MEDICARE'S HOSPICE EITHER-OR CHOICE: IS IT FAIR?

Ever since Medicare decided – and wisely so – to cover hospice care they’ve forced people into making a tough choice: If you accept receiving hospice then you must refuse advanced medical care such as chemotherapy, radiation, transfusions or dialysis intended to extend your life or even cure you of your life-limiting illness.


Hospice focuses on caring for people physically, socially, emotionally and spiritually throughout their end-of-life treatment. The hospice philosophy is holistic supporting not only the person but the entire family. Medicare covers hospice for individuals with an incurable illness most likely limiting their lives to less than six months based upon a physician’s diagnosis. The Medicare Handbook states that the benefit includes covering drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare such as grief counseling. The care may be given in your home or a nursing facility if this is where you currently reside and in an inpatient hospice facility. Medicare hospice care also covers some short-term hospital and inpatient respite care to relieve a caregiver.

Even though millions would benefit from hospice care every year, large numbers walk away from the service because they don’t want to make the choice of either accepting hospice or rejecting life-extending care. “For too many of those patients, “that’s not hospice; it’s last rites,” counters Dr. John W. Rowe former CEO of Aetna in a recent NYT article. Regretfully, many people believe signing up for hospice care is a sign of giving-up all hope, so they hold-off making the choice and lose the opportunity to receive emotional guidance, pain management, and coordinated care during the most heart wrenching time of their lives.

Medicare beneficiaries can sign-up for hospice care, opt out in the middle of that care and then rejoin later with no waiting period imposed. For example, you may have advanced breast cancer and are receiving hospice care but you’re offered a round of radiation therapy to slow down the growth of a tumor that could hopefully extend your life by months. In this instance, you may decide that you’d like to try the radiation therapy forcing you to end your relationship and care with hospice. Or, perhaps a blood transfusion would bring you much needed energy and you’d like to enhance the quality of your remaining time. The revolving door approach is confusing to families and patients and greatly increases the likelihood of them falling through the cracks in an already fragmented system.

But times are changing. A growing number of hospice providers, experts and insurers believe that this either-or choice is unfair and outdated given new medical advances that were not available since Medicare began covering the benefit over twenty years ago. Hospices throughout the country and locally are exploring an “open access” concept allowing patients to receive the palliative care of medical and social support that have become the hallmark of hospice care and be given access to medical advances that can slow down the course of their disease. “We’ve had a few patients receive treatment such as radiation and chemotherapy while in our hospice and we’ve seen other hospice programs throughout the country exploring this new approach, too,” reports Karen Paris, LSW and Director of Hospice of Central Pennsylvania. “Its goal is to help patients make transitions in their care rather than make an either/or choice.” Open access proponents believe they will be better able to support patients and families struggling with a life-limiting illness who do not wish to discontinue certain treatment regimens.

But Medicare officials contend that if people can receive both curative medical care and palliative (soothing) care at the same time, then their costs will soar. Yet those in the field report that patients who are not in hospice tend to use emergency rooms much more because they don’t have the 24/7 advice of nurses and doctors who understand the course of the disease and can help families care for someone at home. As a result, patients end up in the hospital at much higher costs to Medicare and in the least favored setting for a dying person. Medicare doesn’t ban a hospice from offering advanced medical care – they just won’t pay for it. But what hospice provider can afford including chemotherapy or other advanced medical procedures on a $130 per diem rate for routine care no matter what the patient’s condition?

The other side of the debate is philosophical. If hospice’s mission is to bring holistic care and comfort to those who have accepted that their life is coming to a close then embracing treatments seen as life-saving or prolonging undercuts that acceptance. It sends mixed messages and interferes with their spiritual and psychological development towards achieving a peaceful dignified death. And it seduces families into accepting futile and unrealistic attempts that deny the inevitable.

YOUR TURN
Should Medicare stop forcing people to choose between hospice care and advanced medical care intended to prolong their lives? Or does the system work well as it stands now allowing people to opt out whenever they want and rejoin when they need to?

Prescribing Under the Influence?

Earlier this year, a group of physician leaders from some of the nation’s top medical schools called for a ban on physicians receiving gifts like stethoscopes office supplies, free lunches, tickets to sporting and entertainment events, drug samples, and money
for attending educational seminars sponsored by drug companies often held at vacation destinations and/or fine restaurants. Drug companies also pay physicians as “consultants” when they appear on panels at conferences and seminars speaking on behalf of the benefits of the drug. Some physicians are even provided “ghost writers” from the drug companies so that the doctor can publish an article in a journal regarding the use of the drug and may be recruited to be a member of their speaker’s bureau. The doctors published an article calling for the ban in the Journal of the American Medical Association (February 2006).

The marketing budget of drug companies is huge: last year it was estimated at $21 billion of which the majority is directed at physicians. By law, pharmaceutical companies are forbidden to directly pay a physician for prescribing a drug or a medical device. But beyond that, everything else is self-regulated and voluntary.

Drug detail representatives visit doctor’s offices and hospitals in the hopes of gaining direct “face time” with physicians. Their intent is to convince the doctor that their particular drug is better than others to treat his or her patients. With so many new drugs available today, some physicians welcome the latest information on what medications are available and believe that if they are given anything, it’s simply a transaction reimbursing them for their time. Doctors contend that they certainly are not “bought off” with marketing trinkets of pens, pads, or lunches brought to their office. On that score, most of us would be inclined to agree.

Yet, some studies have shown that doctor’s prescribing habits are related to the drug samples they have on hand to give out to patients and that the subtle psychology of repeatedly seeing drug company logos on office and medical paraphernalia along with the unspoken need to reciprocate when given a gift (no matter how small) is having a positive effect in increased drug sales. It’s hard to believe that an industry would spend billions of dollars on a strategy that clearly wasn’t working.

The more troubling marketing tactics, I believe, are those that offer physicians consulting arrangements, doctors participating in drug company sponsored speaker’s bureaus, journal articles prepared by drug company medical writers on behalf of a physician reporting positive results in using the drug and sponsorship of continuing medical education events that are clearly tied to promoting a drug held at vacation destinations.

Here’s one example: When Searle launched their drug Celebrex they invited 300 doctors and pharmacists to Disney World to recruit them as members of a new speaker's bureau to spread the word
on the wonders of their new anti-inflammatory drug. Besides being paid for their time, they were treated to open bars, filet mignon, and all the hospitality that Mickey Mouse could muster. But even Mickey wasn’t enough, so Searle rented out Universal Studio for the attendees and their families so they could enjoy a whole night of no waiting-in-line rides. The docs were told they’d be paid $500 for every speech they’d give on Celebrex following the conference. The strategy sure seemed to work: Celebrex was the first drug to generate a billion dollars in sales it’s first year out.

Though this may seem like an extreme case, the incident is a lightening rod on the issue and continues to spark the debate as to how much drug company marketing efforts affect prescribing behavior of physicians. To clear up any doubt and maintain the trust and integrity of the doctor-patient relationship, here is what the medical school physicians recommend:

 Ban all gifts, including free, working and/or educational lunches and dinners;

 Prohibit doctors from accepting free samples, which the authors warn is a "powerful inducement ... to rely on medications that are expensive but not more effective." Instead establish a centralized voucher system to distribute samples to low income people;

 Prohibit doctors with financial ties to pharmaceutical companies from serving on panels that recommend which drugs should be prescribed (such as hospital formularies – a preferred list of drugs that a hospital pharmacy dispenses to patients);

 Ban medical school faculty from participating in drug company speakers bureaus or publishing articles ghostwritten by pharmaceutical industry medical writers;

 Require medical school faculty with industry consulting agreements or unconditional grants to post them on a publicly available Web site;

 Prohibit pharmaceutical companies from directly paying for continuing medical education classes and instead create a system by which pharmaceutical manufacturers contribute to a central account that supports educational programs.

These sure seem reasonable to me.

YOUR TURN

1. Would you like your doctor to tell you if he or she had a financial relationship with a drug company? Does it matter to you?

2. Are the drug companies merely offering an educational service that benefits the patient? Or is this influence-peddling that can actually harm patients?


Want to read more?

Kaiser Daily Health Policy Report
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=34993

Abstract of JAMA Article Urging Ban on Drug Company Gifts
http://jama.ama-assn.org/cgi/content/abstract/295/4/429

Hospital Acquired Infections Out of Control

A few weeks ago a historic report released by a state agency in Pennsylvania (PHC4) discovered that during 2005, over 19,000 patients contracted an infection while they were in the hospital which led to one in nine dying. Turns out, patients are almost six times more likely to die during a hospital stay if they acquire an infection than not. It is the first report in the nation identifying the rate of infections acquired by patients by individual hospitals. The Institute of Medicine, a few years back, found that at least 98,000 patients a year die nationwide from acquiring infections while they are hospitalized. Most experts believe this number is even higher.

Imagine if we put these numbers in the context of airplane crashes. Let’s say that only one-third of the infections could have been prevented – that’s just over 32,600 people or three plane crashes EVERY WEEK carrying 200 passengers each. Imagine the public outcry. Think the airlines could go on with business as usual? Think we’d still be flying? Or picture how you’d react tomorrow morning if the local headlines read that nearly 100,000 people were going to die of SARS in the next twelve months. Got your attention?

The industry tells us that hospitals, of course, are places for very sick people, and very sick people have germs. Doctors, nurses and technicians make contact in the most intimate of ways: via blood, urine and bodily contact. It doesn’t take much for germs to travel from one person’s hands to dozens of people every day. The problem for patients, however, is that their immune systems are weakened creating a “Welcome Mat” for bacteria. They contend that the severity of a patient’s illness is what increases the risks of getting a hospital acquired infection (HAI).

BUT health policy expert David Nash, editor of American Journal of Medical Quality and chair of the Department of Health Policy at Thomas Jefferson University, argues that, "It's the process, not the patients" that spawns hospital-acquired infections. According to Nash, three recent independent studies found that “despite hospitals' claim that in the sickest patients it's inevitable that someone is going to get a hospital-acquired infection, that's just not the case." Nash recommends that hand washing among hospital workers, carefully keeping surgical gowns and clothing sterile during procedures, reduced numbers of hospital personnel going in and out of operating rooms and more selective use of antibiotics could significantly reduce the alarming infection rate (Washington Post, 11/21). Marc Volavka, Executive Director of PHC4, is even more adamant: "The simple fact is that every patient who enters a hospital in Pennsylvania and in this country is at risk for a hospital-acquired infection. This is about flawed processes and the chaos currently existing within our health care delivery system."

YOUR TURN

1. Should hospitals require that every doctor, nurse and technician wash their hands in front of patients before examining or treating them? Should they tell patients on admission to ask hospital personnel, "Did you wash your hands?" Would you ask?

2. Should Medicare start linking its payments to hospital infection rates? For example, if someone gets a urinary tract infection that is hospital acquired, Medicare wouldn’t pay the hospital the added costs to treat the patient’s infection.

3. Should every state issue annual consumer reports on hospital acquired infections by hospital? Would you use this data to select a hospital for your next surgery?

Learn How to Prevent Hospital Acquired Infections

In response to the national infection crisis, the American Hospital Association (AHA), the American Medical Association (AMA), and the National Patient Safety Foundation (NPSF) advise that you can take steps to protect yourself in their brochure "Preventing Infections in the Hospital – What you as a patient can do."

They offer ten action steps you can take when you’re hospitalized. Here is what they recommend:

1. Wash your hands carefully after handling any type of soiled material and after you have gone to the bathroom.

2. Do not be afraid to remind doctors and nurses to wash their hands before touching you.

3. If you have an intravenous catheter, keep the skin around the dressing clean and dry. Immediately tell your nurse if the dressing becomes loose or wet. And (this is my recommendation) if your catheter is in for more than 48 hours, ask your doctor why and when it can be removed.

4. Let your nurse know right away if the dressing on a wound becomes loose or wet.

5. If you have any type of catheter or drainage tube, let your nurse know if it becomes loose or dislodged.

6. If you have diabetes, be sure that you and your doctor discuss the best way to control your blood sugar before, during, and after your hospital stay. High blood sugar significantly increases the risk of infection.

7. If you are overweight, losing weight will reduce the risk of infection following surgery.

8. If you are a smoker, quit. This reduces the chance of developing a lung infection and improves healing.

9. Prevent pneumonia by performing deep breathing exercises and getting out of bed.

10. Ask your friends and relatives not to visit if they feel sick. Make sure that all visitors wash their hands when they visit and after they use the bathroom.

Report it! If you ever acquire an infection, ask the doctor for the exact name and spelling of the infection. Also ask to see someone from the Infection Control Unit (every hospital must have one). Ask for an explanation of the nature of the infection, and what best practices are being used to treat it. If this infection has caused a real hardship for you, report the incident to your local health department. You may prevent someone else from going through the same thing since the Health Department will be obligated to look into your report and, if the hospital’s infection rate is above the norm, they will demand corrective action.

Where Infections Strike
Hospital-acquired infections commonly find their breeding ground in the urinary tract, around the wound of the surgical site, in the bloodstream and in the lung leading to pneumonia. The Pennsylvania Health Care Cost Containment Council PHC4 in their recent landmark study learned that wounds resulting from surgeries performed on the small and large intestine, and surgery for blood vessels account for the most frequent incidence of surgical site infections. Patients who suffer heart attacks or have peripheral artery disease are most likely to come down with pneumonia. Patients admitted with lung disease are more likely to acquire blood stream infections. And older patients are far more likely to suffer from urinary tract infections than any other age group. My guess is that this is related to higher catheter use prescribed for the elderly. In a recent study reported in the Journal of the American Geriatrics Society, researchers at the Veterans Administration Ann Arbor Healthcare System found that having a catheter in place for more than two days increases the likelihood of an infection at a rate of 5 percent each day. They found that, all too often, busy doctors with lots of patients simply forgot to give the orders to remove it.