Solutions for avoiding aggressive EOL care

Many older patients today are not getting what they wanted. Instead, they are receiving invasive--and unproductive--care in the last month of their lives. As Paula Span eloquently explains in her The New York Times article, Aggressive Medical Care Remains Common at Life's End, elder care is fraught with these trials and tribulations. While the systemic reasons for these failures and frustrations would take an entire book to explain (trust me--my book is available April 4th), Span points to two potentially powerful solutions:

• Making more of an effort to offer patients Palliative Care Consults before offering aggressive end-of-life treatments like chemotherapy, dialysis, surgery, or a visit to the ICU.

• Allowing patients the option to continue curative treatment while in hospice. Reforming Medicare to allow this would benefit everyone. In fact, VA Insurance has found it beneficial to offer curative care in hospice. Even Medicare itself piloted a project showing that hospice with curative care improves experience and lowers costs.

If you found Span's article of interest, you might benefit from my book, The Journey’s End, which was written to help you avoid a similar fate at your life's end.

When you avoid dealing with a problem, it only gets worse

A general rule of life is that when you avoid dealing with a problem, it only gets worse.

Take the recent Wall Street Journal article "No Basis in Mathematical Reality" by James Freeman. It diagnoses one the most dire issues facing our nation - Medicare and Social Security's underfunded future.

In the article, Freeman focuses on cold, hard facts from a recent Congressional Budget Office (CBO) Report, citing what Brian Riedl of the Manhattan Institute wrote in the New York Times: “Over the next three decades, the Social Security system is scheduled to pay $21 trillion greater than its trust funds will collect…The Medicare system is projected to run a $48 trillion shortfall. These deficits are projected to, in turn, to produce $47 trillion in interest payments to the national debt.”

Of course, Congress is considering tax increases, but those new revenues would likely only cover 66 percent of the projected shortfall in funds. Clearly, some critical thinking is needed here. Fortunately, my forthcoming book, The Journey’s End, offers pragmatic reforms that could help make Medicare more affordable. Speaking of affordable, copies cost less than one trillionth of these projected shortfalls. But make sure to pre-order now...after all, when you avoid dealing with a problem, it only gets worse.

Fraud adds extra layer of worry to end-of-life care

Nathan Gray, a Professor at Johns Hopkins School of Medicine, authored a powerful comic strip illustrating the challenges facing doctors transitioning patients to hospice care - one of healthcare’s most critical end-of-life care options. Gray’s comic starts with an excellent perspective on why hospice is misunderstood: Hospice does not mean giving up. It means the current treatments may be doing more harm than good, and it means honoring the patient's wish to be at home.

He goes on to explain why healthcare has historically struggled with the hospice care option.

“Doctors...struggle to acknowledge that it’s time for a change in strategy, and entrusting

their patients in their final months to a new team can be difficult.”

Overcoming these barriers has been a challenge for decades, but recently, a new set of challenges are being faced by hospice. Confidence in the credibility of hospice care is being challenged by a series of powerful articles exposing fraud in the hospice sector.

What caused fraud to surface in the hospice sector? Changes to the payment model for hospice. Medicare decided to apply “coding” to hospice services. Medicare created “bundled payments” to make this service ‘more efficient.’ Bundled payments depend on the use of a complex coding system. Coding is not only complex, but it distracts caregivers from time with their patients. Miscoding can be fraud, so providers go through elaborate processes to document the codes being used. Manipulating these payment codes is very lucrative.

For profit healthcare focuses on coding to maximize revenues. For-profit healthcare has become increasingly interested in hospice because “bundled payment” and coding make hospice a new profit opportunity for those providers focused on coding and patient selection. Coding invites fraud because of its complexity. Coding makes no sense for a simple labor-intensive and low-technology service like hospice. Bundled payments have increased cost, not decreased costs.

The growth of fraud in hospice is another challenge that this important care option doesn't need. Fraud could be virtually eliminated in hospice by removing coding from their payment formula.

We need to simplify how Medicare pays for Hospice. We also need to simplify access to the benefit for patients. My book The Journey’s End offers pragmatic and comprehensive solutions to these concerns.