Sick To Death > Chapter 4 > Promoting Coordinated Care - A Potential Anchor of Major Reform
How serious is the claim that incentives are misaligned? A few years ago, I worked out the finances of a particularly commonplace example: care of a person with frailty and serious chronic heart failure. The ways to optimize care for patients with "bad pumps" are well known. More than a dozen well-designed and published studies (Rich et al. 1995; Phillips et al. 2004) show that early intervention at the first sign of fluid retention, optimal diet and medication, and gentle exercise greatly reduce the use of hospitals. Indeed, most patients use hospitals less than half as often in a program of coordinated care as they do with uncoordinated care from an ordinary doctor's office. In teams that add advance care planning for the end of life and rapid response to the home for any worsening of symptoms, the rate of use of emergency rooms can go down to one-tenth of the prior rate (Lynn, Schall, et al. 2000). Table 3 tallies the costs of providing services, the Medicare payments, and the net income to providers in two scenarios of care for a typical elderly couple, whose possible stories follow.
Mary Smith, seventy-eight years old, had osteoporosis, diabetes mellitus, mild heart failure, and cataracts at the time of her diagnosis with breast cancer.
Her husband, eighty-four, had cognitive impairment and, since having a stroke, was dependent upon her for transfers, bathing, and dressing. They lived on a small pension in a rented apartment. Their children lived at a distance, and the Smiths had few contacts except for health care. During the turmoil and financial challenges of his wife's cancer treatments, Mr. Smith's condition worsened, and he entered a nursing home. Mrs. Smith wore herself out with worry, and her heart failure worsened. Her husband died of a urinary tract infection in a hospital intensive-care unit. Mrs. Smith developed back pain and constipation but would not go to her physician's office for an evaluation. Eventually she became delirious and was admitted to the hospital as an emergency patient. She could not keep her apartment and entered a nursing home. A few months later, Mrs. Smith also died in the hospital, after being transferred because of pulmonary edema. Through all this, the couple had much suffering, a dozen different physicians, and several hospitalizations (and, for each, death in the hospital).
As soon as Mary Smith was diagnosed with cancer, her physician recognized that the Smiths' situation was rife with risks. He involved a nurse care coordinator who worked with the couple through the rest of their lives, planning ahead and marshaling needed services in a timely way. The care coordinator contacted the church the Smiths had attended and elicited some friendly visitors and volunteer help. The city provided in-home aides and repair services to enable them to stay in their apartment, even when chemotherapy left Mrs. Smith fatigued. When Mr. Smith had another stroke, a home-care program helped for a few weeks until he died at home. Suffering from heart failure, Mrs. Smith had more trouble with shopping and housework, so she moved to senior apartments that provided meal and maid service. She died in her sleep quietly one night.
|Ordinary Care (U.S. $)||Better Care (U.S. $)|
|Service||Production cost||Medicare payment||Provider net income*||Production cost||Medicare payment||Provider net income*|
|Home nursing visits||200||210||10||3,000||2,300||(700)|
|Physician office visits||600||350||(250)||100||120||20|
|Physician home visits||0||0||0||1,000||450||(550)|
|Physician hospital visits||2,000||2,300||300||0||0||0|
|ER and ambulance||1,500||2,000||500||0||0||0|
Source: Adapted from Lynn J, Wilkinson A, Etheredge L. 2001. Financing of care for fatal chronic disease: opportunities for Medicare reform. Table 1. West J Med. 175:299–302. With permission from the BMJ Publishing Group.
Note: Amounts are estimated from experience and from published tables of Medicare reimbursements. Estimates exclude costs that are not generally covered by Medicare, such as nursing facility, home health aide, assisted-living facility, and prescription drugs.
* Provider net income is the difference between the payments and the costs of production, which include salary costs for the professionals and their practice costs. Numbers in parentheses represent net losses.
This table is also available as a graphic image:
Many readers will find the discrepancy in care hard to believe. That's good: it should seem astonishing, but it's accurate. Our care system regularly pays more than $25,000 for services that provide emergency care for preventable complications of heart failure, although better care could be had for $8,000. Why aren't doctors and hospitals organizing to provide this better care? Current care arrangements use the services of every type of provider. Hospitals make money, doctors make money, and patients and families are grateful for the rescue services. In better care, with present reimbursement plans, every provider loses money. No one can afford to provide services that regularly lose money. Thus, moving to the improved arrangement faces the certainty of financial disaster, as well as the commonplace resistance to change. Even though the improved practices would do more to relieve suffering and extend life than most drugs and devices for heart failure, which have eager markets, those improved practices are not generally available. Medicare's coverage policies and the necessary self-interest of providers ensure inadequate and costly care.
This gap in practices has been widely known, and managed care, employer-sponsored disease management, and the veterans health system have been able to implement better practices. But fee-for-service Medicare covers the vast majorityof people suffering from advanced chronic heart failure, and fee-for-service beneficiaries have usually not been able to have better care. This would seem to offer an opportunityfor dramatic improvement that could sweep in larger reforms. Under the Medicare reform statute enacted in 2003, Medicare will pay for disease management services for patients with chronic heart failure, diabetes, and emphysema (Medicare Prescription Drug, Improvement, and Modernization Act of 2003). Payment requires that providers improve quality of care and keep costs low. Organizations that already provide such services must offer patient education and adhere to guidelines for good care. With the elderly, providers will quickly learn that good care also requires developing more comprehensive services, ensuring continuity, and planning ahead. Adapting the new program to meet the needs could provide the opening wedge for major reforms, such as the strategy for care I present in chapter 5.
In summary, reform could build on the opportunity presented by the troubling shortcomings in care for chronic heart failure: