioned sequestration.  For me (and I’m sure many of you), this is a rather easy concept to understand because that’s how sequestration works in our house when our appropriations exceed our funding: we often call it, “cancelling our dinner reservation for Saturday evening.”

Back in fantasyland, however, the automatic reduction was to be sequestered by the Treasury and not disbursed as originally appropriated by Congress. In theory, the application of the sequestration is to be regarded pro rata across all agencies, though Congress has typically exempted certain programs such as Social Security and Defense.  The practical result has been that agencies not exempt would experience a disproportionate share of the spending reductions in order to achieve the total sequestration amount mandated.

As retired Senator, Phil Gramm, noted, “it was never the objective … to trigger the sequester; the objective was to have the threat of the sequester force compromise and action.”  Well, as we’ve seen, there is one thing that simply cannot be forced in Washington right now, and that is compromise. The reason for this is the stark contrast in political realities currently characterizing the two major parties.

The Obama Administration believes it won an electoral mandate to advance the country further in the direction of European style Social Democracy (different than Socialism, but closer than many in this country probably realize). And as Bob Woodward recently found out, they are taking a Machiavellian approach to whatever – and whoever – stands in their way. Woodward has lifted the curtain on the Administration, and he has garnered the attention and concern of a lot of folks, life myself, who have generally been supportive of it. And though I very much doubt it was his intention – or concern – he has created a strategic political opportunity for Republicans.

Unfortunately for their party, however, the Republicans are still wandering aimlessly in the sociopolitical dessert of the late-middle 20th Century, looking for the ghost of Ronald Reagan – or any ideological mantra that could garner greater than 50% support of their tattered leadership. In addition, because of the tremendous expense involved in campaigning in an era of modern media and super PAC’s (even in fending off same-party candidates in primaries), having party power of the House of Representatives is like having a gun with one bullet.  The party in power now gets one shot in a Congressional session to make a political impact.

So what we have is not a game of Chicken, where we wait to see which side blinks first.  We have a legitimate ideological stalemate that is being advanced and dominated by the promotion of minority interests holding sway over the respective parties. I say this because according to opinion polls I’ve seen, a significant majority of this country is in favor of raising taxes in order to pay down debt. What that majority is not in favor of is raising taxes to expand entitlements (there is also significant support for raising taxes and reducing entitlements).

The Administration wants to raise taxes to protect and expand the entitlements that are a critical component of their social agenda, while the Republicans want to reduce entitlements without raising revenue (taxes) so as not to alienate their primary campaign funding sources. The sad irony here is not that elected officials from both parties are acting selfishly in their political self-interests. That we’ve come to expect.  The sad irony is the perceived belief that placating minority interests is in their political self-interests more so than acting in harmony with the majority. Now, why is that?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Sequestration · Tagged: , , ,
WARNING: Rough Waters Ahead
Feb 19, 2013

WARNING: Rough Waters Ahead

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This is a self-promotional blog post, but the connection to healthcare public policy is clear enough.  Just this morning Erskine Bowles and Alan Simpson released a new plan that seeks to find some balance between the polar opposition of the Republican and Democratic parties over fiscal management.

Their approach would cut $600 billion from Medicare and Medicaid and raise $600 billion in new tax revenue from ending or curbing deductions and tax breaks. It would also include $1.2 trillion in cuts to discretionary spending, along with cuts in cost-of-living increases for social security, farm program and civilian and defense retirement programs. 

The Obama Administration has discussed supporting $400 billion in cuts to Medicaid and Medicare, while the House GOP considers any new revenue a nonstarter.  The self-serving political intransigence of the two parties is unlikely to abate any time soon.  But the metaphorical swirls of focus and attention, like water in a sink flowing toward the drain, are clearly zeroing in squarely on further Medicare and Medicaid cost containment.

Healthcare providers are going to have to double down on lowering expenses while concurrently reacting to market and regulatory forces that are driving demands for improved outcomes, higher safety and better quality.  In reaction to this tremendous challenge, Artower Advisory Services has partnered with StrategyDriven Enterprises to create a new product offering that can accelerate the efforts of healthcare providers to meet these challenges.

The Value-Driven Performance Improvement Model© leverages StrategyDriven’s knowledge and expertise developing and implementing performance improvement models in the nuclear power industry to give healthcare providers the tools they need to improve efficiency, enhance production and improve outcomes while lowering costs (i.e., increase patient value).

Please take a moment to read our new White Paper, which describes the V-D PIM in detail (just click on cover page, below).

Cheers,
  Sparky

Performance Measurement Systems Cover

Filed Under: Healthcare Cost Containment, In the News · Tagged: , ,
Gun Control and the ACA
Feb 17, 2013

Gun Control and the ACA

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imageThis is the second occasion I have had in the past four months to correct a news piece that has appeared on the Breitbart web site regarding the Affordable Care Act.  Last November, I shared my disagreement with Dr. Susan Berry’s fallacious interpretation of a Journal of American Medical Association article on knee replacements under the Affordable Care Act.

Interestingly, that post – Death Panels Just Won’t Die – remains the most popular PolicyPub article landed upon.  Visitors come to it by using search engines and wanting to learn more about “Obamacare and knee replacements.” But today I am writing about Awr Hawkins’ piece from January 9, Obamacare Amendment Forbids Gun and Ammo Registration.

A good friend brought this to my attention via  forwarded e-mail. As with many topics of this type, the news gets passed around in emails, blogs and web sites and then reproduced, repurposed and morphed into all varieties of content (just as I am doing here).  As I did in my post on death panels referenced above, however, I will try again to be diligent here in providing to readers original source content, so that you can do your own research – and thinking.  I wish Mr. Hawkins had gone to such effort.  Here is what he wrote:

“Good news — it has become known that hidden deep within the massive 2800-page bill called Obamacare there is a Senate Amendment protecting the right to keep and bear arms.

It seems that in their haste to cram socialized medicine down the throats of the American people, then-Speaker Nancy Pelosi (D-CA) and Barack Obama overlooked Senate amendment 3276, Sec. 2716, part c.

According to reports, that amendment says the government cannot use doctors to collect ‘any information relating to the lawful ownership or possession of a firearm or ammunition.’

CNN is calling it ‘a gift to the nation’s powerful gun lobby.’

And according to Senate Majority Leader Harry Reid (D-NV), that’s exactly right. He says he added the provision in order to keep the NRA from getting involved in the legislative fight over Obamacare, which was so ubiquitous in 2010.”

In his piece, Hawkins references an article produced by HotAir.com, which, in turn, references a video report produced by CNN on the subject that Hawkins’ references in his article (following, so far?).  What the original reporting claims is that Title X, Sec. 2716, Subsection C was a, “little known” piece of the Affordable Care Act that was unwittingly passed in support of the gun ownership lobby by lawmakers whom many would assume are gun control advocates.  In particular, Harry Reid.

As the CNN piece points out, however, up until very recently, Harry Reid has been a rather reliable gun rights advocate.  More importantly, as Ed Morrissey writes on the HotAir site, “this isn’t that much of a bar on Congressional action. What can be done in this manner can be undone in the same manner.”

Even beyond Mr. Morrissey’s interpretation, however, what the above referenced section does is make it explicit the ACA does not empower the Federal government (primarily under the Secretary of the Department of Health and Human Services) with the right to collect, analyze and/or report data and information on gun ownership.  And it was rather widely understood at the time (sorry conspiracy theorists) that in order to achieve some measure of political support of the ACA by the Gun Lobby, this section was intended to provide assurance the ACA was not granting new Federal powers.

That is not the same thing as saying such powers have been henceforth forbidden or cannot be achieved through other means (i.e., through future legislation).  In other words, if Congress were to advance gun control legislation currently under consideration that requires stricter registration, tracking and reporting of gun ownership, there is nothing in the ACA that would conflict with that legislation.

President Obama recently issued 23 executive actions on gun control.  One of these is to, “clarify that the Affordable Care Act does not prohibit doctors asking their patients about guns in their homes." This has also been unfortunately interpreted by some media sources as a new Federal requirement that doctors are being required to act as deputies in ferreting out individuals at risk of committing gun violence.

In any event, while speaking on gun control during last week’s State of the Union, the President noted that, “each of these [gun control] proposals deserves a vote in Congress.  If you want to vote no, that’s your choice. But these proposals deserve a vote. Because in the two months since Newtown, more than a thousand birthdays, graduations and anniversaries have been stolen from our lives by a bullet from a gun."

What I believe this to mean is the President does not have the votes in Congress to pass any meaningful gun control legislation at this time.  But he is seeking to gain some measure of political capital by getting those opposed on record.

This is a very difficult ball of public policy yarn: wrapped in together you have healthcare delivery policy, mental health policy and gun ownership/gun control policy.  It requires serious efforts in research, understanding and debate.  It requires, wherever possible, a clear articulation of the known facts.  Although my readership is paltry compared to what Breitbart controls, I hope my efforts here will combat this latest demonstration of reporting laziness, manifested in unhelpful misinformation.

Cheers,
  Sparky

Blog post picture courtesy of www.sodahead.com

Filed Under: Editorials & Opinions, Gun Control · Tagged: , , ,
Feb 15, 2013

Update: Hospital Readmissions

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Hospital Readmissions continues to be a driving topic of concern, debate and contention in the healthcare industry.  It also continues to be an area of great interest for potential partnerships between acute and post-acute care organizations.  Whether that interest is warranted based upon expected improvement in outcomes and cost reductions remains to be seen.

JAMA Study: Assessing Program Risk
On Tuesday of this week the Journal of the American Medical Association published a study, which looked at the relationship between risk-adjusted mortality and 30-day hospital readmissions.  The reasons for testing this relationship are because of concern that artificial incentives will drive behaviors with unintended consequences.

First, the concern is that hospitals may invest resources to lower readmissions for targeted conditions at the expense of quality care for other conditions.  Second, there is concern that patients may not cared for in an environment that is determined by clinical needs and requirements, but instead by financial considerations.  For those who believe these concern are overstated the results of this research will serve to reinforce their perception. 

Data was analyzed for Medicare beneficiaries admitted to hospitals between July 2005 and June 2008 with a heart attack, heart failure and pneumonia. These are the three conditions hospitals are now being penalized for 30-day readmissions under the Medicare Hospital Readmissions Reduction Program.  According to the study, “risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.”

RWJ Foundation: Revolving Door
Another report released this week, by the Robert Wood Johnson Foundation, found that hospitals and their partner relationships made little progress from 2008 to 2010 at reducing hospital readmissions for elderly patients.  Using new Medicare data from the Dartmouth Atlas Project, researchers found , “one in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while one in six patients returned to the hospital within a month of leaving the hospital after receiving medical care. Patients were not significantly less likely to be readmitted in 2010 than in 2008.”

The report also shares findings from interviews with patients and providers that sought to better understand the root causes of patient readmissions.  While some portion of those readmissions were either anticipated or necessary, there were also a significant number of readmissions that could primarily be attributed to non-clinical considerations, such as discharge planning, the individual’s support system, care coordination and the availability of primary care post-discharge.

So what to make of this? Research is continuing to support the hypothesis that cost savings are achievable by creating better alignment of care requirements and care settings without sacrificing quality.  The ways in which providers achieve such savings, however, are no clearer today than they were several years ago.  Also up for debate is whether the Hospital Readmissions Reduction Program is providing a meaningful incentive to drive innovation – or whether providers are reacting to market realities (likely some combination thereof).

What does not seem to be up for debate is the reality that proactive healthcare providers are pushing integrated delivery models that seek to facilitate better resource alignment.  Are you one of those organizations?

Cheers,
  Sparky

Filed Under: Hospital Readmissions, In the News · Tagged: , ,
Leadership Opportunity for Hospice
Feb 6, 2013

Leadership Opportunity for Hospice

By · 1 Comment

imageIn an article that has received a good amount of advanced press, today’s Journal of the American Medical Association publishes research findings on end of life care, or more particularly, utilization of hospice care.  The article, entitled, Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009, shares the findings of research seeking to determine changes in site of death, place of care and care transitions for Medicare decedents between 2000, 2005, and 2009.

Research results indicated that while more individuals aged 65 and older are dying at home, their utilization of intensive care services (i.e., hospital ICU) during the last month of life increased (29.2% of decedents utilized ICU in 2009).  In addition, 11.5% of decedents in 2009 had three or greater hospitalizations during the last 90 days of their lives.  And while hospice use increased, upwards of 28% used hospice services for three days or less in 2009.

A key finding of the research is that increased use of hospice may not lead to a reduction in resource utilization.  The authors believe their findings could, “raise concerns that hospice is an ‘add-on’ to a growing pattern of more utilization of intensive services at the end of life.” Hospice providers hoping to avoid the sequestration axe take note: while your inherent value proposition of improving the quality of life, while easing the individual pain and family burden associated with end of life care is invaluable, getting paid for your efforts in this environment also requires demonstrable cost savings.

As I have written here before, the Death Panels moniker given to us courtesy of Sarah Palin has been a tremendous disservice to encouraging open and candid discussion on the personal, social and economic challenges of dealing with end of life care.  But I see a huge opportunity here for hospice providers – and the trade associations that represent them – to seize this important initiative back from politicians and elected officials.

They should use this opportunity to take a leadership role in creating a national framework for encouraging candid dialogue, open sharing of concerns, fears and ideas – and for advancing policy initiatives that encourage knowledge and education regarding the alternatives available to individuals and their families facing end of life decisions.

Oscar Wilde wrote that, “life is too important to be taken seriously.”  Well, I posit that death is too scary to run in fear from.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Hospice Care · Tagged: , , ,
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