Quality health care at lower cost? It could happen

It seems a no-brainer: reward the doctors and hospitals that give the best care, latch on to programs and ideas that offer quality over quantity. But innovation in health care, even when it proves out, has always taken a very long time to work into the system.

In a ‘Talk of the Town’ piece appearing in the latest New Yorker magazine, writer Atul Gawande offers a thoughtful look at some of the hurdles ahead for the newly-passed health bill. They are primarily political: conservatives — even if they’re talking less and less about repeal — will run on pieces they plan to strip out, states will fight the insurance exchanges (such as those that make health coverage near universal in Senator Scott Brown‘s Massachusetts.) And other battle lines will be drawn.

But one primary problem with the dysfunction we are hoping to fix, Gawande points out, is that the current system “pays for quantity of care rather than the value of it.” He illustrates this with a case that makes you cheer, and then feel a little hopeless:

Recently, clinicians at Children’s Hospital Boston adopted a more systematic approach for managing inner-city children who suffer severe asthma attacks, by introducing a bundle of preventive measures. Insurance would cover just one: prescribing an inhaler. The hospital agreed to pay for the rest, which included nurses who would visit parents after discharge and make sure that they had their child’s medicine, knew how to administer it, and had a follow-up appointment with a pediatrician; home inspections for mold and pests; and vacuum cleaners for families without one (which is cheaper than medication). After a year, the hospital readmission rate for these patients dropped by more than eighty per cent, and costs plunged. But an empty hospital bed is a revenue loss, and asthma is Children’s Hospital’s leading source of admissions. Under the current system, this sensible program could threaten to bankrupt it. So far, neither the government nor the insurance companies have figured out a solution.

There is in the new bill, though, a ray of hope:

The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.

Imagine innovation being rewarded, communities being encouraged to find ways to improve quality of care at lower cost. That’s real reform, and it could just happen.

The next attacks on health-care reform : The New Yorker.

Moving in with mom and dad

Waiting lines at the bathroom? Overflow in the kitchen cabinets? Welcome to the suddenly multi-generational family home.

Yesterday a friend of mine was alternately laughing and crying (I mean, literally) over the tales of her once comfortable, now overstuffed home. Her daughter and son-in-law, both unemployed for an extended time and overwhelmed by mounting debt and loss of health insurance, recently moved in with the older generation. With them came three grandchildren, ages 3, 8 and 11. It could make a great sitcom pilot. “My husband was so desperate to get into one of our two and a half bathrooms the other day,” she said, “that he suggested getting one of those take-a-number things they have in hospital waiting areas. The kids put labels on their snack bar boxes, but now I can’t even find which shelf the boxes got stuffed into or what they’re hiding behind.”

Welcome to the brave new world of extended-family housing.

The extended family is making something of a comeback, thanks to delayed marriage, immigration and recession-induced job losses and foreclosures that have forced people to double-up under one roof, an analysis of Census Bureau figures has found.

“The Waltons are back,” said Paul Taylor, executive vice president of the Pew Research Center, which conducted the analysis.

Multigenerational families, which accounted for 25 percent of the population in 1940 but only 12 percent by 1980, inched up to 16 percent in 2008, according to the analysis.

For the rapidly growing 65+ segment of the population, there’s good news and bad news in this. Loneliness is often cited as a great fear among the aged. At talks and workshops this writer often does on end-of-life issues (advance directives, end-of-life choices, etc.) the response to any “What do you fear most?” question is never “death,” almost always “pain,” “isolation” or “loneliness.” When younger generations move in, loneliness is unlikely, but other problems may well take its place.

The analysis also found that the proportion of people 65 and older who live alone, which had been rising steeply for nearly a century — from 6 percent in 1900 to 29 percent in 1990 — declined slightly, to 27 percent.

At the same time, the share of older people living in multigenerational families, which plummeted to 17 percent in 1980 from 57 percent in 1900, rose to 20 percent.

While the pre-World War II extended family may have been idealized as a nurturing cocoon, the latest manifestation is too recent and a result of too many factors, positive and negative, to be romanticized.

“It calls to mind one of the famous lines in American poetry, from Robert Frost: ‘Home is the place where, when you have to go there, they have to take you in,’ ” Mr. Taylor said. “I don’t know that I can offer a value judgment of whether it’s good or bad. It reflects our time.”

The decline of extended families coincided with an exodus to the suburbs, where many young adults preferred to raise their children, and the enactment of Social Security and Medicare, which made older adults more financially independent.

A lot of factors combine to create the more than 49 million adults currently living in multi-generational homes, the census figures show. We’re living longer, getting married later, getting divorced more often, losing jobs and losing homes. One ray of good news is that the homes now housing multiple generations tend to be larger than a generation ago. Two and a half bathrooms for three generations still beats the olden days of one bathroom for a family of five. But not many families get along as well as the Waltons did. “We love the kids and the grandchidren,” remarked my stressed-out friend mentioned above, “but my son-in-law’s first paycheck is going to go for the down payment on a new apartment.”

Households With Extended Families Are on the Rise, Census Shows – NYTimes.com.

An elder revolution? It's possible

If you are over 50, or plan to be over 50 at some future date, you have just been issued a challenge. You might call it a leadership alert.

New York Times columnist David Brooks, who does have a good head on his shoulders, yesterday published an interesting column advancing the theory that real social change will come from the geezer generation. Those at the time of life traditionally perceived as fuzzy, withdrawing and passive. Or at best, the time of life in which most are inclined to let the young folks do the heavy lifting. But those times, Brooks maintains, have changed.

Citing studies undertaken over past decades, Brooks explains that the geezer generation (in which I am a fully accredited member) is now understood to be not so dimwitted and inept as long thought. Beyond new research that shows brains can continue to thrive and develop into one’s late years, people who had been studied over a 50-year period proved to be increasingly outgoing, self-confident and compassionate.

That’s the good news.

The bad news is that we geezers — a population about to boom as the Boomers hit Medicare age — are eating up a way disproportionate share of the GDP. So pensions are going to keep getting money that would better be spent on education, taxes will go to fulfill earlier promises, etc.

Then, though, Brooks turns it all around a new corner:

In the private sphere, in other words, seniors provide wonderful gifts to their grandchildren, loving attention that will linger in young minds, providing support for decades to come. In the public sphere, they take it away.

I used to think that political leaders could avert fiscal suicide. But it’s now clear change will not be led from Washington. On the other hand, over the past couple of years we’ve seen the power of spontaneous social movements: first the movement that formed behind Barack Obama, and now, equally large, the Tea Party movement.

Spontaneous social movements can make the unthinkable thinkable, and they can do it quickly. It now seems clear that the only way the U.S. is going to avoid an economic crisis is if the oldsters take it upon themselves to arise and force change. The young lack the political power. Only the old can lead a generativity revolution — millions of people demanding changes in health care spending and the retirement age to make life better for their grandchildren.

It may seem unrealistic — to expect a generation to organize around the cause of nonselfishness. But in the private sphere, you see it every day. Old people now have the time, the energy and, with the Internet, the tools to organize.

The elderly. They are our future.

We could start by convincing seniors to ignore the scare tactics of their conservative friends and support health reform. Mount a movement for what is morally right: health care for all Americans. Their grandchildren will thank them.

Not being a community organizer myself, I don’t know how to start this campaign. But if you have any suggestions I’ll join the movement.

Op-Ed Columnist – The Geezers’ Crusade – NYTimes.com.

Democrats have a survey too — they just don't call it a Census

In the interest of fair-and-balanced commentary in this space, we want to report receipt of an Official Document from the Democrats. This one, unlike that decidedly suspect missile from the Republicans last week, does not advertise itself as an Official Census Document and does not raise the fear level to code red. It advertises itself as a 2010 Priority Issues Survey, which, in fact, it is.

The envelope, though, does bear the admonition: Do Not Tamper. We wonder who’s been tampering with Democratic issues, other than the hapless invaders of Louisiana Senator Mary Landrieu’s office. We’re not even sure how one can Tamper with an Official Document.

Nevertheless. Because the Democratic Party Headquarters bothered to send a fairly straightforward questionnaire, with a minimum of weighted sentences, below are listed a few considered responses to this “opportunity to help shape Democratic priorities and build a brighter future for America.” You are invited to send your own answers to www.dccc.org, even if you lack an Official Survey Registration number, and we’ll see who’s paying attention. One citizen’s response:

Yes, I believe waterboarding is torture and the U.S. has a moral responsibility to not engage in or condone any form of torture.

Yes, every American should be guaranteed access to affordable, quality health care.

No, I don’t support privatization of Social Security, but Yes, the Medicare prescription benefit plan should be reformed so the government can negotiate lower drug prices with big pharmaceutical companies. (Good luck with that, government.)

Yes, the federal government would do well to provide more assistance to Americans who want to continue their education beyond high school. Cutting student loan interest rates, increasing college tuition tax deductions, increasing Pell grants – all sound good to me.

Weighted question next: How concerned are you about the environmental damage resulting from last-minute Bush Administration maneuvers to weaken laws like the Clean Air Act, Clean Water Act and Endangered Species Act. Well, since I happen to agree, pretty darned concerned.

Slightly different phraseology question: How serious a threat is global warming? Thanks for not asking, as the Republicans did, if I believe it’s real. I’ll go with Very Serious.

That’s about it for the Democrats. They do also provide a postage-paid envelope, and they also invite your contribution.

If the Independents have an Official Survey going, it will be duly reported in this space.

Health care reform: comatose but breathing

Virginia Governor McDonnell, who proclaimed in his rebuttal to President Obama’s State of the Union address that we have “the best medical system in the world” has my qualified agreement on one point. My personal medical system is the best in the world. As a member of Kaiser Permanente, I consider my physicians among the best in the world and my care right up there. I can e-mail any of my physicians with any question; most of them reply in 24 hours or less. I can schedule appointments with specialists with ease; usually I see anyone I want within a few weeks. Medicare helps me pay for all this.

Problem is, not everyone in America enjoys such care at such cost. Millions of my fellow Americans – who might not agree with Governor McDonnell – would be happy for any kind of medical care at any remotely affordable cost. Millions of Americans are suffering and dying for lack of care. Maybe, to correct this, I’ll have to settle for just moderately excellent care rather than the best. So be it. Maybe my costs would go up. So be it. It is morally wrong for people in this country to be without health care.

(In a recent comment on this page written very late at night I attributed Governor McDonnell’s interesting phrase to former Virginia Governor Tim Kaine. Even before my astute True/Slant editors had caught the gaffe an astute reader had brought my attention to it. After I thanked him, Astute Reader replied, “Virginia might be better off if you did give it back to Tim Kaine.” We’ll see.)

But back to health care. Although it has faded slightly into the background, word is that House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid are still hoping to salvage the sprawling bill. It could be done, if the Senate bill’s sprawl. As Noam Levey reported in Sunday’s Los Angeles Times,

(I)n the coming weeks, Pelosi and Reid hope to rally House Democrats behind the healthcare bill passed by the Senate while simultaneously trying persuade Senate Democrats to approve a series of changes to the legislation using budget procedures that bar filibusters.

At the same time, leading consumer groups, doctors and labor unions that have backed the healthcare legislative effort for more than a year are stepping up attempts to stiffen lawmakers’ resolve.

These included scaling back the Cadillac tax, boosting aid to help low- and moderate-income Americans buy insurance, closing the “doughnut hole” in the Medicare prescription drug plan, and giving all states the assistance that Nebraska secured to expand Medicaid.

But many House Democrats do not want to vote on the Senate bill until the Senate passes the fixes they want. And it is unclear whether the Senate could approve a package of changes to its bill before the House approves the underlying legislation, according to senior Democratic aides. Democratic leaders hope to agree on a procedural path forward by the end of this week.

Despite the hurdles, there is a growing consensus that a modified Senate bill may offer the best hope for enacting a healthcare overhaul.

“The more they think about it, the more they can appreciate that it may be a viable . . . vehicle for getting healthcare reform done,” said Rep. Gerald E. Connolly (D-Va.), president of the Democratic freshman class in the House.

Sen. Tom Harkin (D-Iowa), who chairs the Senate health committee, noted that even before the Massachusetts election, senior Democrats had substantially agreed on a series of compromises that addressed differences between the House and Senate healthcare bills.

This space still hopes that “the best medical system in the world” can be made available to a few of the millions in America who still so desperately need it.

The cost of trying to live forever

Why is this not an encouraging word? In a front page article, part of a Months to Live series,  New York Times writer Reed Abelson leads with a glimpse into the Ronald Reagan U.C.L.A. Medical Center, a top-rated academic hospital noted for extensive, aggressive end-of-life care (and very high costs):

‘If you come into this hospital, we’re not going to let you die,’ said Dr. David T. Feinberg, the hospital system’s chief executive.

Feinberg’s commitment to “success” might be admirable, but the statement is patently false; people die at U.C.L.A. Medical Center. This is what people do: we die. Until this culture gets its act together on that subject our health care system — whatever the reform bill eventually looks like — will continue to flounder.

Difficult as it is to talk dollars when you’re talking lives, the issue of cost has to be factored in. There are only so many dollars, and there are countless lives needing care those dollars can buy: infants, children, young adults, boomers, elderly. In each of those care-needing groups, some die.  Feinberg’s philosophy somewhere has to encounter reality.

…that ethos (keep testing, treating, keeping alive no matter what) has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

No one, not the doctors, not the patients, not the best crystal ball reader around can guarantee that this patient will die or that patient will live. If there is a good chance a patient will survive — and it would be nice to add “with a reasonable quality of life” here — everything possible, and affordable, certainly should be done. Abelson’s carefully balanced article details the arguments for going to extraordinary lengths to save lives, as well as the arguments to draw the line on end-of-life expenses.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

So…. to spend that $25,000/$50,000 or not to spend? Unless we the people somehow face the reality that living forever is not a human option, the dilemma will continue.

The benefits of coming to terms with non-optional dying could be huge. We could focus on quality living. On palliative care and hospice care and end-of-life peace and comfort. Advances in palliative care now make it possible for most of us to spend final months at home (or in special hospital rooms), in comfort, surrounded by loved ones; given the choice, would you prefer a few weeks or months in a bright-lit sterile room with a lot of tubes and wires keeping you alive? U.C.L.A. now offers the choice of palliative care. Not everyone in charge, however, is convinced.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

We the people would do well to quit being the bad guys. To quit behaving as if death were always preventable. We could learn about the options to spending all those thousands of dollars on exhaustive, often futile treatment. We could talk about what we would or would not want for ourselves, write things down, make choices.

If more of us would do that for ourselves, the House and Senate wouldn’t have such a time trying to do it for us.