Medicare End of Life Care part 3

The views expressed in this blog are my own personal opinions and do not represent the views of Cottonwood nor it's administration.

I want to finish up on the topic of end of life care as it is an issue that needs to be faced which hasn't happened in this year's political debates on health care reform.

I will briefly recap the problem. Medicare is going broke. At current spending levels all asserts will be depleted in eight years. To save Medicare it will require a significant increase in payroll taxes as well as spending reductions. The 2009 Annual Report of the Medicare Board of Trustees indicated that payroll taxes may have to be raised to 6.78% (currently it is 2.9) and spending may have to be reduced by as much as 50%. That's a large reduction! So where are these reductions going to come from? They will come from where the money is now and that is in end of life care which currently takes 27.4% of the entire Medicare budget. 40% of that amount is spent in the last thirty days of life. The reality is that we will have to come up with some solutions that are neither "death panels" and'"We are not going to pull the plug on Grandma". At some point the plug will be pulled on Grandma and someone will be making those decisions.

I am not hopeful that we will have this debate in the public arena as we need to. It would be political suicide for a congressman or senator to bring up the idea of reducing end of life care. So I believe that we will not have this debate but that changes will come gradually with no thought or foresight.

I fear that the first change will be limitations on dialysis for end stage renal disease. Medicare pays for all dialysis regardless of age and the costs are over 6 billion dollars per year. I am concerned that we are not going to go about rethinking use of dialysis but just slowly to provide subtle encouragement for patients to voluntarily cease dialysis at some point. I don't know. I can't really say what will happen. I certainly don't have any solutions to the problem, but I do hope at some point in the near future we can have a public debate on this issue which is not going to go away by hiding from it.

Thought for the day

There is no reason we can't have that debate here. I encourage any readers to make comments or raise questions about this issue.

Medicare End of Life Care Part 2

I want to continue to talk about the issue of end of life care and Medicare, and point out some of the problems we are going to have to come to terms with without the rhetoric of "death panels'" and "We are not going to pull the plug on Grandma".

I am using the definition of end of life care to include all the medical services and costs associated with treatments provided in the last year of a person's life. Since the majority of deaths are in patients 65 and older Medicare is the primary payor for these services and it is important to know what I pointed out yesterday in that Medicare is going broke and it is projected that within eight years all assets will be completely depleted. This is a dire circumstance and one that is being avoided by both political parties in all the discussions about health care reform.

So how does this relate to end of life care? 80% of people who die here in the United States are Medicare beneficiaries. 27% of Medicare's total budget is spent on last year of life care with 40% of that in the last 30 days of life. Any reductions in Medicare costs is going to have to take into account end of life care with the goal of having more people who die of chronic terminal illnesses die at home or in hospice care rather than in hospitals. Hospital care results in greater costs not just for the hospitalization itself but all the expensive tests including MRIs and laboratory work. Many of these costs are for treatments that may extend the life span of someone with a chronic terminal illness by one or two days. That will have to change. Unfortunately, most people don't have access to hospice care and ethnic minorities have even less access that whites.

I am not saying that limiting end of life care is a good thing. But it will have to be done and this is an area that is being avoided in all the various discussions about health care reform.

Thought for the day

One of the problems of deliberate rationed care is that someone has to do the rationing.

Medicare End of Life Care Part 1

Lost in the rhetoric about "death panels" and "We're not going to pull the plug on Grandma" in health care reform there is a real issue that we are going to need to come to terms with and that is we can no longer afford to pay for end of life care as we are now doing. End of life care can be defined as those treatments and costs associated with the last year of an individuals life. Because most end of life care is provided through Medicare for the elderly I want to talk first a little bit about our current Medicare dilemma.

We already have a form of socialized medicine in the United States and that is Medicare. Medicare is a public plan in which the Federal government is in effect the single payor. Medicare pays for treatment for all individuals over 65 as well as paying for the disabled and those on renal dialysis. There are approximately 45 million people now covered by Medicare. Our current dilemma is that Medicare is running out of money. This is one of the reasons I have been opposed to a "public plan" option in health care reform. We are in dire straits to pay for those already on the public Medicare plan. We simply can't afford to add the estimated additional 45 million people that would be covered under such a plan.

So what is our situation now? The Medicare Board of Trustees in it's 2009 annual report indicate "The projected long term costs are not sustainable under current program parameters". "Medicare's financial situation is much worse (than Social Security)". The report indicates that by 2012 the projected assets of the Hospital Insurance Fund will drop below annual expenditures and that by 2017 the resources will be "exhausted". In just eight more years Medicare will be out of money completely. The report indicates that it will take 75 more years to bring Medicare back in balance but that is only if there is "immediate" change by increasing payroll taxes by 134% from what is now 2.9% to 6.78% or by a 53% reduction in outlays or some combination of the two. I don't anticipate we will see either of these actions anytime soon as it would be political suicide for any member of Congress to propose this.

So how does this affect end of life care? I will discuss that over the next several days.

Thought for the day

Both political parties are avoiding the Medicare issue in all the discussions about health care reform.

Health Care Reform Medicare Payments

The views expressed in this blog are my own personal opinions and do not represent the view's  of Cottonwood nor it's administration.

The American Academy of Neurologists has sent a letter to Congress about some concerns regarding any health care reform. What they indicated in their letter is similar to what I have been saying on this blog, that current Medicare reimbursement is inadequate and undervalues many specialties. The letter was also signed off on by the American Society of Hematology, the American College of Allergy, Asthma, and Immunology, the American College of Rheumatology and the American Gastroentrological Association.

You might initially think that this is just some whining by doctors who make enough anyway, why should they be asking for more when we are at a time of cutbacks? But it is not whining. It is stating the reality that in today's medicine procedures are highly reimbursed while time spent with patients is not. I want to emphasize that. Time spent with patients is not adequately reimbursed, not under Medicare and certainly will not be under any Medicare like public health plan. We all want our doctors to take time for us, and these are specialties where time spent with patients is essential not only for diagnosis but for ongoing management of often difficult serious chronic diseases. A neurologist, hematologist, immunologist, or a rheumatologist cannot continue to support a practice at current Medicare reimbursement rates. It is as simple as that. We pay highly for any surgery or specialized procedures but not for taking time with patients.

This reality is not lost upon young physicians who simply are not entering these fields of medicine. Why would they? I think that the letter sent to Congress was a good idea and clearly states the problem but I don't anticipate any reimbursement rates under Medicare going up any time soon.

Thought for the day

If you won't pay for it you won't have it.