Why end of life care needs to change

Casey Mean’s best selling book Good Energy offers a powerful personal analysis of how healthcare needs to change. The book offers individuals lifestyle changes that can significantly improve one’s health. The book also gives advice on why individuals need to trust themselves and not the health system with the management of their chronic illness.

The health system is designed to treat acute care issues. However, that design inhibits healthcare from managing a very different health issue - chronic illness. Chronic illnesses manifest themselves in multiples - if you have one chronic illness you likely have several others. Health care is siloed - specialties seldom coordinate care. This is a real problem. Illnesses like diabetes, COPD, and heart failure are often interconnected. The health system is not interconnected.

Dr. Mean’s illustrates this problem with her mother’s end of life care. Her mother has cancer, but she also has multiple other chronic issues that will cause the cancer treatment to fail. The siloed physicians are oblivious to this reality. This quote from the book describes the problem well: ”The most important thirteen days of my life came from ignoring a team of doctors. Right after my mom’s pancreatic cancer diagnosis, a medical team out of Stanford and Palo Alto Medical Foundation jumped to action, recommending a laundry list of surgeries and procedures…"

Her mother was clear that she did not want extraordinary measures - especially anything causing pain, nausea, and isolation.

“I confirmed with the oncologist: ‘You are recommending an invasive diagnostic procedure that would under no scenario extend her life more than a couple of months and risk my mom dying alone in a hospital room?"

Note this was during the COVID outbreak.

"Even though we were certain that this is Stage 4 pancreatic cancer…and that she has liver failure and almost no red blood cells left?’”

"'Yes, that is what we are recommending,' the doctor replied.”

This physician panel of nationally renowned experts is solely focused on treating the patient's cancer - not on the patient's/family's stated preferences to allow the patient to die without further futile treatment.

The family took their mother home without any further treatment.

“The final thirteen days I shared with my mom were the most meaningful of my life.

If we had taken the advice of the medical system, they wouldn’t they wouldn’t have happened.”

Most patients don’t have a skilled advocate like Dr. Means protecting their care. By the way, that is the role of palliative care but this specialty is seldom part of the acute care treatment model. 

Fundamental changes are needed for end of life care. Pragmatic solutions to these issues are offered in my book The Journey's End.

Helpful visits or way to milk the system?

The Wall Street Journal’s investigative report on Medicare Advantage (MA) deftly uncovers little known concerns about how these plans harm taxpayers. Specifically, these plans exploit Medicare by manipulating coding to increase their payments. This particular report on The One Hour Nurse Visit illustrates how these private insurers use coding to gerrymander a patient's list of illnesses, making them look sicker, so the insurers can collect billions in higher government payments.

This nurse visit strategy is merely one of hundreds of practices by the insurers to increase their government reimbursement through coding. What makes this manipulation of coding possible is complexity. Coding is unbelievably complex and this complexity creates a gray space where MA plans can justify their actions as defensible. In this case, insurers argue

these nurse visits are good for patients, when in fact, the nurses are not there to treat anyone, they are there to gather new diagnoses to increase payments.

Unfortunately, Medicare, which does acknowledge this problem, seeks to cure it by making coding even more complex and by increasing their efforts at fraud oversight. This strategy has not worked and will not work. The answer is to decrease the use of coding for the determination of payments.

Basing premium payments on a patient's list of diagnoses, in theory, is a good idea. However, the continuous increase in coding complexity creates the gray space and invites fraudulent actions like the One Hour Nurse Visit. There are less complex methods of adjusting patient risk for insurance premiums that are technically less accurate but are simple and not subject to billions of dollars in manipulation. Healthcare needs to start embracing simple solutions to our challenges in healthcare payment.

Why there's a shortage of primary care doctors

Two recent articles illustrate how healthcare policy consistently creates barriers to advancing primary care.

In the first, Debra L. Glasser, MD boldly declares that internal medicine primary care is dead, and she offers a powerful summary of the reasons for the decline:

"Why are they not choosing primary care? Primary care is the lowest-paid specialty at a time when medical education is not strongly subsidized (medical students can incur up to $500K of debt). It no longer offers professional satisfaction, continuity of care, and collegiality.

Primary care physicians are the most overburdened by administrative tasks. They are increasingly pressured to see more patients in shorter time slots, and it feels impossible to offer quality care. Many work for large systems where they feel powerless to effect change.”

The second article by Randy Dotinga reports on recent research documenting the excessive burden of numerous and diverse quality measures required of physician value-based programs. One physician group had 57 different quality measures across multiple insurers. The research concluded that “The magnitude of that number surprised us…Primary care physicians and their practices have a lot on their plate. Now we know one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.”

By the way, there is little evidence that using these burdensome quality measures improves the quality of care.

In summary, we have a severe and increasing shortage of primary care physicians to serve the growing elderly population, and we have intentionally created a health policy to make it worse. We need to immediately start creating health policy to promote and support primary care physicians. That policy needs to pay them better and dramatically simplify their work environment. My book The Journey’s End offers one path to make that policy a reality.