If you were tasked to stretch the Medicare Budget..

  1. There are so many requirements and restrictions that make us face palm , what changes, policies etc would you put into place?
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  2. 6 Comments

  3. by   Ruby Vee
    Medicare already does very well in administrative costs -- far less than private insurance companies. In my capacity as ICU nurse, I've seen far too much money spent on futile care in the last two weeks of someone's life. I don't have any real statistics, just anecdotes -- and one Wall Street Journal article that has stayed with me since I read it first.

    For some reason, my phone won't let me copy and paste a link the the article, which appeared in the WSJ in 2012 and was entitled "The Crushing Cost of Health Care." The article described a young man named Scott Crawford and his $2.1 million hospital bill for the year of 2009. Prior to 2009, Medicare paid for an implanted defibrillator (over $75,000) and a left ventricular assist device (nearly $276,000). In 2009, Scott received not one but two heart transplants and a plethora of other treatments and surgeries to treat complications. Mr. Crawford died just before Christmas in 2009.

    According the the article, 10% of patients account for around 64% of hospital costs in any given year, and although most of those patients are seniors, young patients on Medicaid account for significant costs as well.

    I have long said that if we're going to control health care costs in America, the place to start is with those costs who BEST benefit would be to extend the dying process of someone for a few short weeks or, in Mr. Crawford's case, months. Physicians are responsible for much of these costs. It is difficult to lose patients, and some physicians develop tunnel visions. Reading between the lines, it seems that Dr. Shah, who was Crawford's surgeon, developed such tunnel vision. Each separate health crisis, by itself, may have been survivable. But when you looked at the whole picture, as suggested by Dr. Pronovost, Scott's prospects of survival seemed bleak.

    The conversation is a difficult one -- I've participated in many of them, both in my role as a daughter and daughter-in-law and in my role as an ICU nurse. Different physicians handle the conversation in different ways, but it is the rare physician who just lays it out for the family. "Your father/son/brother isn't likely to get better, and we have nothing to offer him that fix his problems. It is time now to consider making his death as comfortable as possible. How would you like to achieve that?" Instead, the doctor may offer some wishy washy "might do" solutions. "We can do another surgery to fix this problem, but it won't fix that one, and his recovery time would be significantly longer," and families seize upon the idea that another surgery might "fix him" even after the physician has just ***** footed around the fact that it really won't. So t hey opt for another surgery. And another. Until the patient just wears out.

    If physicians didn't OFFER the extra surgeries that aren't really going to improve Dad's chances of long term survival and independent living, families would be far more content to focus on making Dad comfortable in his last days. Or if Medicare stopped COVERING these extra surgeries and families were told that the surgery was available, unliklely to result in Dad returning to his former quality of life and that since Medicare didn't cover it they would have to pay for it themselves, people might make better decisions.

    When my father was dying, the doctors didn't offer us the hope that dialysis would fix his renal failure and a CABG alleviate some of his cardiac symptoms. He just told us that given the damage from Dad's stroke, he would never be able to see, participate in conversation or use his right side again. Ever. And after that had a moment to sink in, he suggested we think about getting the family together and making Dad comfortable. My mother and my sister were able to take that suggestion without ever second guessing themselves, and without ever wondering whether they should have opted for another surgery to "fix" something. That was not only kinder to my family, but it saved Medicare the money it COULD have spent on additional procedures that would have extended Dad's dying.

    Sorry this has gotten so long. I have strong feelings on the subject, perhaps not expressed as well as I'd like.
  4. by   Libby1987
    Quote from Ruby Vee
    Medicare already does very well in administrative costs -- far less than private insurance companies. In my capacity as ICU nurse, I've seen far too much money spent on futile care in the last two weeks of someone's life. I don't have any real statistics, just anecdotes -- and one Wall Street Journal article that has stayed with me since I read it first.

    For some reason, my phone won't let me copy and paste a link the the article, which appeared in the WSJ in 2012 and was entitled "The Crushing Cost of Health Care." The article described a young man named Scott Crawford and his $2.1 million hospital bill for the year of 2009. Prior to 2009, Medicare paid for an implanted defibrillator (over $75,000) and a left ventricular assist device (nearly $276,000). In 2009, Scott received not one but two heart transplants and a plethora of other treatments and surgeries to treat complications. Mr. Crawford died just before Christmas in 2009.

    According the the article, 10% of patients account for around 64% of hospital costs in any given year, and although most of those patients are seniors, young patients on Medicaid account for significant costs as well.

    I have long said that if we're going to control health care costs in America, the place to start is with those costs who BEST benefit would be to extend the dying process of someone for a few short weeks or, in Mr. Crawford's case, months. Physicians are responsible for much of these costs. It is difficult to lose patients, and some physicians develop tunnel visions. Reading between the lines, it seems that Dr. Shah, who was Crawford's surgeon, developed such tunnel vision. Each separate health crisis, by itself, may have been survivable. But when you looked at the whole picture, as suggested by Dr. Pronovost, Scott's prospects of survival seemed bleak.

    The conversation is a difficult one -- I've participated in many of them, both in my role as a daughter and daughter-in-law and in my role as an ICU nurse. Different physicians handle the conversation in different ways, but it is the rare physician who just lays it out for the family. "Your father/son/brother isn't likely to get better, and we have nothing to offer him that fix his problems. It is time now to consider making his death as comfortable as possible. How would you like to achieve that?" Instead, the doctor may offer some wishy washy "might do" solutions. "We can do another surgery to fix this problem, but it won't fix that one, and his recovery time would be significantly longer," and families seize upon the idea that another surgery might "fix him" even after the physician has just ***** footed around the fact that it really won't. So t hey opt for another surgery. And another. Until the patient just wears out.

    If physicians didn't OFFER the extra surgeries that aren't really going to improve Dad's chances of long term survival and independent living, families would be far more content to focus on making Dad comfortable in his last days. Or if Medicare stopped COVERING these extra surgeries and families were told that the surgery was available, unliklely to result in Dad returning to his former quality of life and that since Medicare didn't cover it they would have to pay for it themselves, people might make better decisions.

    When my father was dying, the doctors didn't offer us the hope that dialysis would fix his renal failure and a CABG alleviate some of his cardiac symptoms. He just told us that given the damage from Dad's stroke, he would never be able to see, participate in conversation or use his right side again. Ever. And after that had a moment to sink in, he suggested we think about getting the family together and making Dad comfortable. My mother and my sister were able to take that suggestion without ever second guessing themselves, and without ever wondering whether they should have opted for another surgery to "fix" something. That was not only kinder to my family, but it saved Medicare the money it COULD have spent on additional procedures that would have extended Dad's dying.

    Sorry this has gotten so long. I have strong feelings on the subject, perhaps not expressed as well as I'd like.
    No, you expressed it quite well, from a real place.
  5. by   Dave_In_Florida
    Quote from Ruby Vee
    I've seen far too much money spent on futile care in the last two weeks of someone's life. I don't have any real statistics, just anecdotes -- and one Wall Street Journal article that has stayed with me since I read it first.
    While I wholeheartedly agree with your post, many will scream in fear of "death panels" as we heard during the Obamacare debate (and keep in mind, I'm a fiscal conservative).

    Perhaps as states adopt laws allowing patients to choose to end their own lives on their terms, the thinking in this country will shift from the current "keep grandma alive at all costs" philosophy.
  6. by   Rose_Queen
    There really needs to be a shift in the thinking of providers. Not all patients can be saved; that's the cold hard truth. Those providers need to be honest with the families, not just "we can fix this...". I witnessed this just the other day- a young trauma patient, definitely with 1.75 feet in the grave. Last ditch effort? ECMO. The physician flat out told the family "We can do this, but it most likely won't work". Family still opted to proceed. Patient expired less than 4 hours after the procedure. But at least the family was aware of the fact that chances were slim. Other families aren't given the odds at all, and it makes me wonder sometimes if it's because of the number of various specialties that are consulted on a single patient. My facility doesn't have intensivists- it's very fragmented with conflicting orders being written by one specialty vs another, nurses having to go back and forth getting the OK from specialist X to do what specialist A wants. Either way, something's gotta change.
  7. by   toomuchbaloney
    We need to invest in Palliative Care and Hospice and expand Home Care services.
    It is a shame that so many choices made in the last 2 years of many elderly lives are ineffective and terribly expensive in terms of overall health and function and in economical terms.

    This concept scares the daylights out of some people...death panels and all...but it only makes good sense to keep people out of the hospital if we want to reduce costs.
  8. by   azhiker96
    Part of the problem is unrealistic prognoses from providers but larger still is that many people and families want to do everything regardless of the chances of a good outcome. I think CMS needs to setup clear guidelines for what it will cover and what patients/families must cover. It is not a death panel, it would be better termed a refusal to torture panel.
    It is a tough topic to approach. Relatively futile care can occur all along the lifeline from premature birth through the elderly.

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