Primary care is key to reforming healthcare but we have to fix it first

Primary care is critical to successfully reforming healthcare and yet this specialty has been seriously neglected for decades. This article once again documents the nature of this neglect which it defines as follows:

1. Financial neglect

2. Excessive panel size

3. Poor access for patients

4. Burnout

Unfortunately, these problems are long standing and getting worse. The dilemma is that we can not seem to offer a practical road forward to address these issues.

My book The Journey’s End (thejourneys-end.org/) covers the history of all these challenges in great depth and most importantly offers a road map to correct them. Ironically, addressing these concerns will dramatically improve End of Life care as well.

Why is private equity interested in hospice?

Hospice is becoming an increasingly important model of care in our nation. Unfortunately, Medicare has adopted an overly complex payment system with coding as its foundation. The coding payment model has invited the private equity world into this care, as this article notes.

One of the reasons for the stark contrast in profit margins between for profit and non-profit hospice relates to coding manipulation. For profit hospice is much better at optimizing profit in the coding world.

It would help immensely if Medicare stopped using coding for hospice payment because it is costly and creates conflicting incentives. Hospice services are not complex - hence the ease of entrance for private equity mentioned in the article. Coding is complex and costly.

Hospice could be paid for on a reasonable cost basis. This would make margins similar for all providers, it would reduce costs, virtually eliminate claims about fraud and most importantly, incentivize providers to focus on the patient's needs. 

My new book, The Journey's End, discusses this recommendation and several others to improve EOL care.

How to improve the experience of death and dying in America

The more sophisticated our society becomes, the more we resist death. Our medical care models are overly rigid and controlling and fail to adapt to an individual’s changing needs or offer alternatives in terms of settings and services.

More than a change in care models, we need a shift in attitude away from medicalizing death, which is, and should be, a natural process. Knowing a patient’s preferences is crucial to this process, but because we don’t candidly discuss end-of-life care, few caregivers really know the care their patient truly desires.

As The Journey’s End argues, grappling with the reality of death has both practical and philosophical benefits. It can give us closure, freedom and a sense of purpose, yet many of us will fail to have that kind of death experience. We’ve lost our “death literacy,” the skills, traditions, and values that our predecessors used to deal with death.

A societal appreciation for death is long overdue. Today dying is no longer a familial experience but rather a cold, clinical, and medical ordeal. Modern medicine overreaches in its attempts to fend off death and this excessive focus on clinical intervention at the end of life is costly and comes at the expense of other social needs.

While investigating the experience of death and dying in the United States, The Journey’s End:

• Argues the benefits of developing death literacy

• Examines the root causes of healthcare dysfunction that shortchanges the elderly

• Provides recommendations on how we can improve elder care and dramatically reduce healthcare expenses

The process of dying should be owned by individuals and family members with support from health professionals instead of the other way around. The status quo of ineffective and expensive care for the elderly is not the only option. We can take a different approach by changing the system’s incentives and embracing natural death. We can drive change by developing death literacy and owning how we wish to face death.

I’ll explore these topics in future blogs and in greater detail in The Journey’s End, available in April.