The Trouble with Cost Containment
by Tom aka Rusty
The Trouble with Cost Containment
Long-term care facilities face multiple pressures thwarting cost containment attempts.
The nursing homes have three types of patients:
rehab: typically younger post orthopedic surgery or cardiac care, short stay
joint hospice patients: who are to be provided comfort care while dying
true long-term care residents: typically an 84 year-old with multiple chronic conditions, unable to live in a residence and who will likely die in the facility
Patients #1 and #2 are pretty clear cut as to costs and treatments. #3 is a problem.
The facility is in a vise created by regulators, physicians, families, residents and malpractice lawyers. Too much aggressive care is a waste of money and often violates patient wishes. But some family members want aggressive care.
Some family members hound physicians to provide more care, and the physicians may cave in. Nurses are often put in the middle of family battles (Mrs. Rustbelt once had a distraught daughter call 911 and had paramedics arrive to resuscitate a dead cancer patient, while family members screamed at each other in the hall).
Too little care is declared neglect by regulators and malpractice lawyers. And who wants a parent or grandparent to die? How much do you want to put someone through who is on the threshold of death?
The pressure on nurses is insane, partially accounting for high burnout and high turnover rates.
So what do harried nurses and physicians do? Transfer the patient to the hospital ER, for a stay that may last 2 hours to several days. The easiest course for a physician is to approve the transfer. This drives huge Medicare costs for little value. This drives Medicare administrators batty.
Some of the transfers make sense, rehydrating a flu patient who is nowhere near dying.
Other transfers create severe discomfort for the resident, with little to show for it.
How do we solve this?
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Tom aka Rusty Rustbelt
Nice article Rusty,
To some extent your example of long tem care makes a case for tort reform. Removing the legal path from irrational family members would leave the decision making to the professionals and the patieint reliant upon the patient’s written wishes.
Long term care is the core of the patient load and revenue in most facilities. Those who are able to pay from private funds are preferred to take some of the external (make that Govt) constraints off revenue.
This is precisly what the proposed paying for end of life counseling is all about. Have a person while healthy decide what level of care they want and document it. In most states this is binding on medical professionals. In addition encourage family conversations on the subject while all are healthy. For example if Terry Shaivo had had this conversation and document, then the whole court issue would have been moot. Clealy a full defense to a malpractice claim by relatives should be the explicit wishes of the patient expressed when competent. I am suprised that this is not the case since the instructions are supposed to be binding. It is more complicated if the conversation had not been held.
If torts were a major problem in overall health care costs, then there would be a strong argument for tort reform. Torts aren’t a major problem in overall health care costs. Torts are a specific problem for some parts of the health care system, and should be examined in the context of those specific problems.
What we have here is the inclusion of torts among a list of issues that make long-term care a major expense for nursing homes. One of several, for nursing homes.
In arguing for “tort reform”, we rarely hear calls for a strengthening of the right to sue. Typically, “tort reform” means weakening the right to sue. Typically, it means weakening the right for individuals to sue, but not corporations. Big Software Company A would still be able to sue Big softwar Comany B with impunity, under most tort reform proposals. Tort reform typically has to do with weakening the rights of the weaker party. So, what alternative do we have that would give individuals equal power in relations with an institution with more money, more information, and mixed motives in dealing with the care of loved ones? Does any such alternative that works in the narrow case of nursing homes also work in the case of surgeons? In the case of restaurants? Car makers? Do we want a bunch of special-case treatments, one for nursing homes, one for surgeons, one for consumer goods producers, and so on, to replace torts? Or do we want a one-size-fits-all alternative to torts?
The standard analysis is that advanced societies all have either strong regulation, strong tort protection, or amix of both. Just saying “tort reform” without identifying the nature of the reform, this late in the debate, doesn’t take us very far. If we have a specific problem with nursing homes, then dealing with that through specifc legislation removing abiguity as to the responsibility to the dying, level of care to be offered, the extent to which parties other than patient and doctor have a say in treatment, would go some way to solving the problem. That is to say, a substitution of regulation for tort.
Keep in mind that differing reimbursements mean that the three types of patients are regularly miss-classified.
Huh?
Since rehab and hospice require very cpecific entry criteria, I don’t see this happening very often.
There is some confusion about care protocols for hospice patients, but that is more a clinical matter.
Until I read this I did not know that patient transfers to relieve insane pressure on harried nurses and doctors was such an important factor in driving up healthcare costs. The public discourse has been dominated by healthcare for the last year and I thought I was familiar with the key issues. It’s a complicated set of issues indeed.
Something I learned a few months ago could give this a bit of useful context so it doesn’t devolve into the usual healthcare arguments:
The US doesn’t spend disproportionately on long term care compared to other wealthy nations.
I was rather suprised. The US is at about the 75th percentile for LTC spending among wealthy nations. In every other category except “durable medical goods” which I think includes stuff like wheelchairs the US is #1, usually by a long way, but in LTC we aren’t extraordinary.
I think the top spender was Sweden, which apparrantly has very high quality LTC facilities.
Another interesting thing about LTC in the US is that it is one of the most government funded parts of the healthcare system. Something like 70%. Most of this funding is from medicaid. The typical case is that a person goes into an LTC facility and depending how they got there medicare might pay for the first year or so, then the individual pays until they are broke, then medicaid pays. Medicare’s LTC coverage was designed to serve the first situation layed out by Tom: temporary care while recovering, but most of the patient years are from the third scenario: care of a highly disabled person for some years until death.
Oh one way we could help this is the “death panels” recently shot down.
Extra councling on making end of life arrangements so that we don’t as often have to fall back on the default position of doing whatever we can to extend life. If we did a better job of that, say by having medicare pay for such consultation (aka “death panels”) more very ill people would have specific instructions to stop trying to keep them ticking over and more unwanted treatment could be avoided.
Medicare at most pays for 90 days in a nursing home, less if there is no sign of recovery. Then you go to deplete assets, and finally medicaid. Of course if you are forward looking buying an LTC policy thru your employeer is a good idea at 50 or so, the premiums are low, and you do get a couple more years of protection. Its interesting to reflect that one could take the life insurance premiums that are no longer needed once the children are on their own (or of an age to be so) and apply them to LTC coverage.
Now one thing the faith community could do is for pastors to provide the counseling as well, since this is at least in some sense an ethical issue it makes sense to provide that sort of assistance to the members of their congregation.
The real problem are the economists who always find an excuse for those who are really driving up costs. Medical care did not get expensive because people did not want to die. Not dying was the entire point of the exercise!
Why contain cost in long term care facilties? Doesn’t someone earn wages and make a living there?
Why not cut costs in war spending? The F-35 is over weight, unreliable, nothing to write home about unless you make $150,000 a year from it, has cost too much to bring to a retarded state of development and they cannot deliver airplanes, which are so unreliable they cannot be tested, on any schedule.
Why keep throwing money done that rat hole?
When you answer that question let’s worry about end of life costs, and burdens providing some level of comfort to aging Americans.
Sorry in the past 12 months I spent a large part of 6 months each weekend in a nursing faciity dealing personally with end of life issues.
Kill the F-35 and every other trashy war program before you talk about cutting costs for caring for human beings in their last months of life.
Any attempt to address the issue will be drowned out by cries of ‘Death Panel’. It is impossible to touch the issue politically.
For those of us who have lost parents, even those of us who are supposed to see these issues dispassionately, the whole process is really really tough.
In my case my mother had made her wishes clear often during her life in discussing the care of my grandmother, who had the nursing home not caught an electrolite inbalance would have died 6 months earlier. My grandmother had expressed a wish to die. So it was an easy call when my mothers heart stopped, given her statements. If your wishes are clear the survivors need not feel guilt if they follow your wishes. Once we endowed medicine with its modern capabilities we decided to play god, so now we need to make decisions that would not have had to be made earlier.