by ACHE SoCal | Apr 9, 2015 | Blog
The proponents of physician-assisted suicide as an end-of-life option for California residents diagnosed with terminal illnesses are again advancing a bill –SB128 (Wolk and Manning)– through the state legislature. With each attempt, legislators and the public are becoming more knowledgeable and more approving of this form of aid in dying. Should the bill fail passage this time, its sponsors are prepared to ask voters to approve a ballot measure next year. Either way, even its most ardent opponents agree that California is poised to become the fifth state in our nation to adopt medical treatment protocols to proactively end human life.
The good thing about SB 128 is that the protocols it prescribes have been vetted by all the experts in Oregon, Vermont, and Washington where similar laws have been enacted. Montana is the fourth state that allows physician-assisted suicide, but the authorization came by way of a court ruling, not legislation. Similarly, a court ruling that is being appealed could add New Mexico to this list.
I, too, believe that approval of this end-of-life option is long overdue; that we as autonomous individuals should have the right to decide how our lives will end if confronted with a terminal illness. I neither dismiss nor deny effective pain management, hospice and palliative acre, the Advance Health Care Directive, or Physician Orders for Life Sustaining Treatment (POLST) as worthy options, but these are all passive end-of-life choices. Proactive choice should be allowed because persons are entitled to be self-determining without interference. As Kant and other philosophers argued from the earliest days of civilization, this is a fundamental human right.
SB 128 does, however, fall short in one key area; it fails to specify any special training requirements for physicians who want to counsel and advise patients on this end-of-life option. As do the laws in the states that allow physicians to aid in proactively ending a person’s life, this bill would deny doctors their humanity. That can be corrected by adding diversity training and a fellowship in end-of-life care requirement for participating physicians.
A plethora of studies can be found in medical literature to underscore the degree of influence that race, ethnicity, gender, socio-economic status and lifestyle choices have on physician-patient relationships and the medical treatment options prescribed by doctors. This serves to underscore the reality that doctors are no less flawed in their socialization than any of the rest of us. But the rest of us are not given a license to kill. Neither should anyone with just a medical degree, especially in a state with so diverse a population as California.
by ACHE SoCal | Mar 9, 2015 | Blog
“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.” —Isaac Asimov
Of all the accomplishments achieved by Americans in the past century, one of the most dazzling has been the prolonging of the lifespan. In 1900, Americans lived 47 years on average. A healthy 70-year-old today is projected to live to the age of 84.
However, achieving such longevity requires an enormous reservoir of health-care resources devoted to those in the last year or two of their lives. End-of-life care represents 22 percent of all medical expenses, 26 percent of all Medicare expenditures and 25 percent of Medicaid expenditures, even though only 5 percent to 6 percent of Medicare enrollees die in any given year. In California, 38 percent of all medical expenditures for care during the last year of life are spent in the final month prior to death.
Patients also pay for much of that care themselves, with 20 percent of end-of-life medical expenses coming out of their own pockets. The bite can even occur before a family member becomes seriously ill. According to the Employee Benefit Research Institute, the typical working person reaching retirement age in the next decade will need to pay $158,000 in Medigap premiums to ensure proper healthcare coverage to reach the age of 80, and $223,000 to reach 85. If that person reaches age 95 — a not unreasonable near-future expectation — he or she would need $479,000.
Our American perspective on managing death is derived to some extent from the original Puritan notions of our first settlers, along with the Catholicism of our large wave of 19th century immigrants. Also, it is tempered by our steadfastly optimistic embrace of technological innovation and the pursuit of material success.
While debate on virtually every subject is permitted, discussion on end-of-life issues is particularly strained. A combination of our beliefs about the sanctity of life, our disdain of defeatism and our love of cutting-edge technology has created a culture wherein we aspire to defeat the undefeatable. Terminally ill cancer patients, for example, cling to the notion that an emerging drug therapy may cure them, or the parents or spouse of an elderly patient may elect to continue the person’s life support in the hope of a miraculous rally.
The increasing lifespan of Americans, although a remarkable achievement, has created uneasiness with how to deal with death. As a result, patient and family satisfaction with the experience of death is decidedly mixed and has driven up costs for health care at the end of life. Ironically, the vast majority of Americans say they would prefer dying in a low-tech environment such as home, preferably in the presence of their family. Sadly, most end up dying in the cold ICUs of hospitals.
Gail Wilensky, former HCFA (now CMS) administrator, sums up the disconnect between the way Americans die and the way in which they would prefer to go with a succinct irony: “We are one of those societies that regard death as an option,” she said.
Former Colorado Governor Richard Lamm was even more blunt. He observed, “We simply have invented and discovered more things to do to our aging bodies than our aging society can afford to pay for? We have created a Faustian bargain, where our aging bodies can and will divert resources that our children and grandchildren need for their own families, and that public policy needs for other important social goods.”
by ACHE SoCal | Feb 3, 2015 | Blog
I fell ill while away on a business trip last month. If I were in California, I’d simply call my PCP of 25 years and ask him to squeeze me in. “Oh well,” I thought, “I’ll have to do this like regular people do.” Anyway, I wasn’t so sick that I should go to an emergency room, so I asked my host if we could go to a nearby urgent care center. “We could”, he said, “but let’s try to get you into a Minute Clinic instead.” I balked at the suggestion, but soon found myself sitting behind his PC choosing a retail clinic about seven minutes away from his office. An appointment slot was available in less than an hour, so I booked it and keyed in my medical complaint, medical history, and billing information.
Upon arrival, I was directed to a kiosk to sign in. Within moments, I’m called to sign some forms and was escorted to a treatment room. On the way, I see posters on the wall detailing the prices for each and every procedure, test and service provided. “Impressive,” I thought to myself, “I never know what this stuff costs when treated in California unless I ask, and then I’m usually given approximate numbers.” What really wowed me, though, was how quickly and thoroughly I was examined and evaluated. A lab test done in about 20 minutes confirmed my diagnoses, and I left with what I needed to treat my ailment in less than an hour after I had arrived.
Later in the day, as I read through the material they gave me, I learned that a medical record with my medical history had been created and would be available online at all the sites operated nationally by the drug store chain to which this retail clinic belonged . Moreover, I was invited to participate in regular monitoring/check-up programs and, if I had a need, any of several chronic disease management programs they offered in partnership with other providers.
Still ruminating over my experience, I realize that I am having a “crisis of faith” about the supremacy of doctor-dominated primary care delivery. This experience had pandered to my desire for convenient access, ease of use, service integration, portability, and high-quality/low-cost transactions with up-front price transparency.
Bottom line: Being treated as a customer trumps being treated as a patient because customers get high-quality care delivered conveniently, efficiently and with price transparency…and that feels really good.
A recent survey revealed that almost two-thirds of us who have commercial insurance prefer the features and benefits offered by retail clinics over what the traditional approaches to accessing primary care offer. The same survey revealed that about half of the respondents would prefer to interact with a PCP by email, Facetime or Skype to get treated. That, though, is a telehealth discussion for another blog post. But it serves to underscore the thought transformation about health care delivery that is occurring as we integrate personal computing more into the management of our daily lives.
So here is what’s happening with retail clinics. Led by CVS and Walgreens, the five major retailers in the U.S. plan to grow the near-2,000 clinics they now run by almost a third to just under 3,000 by the end of this year. More after that, to be sure.
Forget disruptive change. These retailers are positioned to trigger a seismic shift in our health care delivery model. Here is what the numbers tell us:
- Almost 1-in-5 of physician-led primary care visits in the U.S. could be managed by nurse practitioners at convenient care sites.
- Over a third of all non-urgent hospital emergency room patients in the U.S. could be treated at urgent care centers or retail clinics.
- Over 90 percent of us live within five miles of a CVS or Walgreens. These two retail giants alone are positioned and launching expansive plans to give us a better experience at a lower cost than what is available in the traditional medical care marketplace.
Clearly, when we factor in the looming shortage of primary care physicians, the stars align to support this kind of transformational change.
More to come…
by ACHE SoCal | Jan 6, 2015 | Blog
Movie goers around the world will soon view a new biopic on the late Dr. Martin Luther King, Jr. Selma, the film chronicle of the events that led to the passage of the Voting Rights Act of 1965 is disappointing because of its revisionist distortion of history and President Lyndon B. Johnson’s role. I agree with Julian Bond, who was there and active in the movement as an aide to Dr. King, who recently said that the film needed a villain, so it incorrectly portrays the former president as such. The truth is, President LBJ and Dr. King collaborated on gaining passage of the VRA by a Congress that was reluctant to act on more progressive legislation so soon after passing the landmark Civil Rights Act of 1964.
Arguably, LBJ bested most if not all American presidents at getting Congress to pass progressive legislation (e.g., the CRA, VRA, Medicaid, Medicare), and he deserves better treatment by Hollywood than what was presented in this film.
LBJ personally shepherded through Congress and signed a transformative healthcare bill on July 30, 1965 in Independence Mo., the hometown of President Harry Truman, a predecessor who tried but failed to get this progressive legislation passed. The bill, H.R. 6675, established Medicare, a federal health insurance program for the elderly, and Medicaid, a state-managed healthcare program for people with low income in the United States. President Truman, who was present, then became the first Medicare enrollee.
“In this town, and a thousand other towns like it, there are men and women in pain who will now find ease. There are those, alone in suffering who will now hear the sound of some approaching footsteps coming to help. There are those fearing the terrible darkness of despairing poverty — despite their long years of labor and expectation — who will now look up to see the light of hope and realization,” said President Johnson at the signing.
LBJ’s passion about equality did not end with the passage of this new law. When coverage began in 1966, Medicare was instrumental in the desegregation of hospitals across the United States. Separate-but-equal hospitals had received federal funding since 1946 under the Hill-Burton Act. However, to receive Medicare reimbursement, hospitals were required to desegregate. Although the condition initially met some opposition, more than 1,000 hospitals complied in just four months.
Why is this history lesson important?
Selma will be viewed by new generations of Americans who will see it and believe that LBJ was part of the problem when he was in fact so very much part of the solution to our nation’s issues with race relations and health care for the poor and elderly.
The producers of Selma should take lessons from the producers of Lincoln who gave us an entertaining film that while stretching the truth did not make a shambles of history and the former president’s legacy.
RIP LBJ…and thank you for your herculean efforts for poor and disenfranchised Americans.
by ACHE SoCal | Dec 11, 2014 | Blog
A lot happened this year, to be sure. Marketplace consolidation moved into a higher gear, and the design of new delivery system models got a lot more creative. Anthem Blue Cross’ partnership with seven Los Angeles and Orange County health systems to launch Vivity is an example of an unconventional change model introduced to our region this year. And with the recently-announced relaxation of the rules for Medicare shared savings ACOs, we should expect to see the evolution of change accelerate in the coming year.
Here are more of my favorite health care highlights for the year.
The Good
- The number of Americans without health insurance decreased by almost 9.5 million since the launch of Obamacare coverage initiatives, so says the Commonwealth Fund.
- Hospital-acquired conditions declined by 17 percent since 2010, resulting in an estimated 50,000 fewer deaths and a savings of about $12 billion in health care costs, the Center for Medicare and Medicaid Services (CMS) reports.
- Inflationary growth in overall health care spending slowed dramatically. In fact, health spending in the United States grew at just about the same pace as the overall economy and accounts for 17.4 percent of our gross domestic product, the same as it was in (and has been every year since) 2009, also reported by the CMS.
The Bad
This was another stressful year for the nonprofit health care sector. Unfortunately, the outlook remains bleak in 2015, according to Moody’s Investors Service. In particular, margins for not-for-profit hospitals with annual revenues less than $1 billion will weaken further…have negative operating cash flow growth.
The Ugly
The November election gave the GOP control of both houses of Congress. Republican lawmakers are now positioned to revise or repeal many of the provisions in the Affordable Care Act (ACA) they don’t like, actions that heretofore would have been blocked by the Democrat-led Senate. The budget reconciliation process could be crucial to GOP efforts because it allows for the passage of measures with only 51 votes instead of the 60 votes needed to break filibusters.
Pundits are having a grand time guessing what the new majority party might do. Many believe, for example, that the bar defining full-time employment will be raised from 30 to 40 hours per week, which, according to the Congressional Budget Office, would cost $83 billion over ten years.
To pay for any increased costs resulting from Republican-inspired changes, supporters of the ACA fear that important programs like the Center for Medicare and Medicaid Innovation or the Patient-Centered Outcomes Research Institute will be placed on the chopping block.
I’m not certain about any material threats to the ACA actually happening. Annoying tweaks and ideological posturing…maybe? I’ve always believed that it’s easier to protest, criticize and threaten something you don’t like when you know that you can’t do anything about it. But, those who would undo Obamacare in any substantive way may find it difficult to take enhanced access to health care benefits away from their constituents. We’ll see?
Happy Holidays!
by ACHE SoCal | Nov 10, 2014 | Blog
I really do not understand the malaise that grips most Americans about voting in mid-term elections…I really don’t. My interest in the election on November 4 was as intense as when I first voted in 1968 and in every election held thereafter. Elections are the only venues and the most exciting social engagement parties to which all citizens are invited. And, arguably, participating in elections beats acts of civil unrest as the preferred way to influence government performance.
What I don’t like about elections today, though, is what I do very much like about weather reports. Meteorologists now get their weather predictions right almost always, and, much to my dismay, so do the analysts who predict the outcomes of elections. Because they do, much of the sizzle that elections generate for true public policy junkies like me is eviscerated. I am consoled, though, by the promise that the new and enhanced prediction analytics hold for improving the quality of health care we deliver.
But the subject is elections, and the one we just had was not a complete yawner for me. I was fixated on Proposition 45, the statewide ballot initiative that proposed to rein in health insurance rate increases by subjecting them to a review and approval process by our state insurance commissioner, much like what the passage of Proposition 103 in 1988 did for auto insurance. It was rejected decisively –a near 20-point margin– by California voters. A clear victory for the industry, to be sure. However, the defeat of Proposition 45 leaves us searching for ways to tame health care cost inflation, which promises to cripple our local, state and national economies if not dealt with affirmatively and aggressively.
Over the last decade, the average annual health insurance premium paid by employers rose by 113 percent, and the consumer contribution increased by 131 percent. Moreover, health care spending is projected to grow 1.1 percentage points per year faster than the average overall growth of our economy through 2023, resulting in a 2.1 percentage point expansion of health care’s share of our gross domestic product—from 17.2 percent in 2012 to 19.3 percent in 2023. And that’s with the features and benefits of the federal Affordable Care Act factored in.
Proposition 45 may not have been the answer –and this commentary is not intended to side with either its proponents or opponents– but the problem it addressed unequivocally looms large. In the interim, we should expect more cuts in government payments to providers and more costs shifted to consumers.
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