the high cost of saying goodbye
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The High Cost of saying goodbye. Ifeoma Aguanunu HPA 430 4/15/13. The Issue. - PowerPoint PPT PresentationTRANSCRIPT
THE HIGH COST OF SAYING GOODBYEIfeoma Aguanunu
HPA 430
4/15/13
National Health Expenditure (NHE) has continued to increase substantially and Medicare is a large portion of this growth. Over the past 30 years, Medicare per capita spending has grown at a faster rate than the GDP. Further, though the ACA will help to decrease Medicare spending other factors – such as technological advancements, changes in health coverage, rising prices, reimbursement structures, and an influx of Baby Boomer enrollees – led to a report by the Medicare Trustees predicting that the hospital trust fund will run out of money by 2024 unless serious action is taken to address spending.1
Health care services delivered near the end-of-life consume a large portion of healthcare dollars.
The Issue
Definition of End-of-Life Care
Best practice in end-of-life care focuses on supporting both the dying patient and their family.
End-of-life care attends not just to the physical but also the psychosocial and spiritual concerns of patients and their families, and extends into the bereavement period.
Physical problems that must be anticipated and proactively addressed for the comfort of the dying person include pain, delirium/agitation, dyspnea, respiratory secretions, mouth and skin care, bladder and bowel care, and nausea and vomiting. Burdensome interventions which do not improve the dying person’s comfort should also be ceased whenever possible. - Current treatment regimen- Life-saving medical interventions (i.e. surgery, ACLS, life support, etc.)- Hospice & palliative care services- In-patient and out-patient care (i.e. home health)2
Quick Facts 101
Putting everything into prospective, 2011:- National Healthcare Expenditure (NHE) - $2.7 trillion or $8,680 per person; 17.9% GDP- Medicare - $554.3 billion; 21% of NHE- Medicaid - $407.7 billion; 15% of NHE- Out of pocket - $307.7 billion; 11% of NHE 3
97% of elderly are covered by Medicare 4
5% of beneficiaries die each year use about 30% of Medicare expenditures in the last year of life (aprox. 1/3 of budget) 5,6
The elderly (65 years and older) consume more than 33% of all health care spending. 5
Medicare
Began in 1965 Federal entitlement to provide health insurance
coverage for those 65 years and older 4 parts:
- Part A: hospital care and is financed primarily from payroll tax- Part B: physician care and other types of outpatient care and is financed jointly through general income taxes (75%) and premiums paid by beneficiaries (25%)- Part C: Medicare Advantage- Part D: Prescription drug benefit7
Aging Population Growth
4
4
Expenses
Non-terminal Terminal
$7,365
$37,581
Terminal vs. Non-terminal year expenses
All expenses: $7,365- Medicare: $3,775- Non-Medicare: $3,590
Expenses by services:- In-patient: $2,040- Hospice: negligible5
All expenses: $37,581- Medicare: $23,739- Non-Medicare: $13,842
Expenses by services:- In-patient: $15,461- Hospice: $7355
Non-Terminal years Terminal year
Take Home Points
Whom? - All tax payers
How?- Medicare program looks to today’s workers to pay the cost of today’s retirees.
Why?- The number of active workers per beneficiary is projected to decline from 3.5 in 2009 to 2.4 in 2030.- If cost per beneficiary remains constant then the tax burden on each worker will increase by about 70% in the next 30 years.- Unsustainable7
http://www.youtube.com/watch?v=N8QkwED-zU8
Life saving medical treatment at the end of life
Code BLUE!!!
Basic Life Support- CPR + defibrillation
Advanced Care Life Support (ACLS)- BLS + Medications (i.e. epinephrine, atropine, etc.)
Overall survival rates:- Out-of-hospital arrest 6.4%- In-hospital arrest 17.6%
Consequences:- Brain damage- Broken bones8
2 Prong Approach to decrease costs at the end-of-life
Policy Action Plan
Allow Natural Death (A.N.D)
Educational campaign aimed at healthcare practitioners, terminally ill patients and their families, and the general public to increase public awareness of end-of-life care including hospice and palliative care services, DNR/DNI (Do not resuscitate/incubate) guidelines, living will provisions, advance directives, etc.9
Establish a national workgroup to spear head.-Follow Maryland model: Workgroup on hospice care, palliative care and end-of-life counseling9
Support HR 1339 – Palliative Care and Hospice Education and Training Act- Amend Public Health Service Act10
Reimbursement for Advanced Care Planning Consultation:- advanced directives (i.e. living wills and durable powers of attorney)- health care proxy- national and state specific resources- hospice and palliative care services- DNR/DNI orders, AND orders- life sustaining treatments (i.e. surgery, ventilation, antibiotics, feeding devices, etc.)
Every 5 years → Every 2 years Include in Medicare & You Handbook
1. Broad Public Education Campaign
2. Re-introducing Section 1233 of HR 320011
Section 1233 of HR 3200 (ACA)
‘Advance Care Planning Consultation’ (hhh)(1) Subject to paragraphs (3) and (4), the term ‘advance care
planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years 2 years. Such consultation shall include the following:
(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.
(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.
(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.
…
(4) EFFECTIVE DATE- The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2011 2015.
…
(c) Inclusion of Information in Medicare & You Handbook- (1) MEDICARE & YOU HANDBOOK- (A) IN GENERAL- Not later than 1 year after the date of the enactment of this Act, the
Secretary of Health and Human Services shall update the online version of the Medicare & You Handbook to include the following:
(i) An explanation of advance care planning and advance directives, including-- (I) living wills; (II) durable power of attorney; (III) orders of life-sustaining treatment; and (IV) health care proxies. (ii) A description of Federal and State resources available to assist individuals and their
families with advance care planning and advance directives, including-- (I) available State legal service organizations to assist individuals with advance care planning,
including those organizations that receive funding pursuant to the Older Americans Act of 1965 (42 U.S.C. 93001 et seq.);
(II) website links or addresses for State-specific advance directive forms; and (III) any additional information, as determined by the Secretary. (B) UPDATE OF PAPER AND SUBSEQUENT VERSIONS- The Secretary shall include the
information described in subparagraph (A) in all paper and electronic versions of the Medicare & You Handbook that are published on or after the date that is 1 year after the date of the enactment of this Act.
Policy Paramour: Eliot Engel Democrat NY-16 (Bronx and Westchester) Sponsor HR 1339 – Palliative Care and
Hospice Education and Training Act Energy and Commerce Committee
- Subcommittee on Health- Subcommittee on Energy and Power
House Foreign Affairs Committee Founder and Co-Chair of the House Oil and
National Security Caucus Championed energy independence,
affordable housing, real healthcare reform and education for all Americans.- created the Dependence Reduction through Innovation in Vehicle and Energy (DRIVE) Act- ALS Registry ACT (P.L. 110-373)- Paul D. Wellstone Muscular Dystrophy Act (P.L. 110-361)- Public and Teaching Hospital Preservation Act (P.L. 110-252)- President’s Emergency Plan for AIDS Assistance (PEPFAR) (P.L. 110-293) – Stop Tuberculosis Now Act
Co-sponsors of HR 1336
Lois Capps (CA-D): Energy and Commerce Committee (Health), Congressional Nursing Caucus, House Cancer Caucus
James McGovern (MA-D): Rules Committee and Agriculture Committee
Bobby Rush (IL-D): Energy and Commerce Committee, Congressional Black Caucus
Earl Blumenauer (OR-D): Budget Committee, Committee on Ways and Means (Health and Trade)
Tim Ryan (OH-D): Appropriations Committee, Budget Committee Tom Reed (NY-R): Committee on Ways and Means (Human
Resources and Oversight) Corrine Brown (FL-D): Veterans Affairs Committee, Congressional
black Caucus, Older Americans Caucus Sam Farr (CA-D): Appropriations Committee Bruce Braley (IA-D): Energy and Commerce Committee
Stakeholders
Center for Medicare and Medicaid Services (CMS)
Congressional Budget Office (CBO)
Medicare Advisory Payment Commission (MedPAC)
Agency for Health Care Research and Quality (AHRQ)
US Department of Health and Human Services (HHS)
National Hospice and Palliative Care Organization (NHPCO)
American Association of Retired Persons (AARP)
Center for Medicare Advocacy Medicare Rights Center Medicare Advocacy Recovery
Coalition (MARC) American Medical Association (AMA) American College of Physician (ACP) American Health Care Association Committee on Responsible Federal
Budget
Governmental Non-Governmental
Which do you prefer?
Option 1
Option 2
References 1. MedPac. (March 2012, March). Report to the Congress: Medicare Payment Policy. Retrieved from
http://www.medpac.gov/chapters/Mar12_Ch11.pdf
2. Care Search Palliative Care Knowledge Network Website: http://www.caresearch.com.au/caresearch/tabid/738/Default.aspx
3. Centers for Medicare and Medicaid Services website, National Healthcare Expenditure. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf
4. Centers for Medicare and Medicaid Services website, Medicare Coverage. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/TheChartSeries/downloads/35chartbk.pdf
5. Hoover, D.R., S. Crystal, R. Kumar, U. Sambamoorthi, and J. Cantor. 2002. “Medical Expenditures during the Last Year of Life: Findings from the 1992-1996 Medicare Current Beneficiary Survey.” Health Services Research 37 (6): 1625-1642
6. Zamosky, L. The Bogey Man Hiding in the Affordable Care Act. http://blogs.webmd.com/health-insurance-navigator/2012/07/no-death-panels-in-the-affordable-care-act.html
7. Barr, B.A. Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America.3rd ed. Baltimore, MD: John Hopkins University Press; 2011: 131-136.
8. Copper, J.A., J.D. Cooper, J.M. Cooper. (2006). “Contemporary Reviews in Cardiovascular Medicine: Cardiopulmonary Resuscitation.” American Heart Association Journal 114: (2839-2849) Retrieved from: http://circ.ahajournals.org/content/114/25/2839.full
9. Workgroup Report on Hospice Care, Palliative Care, and End of Life Counseling. (2009). Retrieved from http://www.oag.state.md.us/Healthpol/Hospice_and_Palliative_Care_Workgroup_Report.pdf
3. Rapheal, C.., J. Ahrens, and N. Fowler. 2001. “Financing end-of-life care in the USA.” Journal of the Royal Society of Medicine 94: (458-461).
4. Vincent, G.K. and V. Velkoff. 2010. “The Next Four Decades: The Older Population in the United States 2010 to 2050.” U.S. Census Bureau Current Population Reports P25-1138.
5. McClanahan, Carolyn. The Health Care Reform Post. http://www.forbes.com/sites/carolynmcclanahan/2011/12/16/not-ready-to-die-who-should-pay/
9. Center for Disease Control and Prevention website. http://www.cdc.gov/nchs/fastats/hexpense.htm
10. Congress.gov website: http://beta.congress.gov/bill/113th-congress/house-bill/1339/text
11. Govtrack.us website: http://www.govtrack.us/congress/bills/111/hr3200/text
12. Maryland, H. a. (2009). Testimony for HB1090. Retrieved from http://www.hnmd.org/library/resources/documents/Committee_Activities_Legislative/2012LegislativePositions/TestimonyHB1090PalliativeCareinHospitals.pdf
13. Crowley, R. (2012). American College of Physicians Position Paper on Reforming Medicare in the Age of Deficit Reduction. Retrieved from http://www.acponline.org/acp_policy/policies/reforming_medicare_in_age_of_deficit_reduction_2012.pdf
14. Vernon, S. (2012, December 18). How raising age for Medicare would affect seniors. Retrieved from CBS News: http://www.cbsnews.com/8301-505146_162-57559633/how-raising-age-for-medicare-would-affect-seniors/
15. Bronson, D. (2013, February 15). Letter to Senator Hatch regarding his Medicare/Medicaid reform proposal. Retrieved from American College of Physicians: http://www.acponline.org/advocacy/where_we_stand/assets/letter_to_sen_hatch_regarding_entitlement_reform.pdf
16. Silva, C. a. (2011, January 10). Medicare about-face on end-of-life planning pay. Retrieved from American Medical News: http://www.amednews.com/article/20110110/government/301109961/2/