Nick's Blog

A Time to Reflect On Life

With the passing of Tim Russert, we are all made critically aware of the fragile nature of life and our need to embrace every moment as a gift.  Obviously, within a split second, every aspect of our lives can change, and, as in Mr. Russert's case, can end.  This is not a blog about instant death, and it is not just about recognizing our mortality.  It is about preparing for our passing carefully.

Liz Szabo, a writer with USA Today described in a recent article the cancer patient experience by saying, "Patients with advanced cancer often don't know how long they have to live or how chemotherapy will affect their lives."  According to a study by the Journal of the American Medical Association, many physicians either don't give patients that type of information or the patients only "hear what they choose to hear, or very often misunderstand what is said to them."

This situation often leads to patients requesting incredibly disruptive and sometimes painful therapies that have no hope of succeeding.  According to the study, more than 20% of Medicare patients who have advanced cancer begin a new chemo regimen two weeks before they die.  Many times patients are admitted to hospice days or hours before they die. 

What has been observed in cases like this was that the patient often misses the opportunity to repair relationships, get their spiritual house in order or even prepare the necessary documents such as advanced directives.

Where is this going?  Sarah Harrington, an assistant professor at Virginia Commonwealth University School of Medicine in Richmond, co-author of the quoted article, indicated that "in the last few weeks or months of life, a lot of good work can be done." 

One of the points brought up in the article was that only about 37% of physicians told patients how long they had to live. This fact was not surprising to us because we have seen dozens of patients who were admitted to hospice over the years return home and live several more months or years. This particular prediction is not always dependable. The other fact quoted in the article, however, was that many patients learned more about their cases from other patients than from their physicians. 

The article concluded with the suggestion that "patients and their families may have to take the initiative in finding answers to important questions."  Thomas Smith, co-author and Chairman of Hematology and Oncology at VCU's Massey Cancer Center suggested that the following questions should be asked by any patient in this situation:   What are my options?  Can I be cured?  Will I live longer with Chemo?  Should I consider Hospice or Palliative Care?  Who could help me cope?  What do I want to pass on to my family to tell them about my life?  

Palliative care is not limited to cancer.  All end-of-of life diagnoses qualify patients for hospice and palliative care.  Tim didn't need or have this opportunity, but for those who do, embrace it.  The primary thing that can be delivered to the patient and their family is the comfort of having caregivers dedicated to helping you move through your transition.  It is what they do.  These amazing people, volunteers, employees and physicians are dedicated to "paying it forward." 

So, as we eventually face our own mortality, as we evaluate what it is that we want to share with our families, as we consider the legacy that we wish to leave, having a clear mind and looking to those professionals who can help us is not only necessary, it is imperative. This transition can come in the blink of an eye. 

Medicare Penalties . . . This Could Clarify Priorities in Some Hospitals

If you do the math, you can rather quickly determine that, as the Silver Tsunami continues with the Boomer generation, federal funding for health care will become more and more scarce.  There have been some very serious cutbacks in funding to hospitals recently, and we have not seen even the tip of the iceberg.  As a matter of fact, Windber's total increase in reimbursement from Medicare this year for all inpatient expenses will amount to about $8,000 for twelve months. 

When all expenses are taken into consideration for even a hospital our size, $8,000 won't cover  a  tiny fraction of the cost increases that we will be dealing with from the implementation of new federal regulations alone this month.

 We have written extensively about the amazingly low infection rates here at Windber Medical Center, but, you have also read those sobering national statistics regarding deaths from hospital missteps.  CMS (the Center for Medicare and Medicaid Services), has recently introduced a form of pay for performance, or more appropriately, no pay for performance which will very likely cause a great deal of change in the American Healthcare System. 

CMS has decided to literally stop paying for the treatment costs of preventable medical complications.  At the present time, only seven hospital-acquired conditions are on the no-pay list, but it may include up to seventeen conditions by fiscal 2009, this October. 

This approach is referred to as visibility for good care,and it will very well represent the beginning of a stampede from the third party insurance payers to follow "the CMS Big Dog," and discontinue payments based on the same criteria.  In fact, Cigna Corp recently announced that it will not be reimbursing hospitals for certain errors as well.  

So, what's on the list of "no pays?"  Let's start with the obvious: Objects left in after surgery...clearly, that would seem to come under the duh category.  Then there are the pressure ulcers or bed sores, falls and trauma, catheter associated urinary tract infections, and surgical-site infections after heart surgery. 

As a small hospital in an area where the percentage of octogenarians statistically mirrors Dade County Florida, nursing home admissions often come in with these problems, but CMS contends that the hospital should make sure the infections or bruises were there upon admission. Otherwise, it's a free ride for the government. 

Analysis of the source of infections can often times be almost impossible to determine. Having said that, however, only about 9% of U.S. hospitals use daily reminders to help physicians remember which patients have urinary catheters in place.  According to the University of Michigan's Sanjay Saint, a professor of internal medicine, about 74% don't keep tabs on how long the catheters are in place.

Modern Healthcare had an article by Linda Wilson on this topic, and in that article quoted the number, $23,772, as the approximate loss that each hospital would endure from this first wave of no pays.  Accepting that number as a guide would be like determining how much damage one termite might do to your home.  The decision to impose these no-pay penalties should surely get the attention of those of us in this business whose job it is to keep the place open because the next nine conditions, and the next nine, and the next nine could possibly lead to very serious financial challenges for every hospital.  It is bureaucracy at its finest.

In the carrot and the stick scenario, there will be lots of hits. Some will be fatal to smaller hospitals. Wouldn't it have been better to just reward hospitals like Windber?  Everyone would have lined up to learn our secrets.  Carrots work, too. 

 

$4.3 Trillion in U.S. Health Care Spending?

"Money doesn't make you happy.  I now have $50 million, but I was just as happy when I had $48 million."
–Arnold Schwarzenegger

According to an article in Internal Medicine News by Mary Ellen Schneider, spending on health care in these United States is projected to reach 20% of the gross domestic product on the one hundredth anniversary of my father's birth, 2017.  Of course that projection is only an estimate made by CMS, the Centers for Medicare and Medicaid Services.  That estimate is, of course, based upon a continued escalation of nearly 7% each year for the next nine years.  In lay terms, that escalation would mean that the total dollars spent on health care would hit $4.3 trillion...Whatever a trillion is? I still can't fathom a billion of anything.) 

We all should realize by now that this spending in the public sector, Medicare and Medicaid, will increase due to the first wave of Baby Boomers entering the Medicare system in 2011.  My 78 million peers, like the lemmings, are working their way toward the proverbial wall, and for those of you who will have to carry the load until we are wearing our wings, that is not a pretty financial picture. 

The same economists from CMS are predicting a decrease in reimbursements to physicians over the next several years while Home Health will likely grow faster than most other sectors except perhaps prescription drugs. 

What does it all mean?  We are spending more on health care in the United States than any industrialized country in the world and, truthfully, our overall age of death is significantly surpassed by many of those "spending less" countries.  How can that be?  Well, for one thing, we have 47 million uninsured citizens in this country and no one really knows how many illegal aliens. Why so many uninsured?  They don't vote.  The vast majority are young, single mothers with small children, and this does not take into consideration the illegal aliens who are also not insured. 

Back to the answer. . . prenatal care is inadequate and infant mortality in the United States is still an embarrassment.  A few of the countries that do better than us in the world in infant deaths per thousand are:  Australia, Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Japan, South Korea, New Zealand, Norway, Portugal, Spain, Sweden Switzerland and the United Kingdom.  Hmmmmmm?  Could it be because we spend 30% of our annual health care dollars on the last thirty days of life, and less than 4% of our monies on preventative and wellness care? 

Of course, Hospice would be a tremendous help.  We could reduce expenditures on end of life care, properly care for our babies with the excess funds, and ensure that our uninsured are properly covered as well, but what politician is willing to touch that electric third rail of the electorial subway tracks? 

We could begin by putting in a network of sidewalks, bike trails, and walking trails.  We could actually walk once in a while and treat our bodies like a true temple, not the "Temple of Doom."

One of the least often heard issues revolving around these expenditures is the continuation of our archaic hospital system.  It is based on the acute care model, and the vast majority of our diseases are chronic.  We rush the victim to the hospital, patch them up, send them home and then rush them back again without any commitment to behavioral modification.  I have seen individuals reverse their heart disease from diet, exercise, and stress management.  Why can't we embrace this concept, reward these activities, and change our society?  The millions of bicycles in Europe are no accident. 

So, as I've quoted in some other blogs, "Change or Die," or just spend ourselves into oblivion as we attempt to prop up a system that should have gone out with the Industrial Revolution.  Good luck kids, your ole man needs you to keep working to cover my health insurance.