ABCD Exchange : January 2000 : Public Policy - Challenges in Heart Failure

Policy Challenges in Heart Failure
by Joanne Lynn

• The disease itself has no standards for diagnostic markers. For example, in our “front line” experience, less than half of those referred to hospice for heart failure (CHF) have mention in their record of any imaging study at all. Some experts claim that more than half of residents in nursing homes could be labeled as having heart failure, if there were reason to do so (and that labeling can be clinical examination, no test required)

• The disease has recently come to be understood as having two quite different physiological explanations - diastolic and systolic dysfunction - and the two have quite different courses and treatments. However, there is only one billing code for both.

• Neither type of physiology has objective measures of severity that correlate closely with function, though function correlates well with quality of life and lifespan.

• Current evidence shows that “disease management” can cut exacerbations in half, compared with standard treatment. In part, this is because treatment in the usual setting is so uncoordinated and fragmented. Most patients do not receive self-care education, scales, medications, or other essential elements.

• No setting (except the Veterans Health Administration) can regularly provide disease management for seriously ill people and remain financially viable (managed care fears adverse selection if they generate a good reputation, and fee-for-service directly loses income in providing non-reimbursable services and cutting hospitalization and procedures).

• One can improve upon disease management (in both quality and cost) by blending in some aspects of good end of life care - advance planning, home services, family support, prescription drug coverage, management of co-morbidities, and so on.

• The upcoming risk adjustment gives a substantial rate for CHF in the year after a hospitalization in Medicare + Choice (e.g., about $17,500 for a 75-year old man)

• The potential for upcoding is enormous. Recent analyses by the Center to Improve Care of the Dying showed that more than half of all Medicare patients who died had at least one diagnosis code for heart failure in the year before death. Just adding outpatient codes to hospitalization yields nearly a 10-fold increase in apparent cases in Medicare.

• There are strong commercial forces arguing for outpatient coding inclusion, which would sup-port disease management. In The Federal Register, The Health Care Financing Administration (HCFA) has promised to revise the payment structure for heart failure. However, most disease management focuses upon the many people who have mild disease. None that our researchers have identified (except Franklin Health, which has a rather different targeting strategy) has developed a program that really suits those who are very sick.

• If there were major upcoding of heart failure in Medicare + choice, but not in fee-for-service, then the assumptions of the current risk adjustment would be seriously flawed. The number of people who could be involved is so large as to cause serious problems for the risk adjustment structure itself. Heart failure is the best paid “ambiguous” diagnosis in the PIP-DCG model that will begin being implemented this year.

• As if all this is not enough, heart failure treatment is getting much more expensive. Some of the most expensive medications in common use are for this condition. In addition, new devices such as implantable defibrillators and special pacemakers are making major changes in the course of treatment and the mode of death.

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