Ezekiel J. Emanuel on health policy and other topics.

Tags:

Death and Dying, Health insurance, hospice care, Hospitals, Medicare

IT is conventional wisdom that end-of-life care is an increasingly huge proportion of health care spending. I’ve often heard it said that people spend more on health care in the year before they die than they do in the entire rest of their lives. If we don’t address these costs, the story goes, we can never control health care inflation.

Wrong. Here are the real numbers. The roughly 6 percent of Medicare patients who die each year do make up a large proportion of Medicare costs: 27 to 30 percent. But this figure has not changed significantly in decades. And the total number of Americans, not just older people, who die every year — less than 1 percent of the population — account for much less of total health care spending, just 10 to 12 percent.

MSMDNYC

The more important issue is that just because we spend a lot on end-of-life care does not mean we can save a lot. We do know that costs for dying patients vary widely among hospitals, which suggests that we can do better. And yet no one can reliably say what specific changes would significantly lower costs. There is no body of well-conducted research studies that has proved how to save 5, 10, much less 20 percent.

Recent studies find that hospice may reduce costs in the last year of life for cancer patients by 10 to 20 percent. But they find no savings from hospice care for patients who die of other conditions, like emphysema or heart failure. No one is sure why hospice care doesn’t save more. It may be because patients are enrolled in hospice care too late, or because hospice services themselves are labor-intensive and not cheap.

Even if we can never save a dime, however, there are good reasons to think about changing end-of-life care practices. While end-of-life care has improved considerably over the last 30 years, many Americans still die in hospitals when they would rather die at home. Nearly 20 percent of deaths occur in an intensive care unit or immediately after discharge, and too many patients experience symptoms like pain that are controllable with appropriate palliative care.

Here are four things the health care system should do to try to improve care for the dying, even if they won’t save money.

First, all doctors and nurses should be trained in how to talk to patients and families about end-of-life care. When I was starting out, I was lucky enough to be able to witness how a great oncologist communicated with patients and their families when it was clear they were going to die, but I received no formal training whatsoever. It is hard to improve care for the dying if health professionals don’t know how to talk about it. Fortunately, there are excellent communication techniques and training programs available — they don’t have to be invented from scratch.

A related intervention — an idea that never actually was in the Affordable Care Act but inspired the death panel accusation — is that physicians should be paid a one-time fee to talk with patients about their preferences for end-of-life care. Even if physicians are well trained in communication, these conversations take time and are emotionally draining. This should be recognized through compensation.

Third, every hospital should be required to have palliative care services available both in the hospital and at the homes of dying patients who are discharged. Over 40 percent of hospitals with more than 50 beds do not have palliative care services. And we don’t know how many actually have palliative care services once patients are sent home. These services should be delivered by trained experts in diagnosing and managing common symptoms of the dying, like pain, nausea, insomnia, shortness of breath, fatigue and depression.

Finally, we need to revise eligibility for hospice care. Right now doctors must certify that patients have six months or less to live and patients must agree to forgo life-sustaining treatments. The decision about whether to put a patient in hospice care should not be based on unreliable predictions about how long he has left to live but rather on his needs for specialized care, like morphine infusions.

These changes could be made in at least two ways. The Joint Commission — the nonprofit group that certifies health care organizations — could make training physicians and nurses to talk about end-of-life care and having palliative care available a requirement for hospital accreditation. Alternatively, Medicare, private insurers and, after 2014, state exchanges could require hospitals to provide communication training and palliative services as a condition for payment.

Unfortunately, there is no evidence that these interventions will save money. And I can’t definitively prove they will make the care of dying patients better. But doing nothing to try to help the dying when the rest of the health care system is improving care is not an option.

A version of this article appeared in print on 01/04/2013, on page A23 of the NewYork edition with the headline: Better, if Not Cheaper, Care.

President Barack Obama’s reelection removes questions about the survival of the health care reform law bearing his name, meaning that over the next two years medical insurance will all but certainly be extended to as many as 30 million Americans who now lack coverage.

But even as the endurance of Obamacare no longer appears in doubt, the breadth and impact of the president’s signature health care expansion remains subject to the vagaries of Washington bureaucracy, the inclinations of private employers opposed to extending health care benefits, and the political calculations of elected officials in individual states. Republican governors in six states have vowed to oppose one of health care reform’s central components — a dramatic expansion of Medicaid, the joint federal-state insurance program for poor people.

In essence, Tuesday night’s election result replaced one giant threat to Obamacare — the prospect that the president’s Republican challenger, Mitt Romney, would seek to repeal it — with myriad smaller questions: Will the federal agencies tasked with writing the rules to implement it do their work quickly enough, and despite the lobbying by affected industries seeking favored treatment? Will states opposed to Obamacare limit its reach by refusing federal money that is supposed to finance the Medicaid expansion?

With his reelection secured, it’s now up to Obama to turn those question marks into periods. Failure to do so could jeopardize the entirety of his project, leaving Americans still clamoring for stable and affordable health care disappointed and angry. Success might enshrine him as the president who delivered largest expansion of the social safety net since the Great Society.

“There are going to be some glitches,” said Timothy Jost, a professor at the Washington and Lee University School of Law who advises state and federal officials as a consumer representative to the National Association of Insurance Commissioners. “The implementation of massive programs is always problematic,” he said. “I’m fairly optimistic that this is going to happen. I’m also very optimistic that once it’s been in place a year or two, a lot of people are going to say, ‘How did we ever live without this?'”

In simplest terms, Obamacare amounts to a package of measures that significantly expands options for Americans who now lack health care coverage. The law guarantees health benefits for the poorest Americans by expanding Medicaid to anyone who earns up to 133 percent of the federal poverty level, which is $14,856 this year. Currently, states determine their own Medicaid eligibility levels — though federal minimums apply –and many exclude people once incomes reach as little as half the federal poverty line.

Among those with incomes reaching up to 400 percent of poverty — or $44,680 in 2012 — the federal government will extend tax credits aimed at enabling people to buy their own health insurance policies from providers, shopping for their plans on so-called exchanges that allow them to compare prices and benefits.

 

Not least, Obamacare prohibits some of the health insurance industry’s most notorious practices, such as denying coverage to people who have pre-existing conditions, charging women higher premiums than men, and cutting customers off when their medical bills pile up.

In the nearly three years since his proposed legislation became law, Obamacare has already survived unanimous opposition from Republicans, a Supreme Court challenge, and finally Romney’s vow to undo the law if elected.

With these threats duly vanquished, the health care reform law now confronts a diffuse state-by-state, bureaucrat-by-bureaucrat battle to reach the ordinary Americans hoping for health care coverage.

Some of its measures have already been implemented, such as a requirement that insurance plans allow parents to cover adult children up to 26 years old on their policies. A prohibition against rejecting children with pre-existing conditions is also in place.

But the Obama administration has yet to publish a slew of crucial regulations that will define how health insurance is sold and what it must cover.

Health insurance companies must rush to adapt to a new market and employers will weigh covering workers or dropping health benefits to save money.

And as the Obama administration seeks to navigate this thicket of challenges, it still finds itself grappling with a public that is far from unified and not fully sold on the merits of his reform scheme, as Election Day exit polls revealed.

The biggest obstacle facing successful implementation of Obama’s Affordable Care Act is the law’s reliance on states to carry out one vital component of the law, the Medicaid expansion. While the Supreme Court upheld the broad challenge to Obamacare, finding that the federal government has the power to require people to purchase insurance, it also struck down a provision that obligated states to particpate in adding millions of people to their Medicaid rolls. That means the administration will need to cajole individual governors to go along to have any hope of achieving its goal of near-universal coverage by expanding health insurance to an estimated 30 million uninsured people by 2022.

“The major implementation tasks associated with the law are carried out by the states, especially when it comes to extending health insurance coverage,” said Alan Weil, the executive director of th
e National Academy for State Health Policy.

Republican governors like Florida’s Rick Scott and Texas’ Rick Perry have adamantly refused to extend health coverage to poor residents in their states, which will limit health care reform’s impact on the neediest people.

The stakes are considerable: The Congressional Budget Office calculated that allowing states to opt out of the planned Medicaid expansion could leave some 3 million people uninsured.

Republican recalcitrance and uncertainty about the federal rules have limited states’ readiness to carry out the law. As evidence of the intensity of opposition to Obamacare in some quarters, Alabama, Missouri, Montana and Wyoming voters all backed ballot initiatives Tuesday aiming to limit their states’ ability to comply with the law. A similar measure failed in Florida.

The decisions states make will go a long way toward determining how many poor people gain health coverage because they also have the option of creating their own health insurance exchanges under federal guidelines and have broad leeway to set regulations on health insurance benefits and premiums.

A deadline looms just 10 days away for states to present the administration with their plans for building the health insurance exchanges. According to the consulting company Avalere Health, 20 states are likely to run their own exchanges and 13 are likely to partner with the federal government, leaving federal authorities to manage the remainder.

Private sector interests that opposed health care reform, in whole or in part, will have to set aside their objections and adjust to the new reality if the law is to reach as many uninsured people as Obama aims.

Health insurance companies stand to gain tens of millions of new customers, but face new regulations and a new tax on their sales that will cut into their profits. A statement issued Wednesday by Karen Ignagni, president and CEO of America’s Health Insurance Plans, a trade group, underscores insurers’ mixed view of Obamacare.

“As the health care reform law is implemented, policymakers must prioritize affordability for consumers and employers. Several provisions in the law, such as the new premium tax, minimum coverage requirements, and age rating restrictions, need to be addressed to keep coverage as affordable as possible and ensure broad participation in the system,” Ignagni said.

Possibly the biggest source of potential disruption in the health insurance market could occur in plans offered to workers by their employers. More about 150 million Americans are enrolled in job-based health benefits, making it the most common source of coverage. That won’t change, said Tracy Watts, the national health care reform leader for the consulting firm Mercer.

“Over 90 percent of employers are committed to continuing to offer coverage in 2014,” Watts said, citing the company’s surveys, which are consistent with projections from the Congressional Budget Office and others, and the real-word experience from Romney’s similar 2006 Massachusetts health care law.

Under health care reform, companies with at least 50 employees must provide coverage or face penalties. For smaller companies, paying a penalty and letting workers buy their own coverage on the exchanges might make more sense, Watts said. The biggest cost increases will hit retailers and other companies that typically don’t cover their workers, she said.

By Janet Helm, MS, RD

It’s that time of year when pumpkins get their due. But these orange-fleshed gourds are so much more than seasonal décor or pie filling. Pumpkins are nutritional powerhouses, so I’m thrilled to see such enthusiasm for this fall icon.

Folks have become so enamored with pumpkin that some trend trackers have called it the new bacon. That’s because pumpkin is showing up everywhere. It’s starting to achieve bacon-like ubiquity. The firm Dataessential says more than 60 pumpkin-related dishes are now on the menus of America’s top 250 chains, and this year is on track to be one of the most active years for seasonal pumpkin menuing.  Pumpkin drink offerings have increased 400 percent during the past five years – although you’ll typically only find pumpkin spice flavorings and not the vegetable itself.

I’ve certainly noticed the pumpkin trend on Healthy Aperture, the online food photo gallery I helped created with fellow food blogger Regan Jones. Contributors have gone crazy with creative pumpkin recipes, including pumpkin mac and cheese, ravioli, chili, soup, enchiladas, risotto, granola, pancakes, waffles, oatmeal, doughnuts, pumpkin butter, gelato, cake, cheesecake shooters and smoothies.  You’ll also find interesting ideas for roasting pumpkin seeds, also called pepitas.

It’s a good thing that pumpkin is gaining in popularity. We need to be eating more orange-hued vegetables. The color is an indicator of lots of carotenoids, including beta carotene, which our body converts to vitamin A. Pumpkin is also rich in vitamin C, fiber, and potassium (one of the nutrients most likely to be lacking in the American diet.) You’ll also find the compounds lutein and zeaxanthin, which are good for our eyes.

Canned pumpkin can be used in lots of ways beyond pie – stirred into muffins, quick breads, and pancakes or added to soups, risottos, and pasta dishes. You can also easily make your own pumpkin puree. That way you can control the amount of sugar that’s used.

Yet, one of my favorite ways to enjoy pumpkin is roasted. Cutting a pumpkin is not just for Jack O’Lanterns. Once you remove the seeds (save those for roasting) and the hard outer shell, pumpkin is delicious roasted with a drizzle of olive oil and a sprinkling of sea salt and spices, such as cinnamon or cayenne. But don’t stop there. Check out other winter squashes, such as butternut, acorn, delicata, turban, hubbard, kabocha, and spaghetti squash (which has a stringy flesh that makes a great stand-in for pasta). Don’t be intimidated by their thick, gnarly skins and funny names. These are wondrous vegetables to get to know.

Remember, we need to fill half our plates with vegetables and fruits. Yet, few Americans are actually meeting daily vegetable guidelines. We’re not eating enough, and we’re not varying our veggies. MyPlate recommends 4-6 cups of orange-red vegetables every week. Pumpkin, a uniquely American vegetable, is a good place to start.