Tag: Medicare

Blog Posts (30)

March 7, 2017

Secretary Kathleen Sebelius Presents Big Ideas in End-of-Life Care

By Kathy Greenlee, JD
What are the “big ideas” in end of life care? The Aspen Institute Health Strategy Group (AHSG) is helping to answer this question.

In 2016, AHSG selected end-of-life care as the subject of their year-long research. The effort was co-chaired by former Health and Human Services Secretaries Kathleen Sebelius and Tommy G. Thompson. Aspen worked with leaders in the field, sought public input and documented their findings in a recently released report titled, “Improving Care at the End of Life.” The Center for Practical Bioethics offered ideas as part of the public input process, a fact noted in the Preface to the report.

We are excited that former Secretary Sebelius will provide a keynote address at our Annual Dinner, April 5, where she will discuss these ideas and her role as co-chair of the project. Additional information about the Annual Dinner can be found on our website.

Practitioners will be encouraged to see the scope and depth of the AHSG five recommendation. They are:

Build the development and updating of an advance care plan into the fabric of life.

Redefine Medicare coverage in a way that meets the complex needs of people with serious illnesses.

Develop a set of quality metrics related to end-of-life care that can be used for accountability, transparency, improvements and payment.

Increase the number and types of health professionals who can meet the growing needs of an aging population.

Support model communities embracing fundamental change in the design and delivery of care for people with advanced illness.

Four background papers are included as the second part of the report:

Overview of the End-of-Life Experience in the United States, by Laura C. Hanson, M.D., M.P.H.

Care at the End of Life, by Diane E. Meier, M.D.

Financing Care at the End of Life: Ensuring Access and Quality in an Era of Value-Based Reforms, by Haiden Huskamp, Ph.D. and David Stevenson, Ph.D.

Doing Right by the Seriously Ill: Ethical Norms for Care Near the End of Life, by Mildred Z. Solomon, Ed.D.

You can find this report online at https://assets.aspeninstitute.org/content/uploads/2017/02/AHSG-Report-Improving-Care-at-the-End-of-Life.pdf


Kathy Greenlee joined the Center’s staff as Vice President for Health Policy and Aging in November 2016 after serving the past seven years as Assistant Secretary for Aging in the U.S. Department of Health and Human Services.

February 10, 2017

Medicare Is Reducing the Cost of Knee Replacements (Here’s How That Could Backfire)

Knee replacements are booming. Between 2005 and 2015, the number of knee replacement procedures in the United States doubled, to more than one million. Experts think the figure might rise sixfold more in the next couple decades, because of our … Continue reading

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December 9, 2016

Watch Out Hospitals: Medicare’s Planning to Punish You if You Misbehave

It used to be that hospitals billed Medicare for the services they provided, and Medicare – I know this is crazy! – simply paid the bills. Those days are rapidly receding into history. Soon, a significant chunk of hospital revenue … Continue reading

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November 15, 2016

Making Progress in Improving End-of-Life Care

This past week the JAMA Network and the Kaiser Family Foundation published a one-page graphic providing the latest data and information about Medicare patients and end-of-life care. JAMA. 2016;316(17):1754. In 2014, there were 2.6 million total deaths in the US; 2.1 million or about 80% of the total were persons covered by Medicare. These 2.1 million 2014 Medicare decedents accounted for 13.5% of all Medicare spending. That is about $35,529 per Medicare beneficiary who died in 2014. Other Medicare beneficiaries – those who did not die in 2014 – cost the system about $9,121 per person. This is a remarkable difference from 1978, when Medicare decedents in the last year of life accounted for 28% of program expenditures. Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328(15):1092-1096. Interestingly, the percentage between 1978 and 1988 did not change.

The new data show that trends have changed over the intervening decades. One of the more definitive descriptions of Medicare expenditures for beneficiaries in the last year of life was published in the New England Journal of Medicine in 1993. Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328(15):1092-1096. In some respects the data may not be exactly the same, for example, one compares payments in calendar years, and the other the last 12 months of patients’ lives; but the trends are fairly clear anyway:

·         In 1988, Medicare charges for decedents were 6.9 times those for other Medicare patients. In 2014, Medicare charges for decedents were 3.7 times those for other Medicare patients. That was a 46% reduction in charges for end of life care from 1988.

·         In looking specifically at the 65-year-old range age group of Medicare beneficiaries who died in 1988 and 2014 respectfully, decedent charges were 10.6 and 7.4 times higher than other Medicare beneficiaries in the category. This was a 30% reduction in charges for end-of-life care from 1988.

·         In 2000, about 21% of Medicare patients who died that year received hospice care; in 2014, about 46% of Medicare patients who died that year received hospice care. The number of dying Medicare patients referred to hospice over the 14-year period more than doubled.

·         In 2000, total Medicare hospice spending was $2.3 billion; in 2014, total Medicare hospice spending was $10.4 billion. This was a 352% increase over the 14-year period. This growth comes primarily from the time a Medicare decedent is enrolled in a hospice program. The median length-of-stay in hospice has increased from 15 days in 1994 to 18 days in 2014, but the level of hospice services provided was enhanced. Taylor DH Jr, et al. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science & Medicine. 2007;65(7):1466-1478. Curiously, the percentage of adult patients who died within 7 days of entering hospice care services increased from 22.8% in 1992 to 35.5% in 2014. Han B, et al. National trends in adult hospice use: 1991-1992 to 1999-2000. Health Affairs. 2006;25(3):792-799. National Hospice and Palliative Care Organization 2015 Facts and Figures. http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf.

Regardless, Medicare expenditures for beneficiaries in the last year of life are about half of what they were about 30 years ago. The emphasis on hospice and palliative care services for patients who are near death appears to be making a significant difference in a more appropriate allocation of health care resources while improving the quality of care. But unfortunately, we still have a long way to go in some areas: (1) Many persons 65 and older (73% of respondents) have not discussed end-of-life care preferences with a physician and 40% have not documented end-of-life wishes. (2) Moreover, two-thirds (68%) of physician respondents report not having been trained to discuss end-of-life care with patients.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 14, 2016

Why The Government Tried To Fix Primary Care And Failed

Americans spend more per-capita on medical care than just about any other country and, yet, they often have little to show for it. Americans have worse access to care than people in other countries, and are often less likely to … Continue reading

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August 12, 2016

Your Physician Can’t See You Yet – She’s Busy Filling Out Paperwork!

Left to our own devices, most of us physicians try our best to provide high quality care to our patients. But almost none of us provide perfect care to all of our patients all of the time. In fact, many … Continue reading

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June 30, 2016

The Healthcare Efficiency Myth – What Really Happens When Doctors And Hospitals Join Forces

For much of the history of U.S. medical care, hospitals and physicians have existed as separate financial entities. Physicians in the U.S. have typically been self-employed, as solo or group practitioners and not as hospital employees. An internist like me … Continue reading

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May 26, 2016

An Easy (But Politically Complicated) Way To Save Billions Of Dollars On Medical Care

I sometimes worry that my wife Paula won’t be able to see me grow old. Not that I expect to outlive her. She is four years my junior and has the blood pressure of a 17-year-old track star. It’s her … Continue reading

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February 3, 2016

Can’t Afford Medical Care? Welcome to America!

David Blumenthal and colleagues recently wrote a wonderful piece in the New England Journal on the future of Medicare. In it, they present a powerful picture comparing how often people in 11 countries have difficulty accessing medical care because of … Continue reading

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December 17, 2015

Finally: Something Republicans and Democrats Can Agree On

The United States Medicare program is forbidden, by law, from negotiating with pharmaceutical companies. This was part of a negotiation that was reached at the time that the government, under the leadership of George W. Bush, created Medicare Part D, … Continue reading

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