ABCD Exchange : March - April 2001 : President's Letter - Stretching Limits

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Stretching the Limits on Reform Ideas
by Joanne Lynn

Even when ideas for policy reform seem unreasonable, unrealistic, and even unduly confrontational, they can be illuminating, because they can show us what we might do if we were convinced and committed. The following ideas may appear to be ahead of their time-but are worth considering as ways to rapidly reform end of life care.

First - let's create incentives for continuity. Consider how quickly physicians would learn to arrange their schedules to stay with patients if primary care physicians who did not provide continuity of care got only half of the going payment rates for their care of people with serious, ongoing illness.

Second - let's hold providers accountable for advance planning. Consider giving hospitals only half of the DRG payment if a patient were hospitalized a second time with the same chronic illness and still had no advance planning.

Third - we need to get serious about supporting family caregivers. Pay them for their work, protect their jobs, give them health insurance, and provide respite care. Family caregiving is as important as the fire department to the well-being of every community - and family caregivers deserve respect and support. At the same time, let's build a cadre of effective paid caregivers - again, pay a living wage, and offer a career ladder, health insurance, training, and respect.

Fourth - when the country realizes that we cannot afford a wide-open prescription drug benefit, let's provide a substantial array of low-cost, highly effective supportive care medications. Just because we are not ready to deal with costly drugs like ACE inhibitors does not mean that we cannot provide morphine, diuretics, inexpensive antibiotics and steroids, and a dozen other cheap but effective drugs.

Fifth - mandate good pain prevention and relief, at least for cancer pain. If a hospital provides Demerol for a substantial number of patients facing serious pain, those hospital stays would not be paid. If more than a small proportion of patients report having serious pain for more than a few hours during the hospitalization, again, just don't pay for the care. One would not expect to pay for a car that came without a transmission, and one should not pay for enduring avoidable pain in a setting where that should almost always be avoidable.

None of these ideas go to the heart of reform. We still need to rearrange care to ensure continuity and comprehensiveness over time and setting. Major payment reforms are required. However, we have to start somewhere. We need innovation and evaluation. We need serious economic analysis. And we also need galvanizing ideas that appeal to the public's outrage. Maybe we should not be reasonable, realistic, and polite - at least not always.

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