PHP310 Exam 2 Review Slides Fall 2024 PDF

2 Lecture 13: Intro to the Delivery System Coco Huang [email protected] Readings Are Hospitals Number of hospitals and hospitalization rates have decreased since the 1900s. Hospitals Becoming Obsolete? seem “life-threatening” and there are more alternative places of...

2 Lecture 13: Intro to the Delivery System Coco Huang [email protected] Readings Are Hospitals Number of hospitals and hospitalization rates have decreased since the 1900s. Hospitals Becoming Obsolete? seem “life-threatening” and there are more alternative places of care now. Hospitals are consolidating and merging, creating local monopolies that raise prices for patients. A Sense of Alarm as In rural areas, lower incomes and higher uninsurance rates contribute to higher levels of Rural Hospitals uncompensated hospital care. Rural populations are declining. Since 2010, nearly 90 rural Keep Closing hospitals have closed. Rural hospital closures are concentrated in non-expansion states. However, hospitals that close have comparatively lower quality care. Arguments that this may offset negative effects associated with increased distances. The Problem with Uneven distribution, incomplete coverage, inconvenient hours, inflexible care models, U.S. Health Care payer aversion, insufficient use of physician labor Isn’t a Shortage of Doctors Health Workforce COVID-19 only exacerbated the already existing issues with the health care labor force. Issues More Health care employment rates have not increased at the same pace as pre-pandemic. Conspicuous After Workers are moving to bigger health systems that can pay more. Onset of COVID-19 Delivery System Delivery: anything and everything related to the delivery of any type of medical care or service Hospitals, providers, nurses, health professionals, and more U.S. healthcare delivery lacks a well-structured system ‼ Trends: Hospitals Slight decline on the number of hospitals Number of inpatient admissions, number of inpatient days, and average length of stay are declining ○ Redeployment: hospitals are doing more and more outpatient care On the other hand, number of hospital outpatient visits is increasing Percentage of outpatient surgeries is increasing In the late 90s, gross inpatient revenue made up 70% of hospital revenue ○ In 2020, the distribution was approaching 50/50 More and more hospital mergers and acquisitions Rural hospital closures are concentrated in non-expansion states Trends: Physicians Projection of a shortage of PCPs and non-primary care specialties There’s an uneven geographic distribution of doctors ○ By state and rurality Physician workforce is aging (men especially) Physician racial/ethnic makeup don’t match up with the demographic distribution of the U.S. population URMs are more likely to work in underserved areas International Medical Graduates (IMGs) make up 24% of practicing physicians in the US ○ Trump’s immigration policy impacted the number of IMGs Trends: Nurses/NPs/PAs Increase in the number of APRNs No projected supply shortage for RNs, NPs, CRNAs, and nurse midwives ○ Small shortage for LPNs However, there is variation in projected shortages by state NPs, PAs, and others such as pharmacists will play an increasingly important role in the future ○ NPs and PAs are expected to grow more rapidly than MDs ○ NPs and PAs make pretty good money and require less years of education/training Lecture 14: Primary Care, Part 1 Coco Huang [email protected] Readings The Heroism of Longitudinal and personal care is impactful. You can only get this kind of care from a PCP. Incremental Care Having a usual source of care impacts health outcomes and mortality rates. The Doctor’s New Doctors (especially PCPs) have to balance administrative work and patient engagement. Dilemma They have to ration time and emotional energy to prevent burnout. However, it’s also also important to build rapport with patients. Twitter Tailwinds — Illustrated and highlighted the upsides of the medical profession. Media tends to amplify Little Capsules of the negative aspects of the profession and industry. Gratitude Headwind/tailwind asymmetry: the tendency to focus on the bad (headwind) vs. the good (tailwind) State of the Primary “Shortages and maldistribution of primary care providers (PCPs), low compensation Care Workforce, compared to other health occupations, increasing burnout and job dissatisfaction, and an 2023 aging and minimally-diverse workforce.” The Dilemma We have a high cost, and often low quality, health care system ○ US is specialty-driven, not primary care-driven Negative trends between Medicare spending and quality of care Primary care is especially needed for our increasingly old, ill, obese, and diverse population Primary Care Definition: the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of person health care needs, developing a sustained partnership with patients, and practicing in the context of family and community Integrated: comprehensive, coordinated, continuous Accessible: ease of patient/provider interaction and elimination of barriers Health care services: full array of services performed to promote, maintain, and restore health Accountable: quality care, patient satisfaction, efficient use of resources, ethics Majority of person health care needs: PCPs are trained to manage a wide range of health needs/problems from patients Sustained partnership: patient-centered care and shared decision making Context of family and community: living conditions, family dynamics, cultural background Distinction Between Levels of Care Primary Care: the provision of Secondary care: short term, can be integrated, accessible health care outpatient, may have technological services by clinicians who are focus accountable for addressing a large Hospitalization, routine surgery, majority of person health care needs, specialty consultation, rehab developing a sustained partnership with Tertiary care: complex, institution patients, and practicing in the context of based, highly specialized family and community Trauma care, open heart surgery Quaternary care: pediatric heart surgery or pediatric bone marrow transplantation Positive Impacts of Primary Care Greater use of preventive services; less use of ED; higher patient satisfaction Improvement in population-level mortality Physician-connected patients more likely to get mammography, cervical cancer screening, colorectal cancer screening, recommended diabetes care, and recommended coronary disease care than practice-connected patients in a large MA study (n=92,315) Having more primary care providers is associated with higher quality and lower costs Having more specialty providers is associated with lower quality and higher costs There is broad consensus that care in the US (and in Europe) should be more primary care based and focused High Value Primary Care Attributes of high value primary care identified by Simon Paper (using definition of low cost and high quality as high value) Decision support for evidence-based medicine ○ Guideline-based reminders in EHR/EMR Risk-stratified care management ○ Each patient receives care that is matched to their unique needs ○ High-risk patients receive higher-intensity care Careful selection of specialists ○ Specialists trusted by the PCP, whom they can keep in close contact with throughout patient’s care Coordinated care ○ Monitoring patient care outside of primary care, referrals, follow-ups, etc. Standing orders and protocols ○ Streamlines care and ensures quality care ○ Non-clinician team members can use these treat non-complicated health issues Balanced compensation ○ Physician salary is linked to value and not just volume Lecture 15: Primary Care, Part 2 Kate Choi [email protected] Emphasized Readings in Lecture Stressed Out and Burned Out: The Survey highlights (most physicians reported increases in their workload Global Primary Care Crisis since the start of COVID-19, but younger physicians were more likely to be stressed/burned-out - many older physicians reported intent to retire soon → primary care workforce consisting of younger/more stressed/burned-out physicians) Republicans’ drive to tighten Article reviews the role of IMGs in the physician workforce immigration overlooks need for doctors Discusses patients’ bias, discrimination faced by IMGs as practitioners in rural areas & opportunities lost by U.S. immigration policies Quality of Life for Primary Care Physicians An effort/reward imbalance for Recent Trends primary care physicians ○ Particularly evident when compared to Primary care usage frequency has been specialty care physicians decreasing compared to specialty care Primary care physicians increasingly work in teams (with other health care professionals) Take-Home Point Well-functioning multidisciplinary teams can help overcome challenges of primary care  Quality of Life for Primary Care Physicians Electronic Health Records (EHR) ○ For many physicians, the current usage of EHRs appeared to significantly worsen professional satisfaction Some sources Time-consuming data entry NOTE → On average, Interference with in-person physicians logged slightly patient care more hours performing Inability to exchange info between EHR products “desktop medicine” What is desktop medicine? rather than “face-to-face ○ Type of work that physicians do online, visit” non in-person work with/for patients (think of behind-the-scene work) Responding to prescription refills Ordering tests Reviewing test results Communicating with patients through portals Reimbursement and Payment Policies RUC (Resource-Based Relative Value Scale Update Committee) Specialists make 40% > more than PCPs ○ $117K difference Sponsored & run by the AMA Recommends RVUs 31 voting members (most appointed by specialty societies) ○ Note → Over 50% of visits are for generalists BUT there is only 1 guaranteed seat for PCPs RUC determining RVUs… Decisions are political There is a growing compensation gap Take-Home Points Q. How are prices set? Payment policies are complex (process of setting prices is dominated by specialists) Emerging evidence - payment policy that advantages PCPs may reduce spending growth Movement away from FFS (fee-for-service) continues → remember that MACRA advantages Advanced Payment Models  Herfindahl-Hirschman Index (HHI) More on PCPs Measures market concentration (higher number = more concentrated) Q. Who are PCPs (Primary Care Practitioners) Examples Note → Difference in concentration of Family physicians Specialists vs. PCPs General internists Geriatricians General pediatricians Nurse practitioners (NP) Physician assistants (PA) Note - sometimes (nurses, pharmacists, health Where do PCPs work? → educators & medical assistants) Health Profession & Primary Care Shortage Areas Take-Home Points Rapid practice of consolidation ○ Driven in part by payment models Only ~43% of physicians in US are PCPs A growing shortage of PCPs Q. What is an issue of PCP distribution? A. Primary care access tends to be — (worse) in rural/lower income areas → contributing to health/health care disparities Q. What drives the geographical distribution of providers? A. Driven by income $$$ of residents in physical areas  Q. What were the largest factors on specialty choices of med school grads? A. NOT income $$$ & education Pipeline for Medical debt, instead personality fit & specialty content School Graduates A paper analyzing physician education debt repayment concluded… ○ “A primary care career remains financially viable for med school graduates with median levels of education debt”  Primary care ○ Proportionally, more IMGs work as a PCP than US grads International Outside of metropolitan areas, what % practiced in areas with PCP shortages? Medical School ○ 68% of IMGs vs. 40% of US grads Graduates (IMGs) Quality of outcomes ○ When IMGs directed hospital care by generalists→ lower mortality than those of US grads ○ When IMGs directed surgical care → equal outcomes to US grads Take-Home ○ IMGs play a critical role in general but particularly in primary care  Lecture 16: Ambulatory Care Kate Choi [email protected] Emphasized Readings in Lecture The Convenience Revolution for Discusses the convenience & filling an unmet need in the healthcare Treatment of Low-Acuity Conditions system though non-traditional methods Can Retail Clinics Transform Health Criticizes the changing landscape of the healthcare system Care? - Author references such trends (including big data, distributed patient care, alignment of financial incentives, etc.) will produce “other disruptive health care developments” Overview of Trends Ambulatory Care → ambul = walking ○ While inpatient care = at least 1 overnight stay This is more convenient and cheaper than inpatient care ○ No costs like accreditation; licensing; recruitment of payers, physicians, and patients Three interrelated trends ○ Inpatient care is expensive, payers won't pay for it unless medically necessary ○ Cost of hospital based outpatient care ($$$) >>> non-hospital outpatient ($) ○ Busy people “demand” convenient care  EDs Ambulatory Care Urgent Care Centers Retail Clinics Settings Concierge Medicine CAM (Complimentary and Alternative Medicine) There are more… But these are the ones that we suggest focusing on. Emergency Departments Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ○ Must provide emergency care to anyone ○ A classic “unfunded mandate” - uncompensated care ○ Brought to counteract “dumping” of uninsured or unprofitable patients ED Use ○ Appeared to be decreasing pre-pandemic, unclear post-pandemic trends Decreases in acute care in PCP offices (why?) Trends in ED use is hard to break ED use is not automatically reduced by better insurance Urgent Care Centers Overall - can walk-in and have more services than PCP but less than hospitals ○ Requires immediate care (24 hrs) but do not require ED level care ○ Extended hours, unscheduled→ Fills need when private offices are closed ○ Fills need for acute care between ED and outpatient settings , more services than PCP offices Compared to ED ○ Pro: Cheaper (often less copay) ○ Con: It’s hard for PCP information sharing to these Urgent Cares Who goes? ○ Many people - b/c convenient (short wait times) Growth demonstrates the demand for these services ○ 67% growth over 8 years (2016 - 2024) Retail Clinics Located in retail stores (ex: grocery stores, drugstores, “big box” - Walmart, etc.) ○ Convenient, walk-in care for minor problems like colds and prevention (e.g., flu shots) ○ They are perfect for preventative care (immunizations, COVID-19 tests) The most dominant player in the market (by # of locations) is CVS Health Decrease costs? ○ Not really (people spent more so modest increase in spending), have to have insurance ○ Utilization wouldn’t happen if the retail clinic didn’t exist/wasn’t convenient (moral hazard) Concierge Medicine Pay a “retainer” of $1,000-$50,000 Get a variety of services ○ Cell phone access to MD 24/7; Same day visits; Longer visits; PCP accompanies you to specialty visits For wealthy people, only 1000 in the country, limited impact (for now) Controversial ○ Pros: why not let people pay more to get more? physicians argue that it allows them to practice the kind of medicine that they think is right ○ Cons: better care for wealthy (two tier system), takes physicians away from those who need them; may exacerbate existing disparities Direct Primary Care Like concierge medicine but cheap - concept: pay $50/month get all office care you need For doctor: focus on care, no hassle with reimbursement For patient: better, easier access Low end of cost spectrum ○ More timely office services High end of cost spectrum ○ More amenities Take Home CM and DPC draw attention to payment system being a real pain ○ Patients aren’t getting what they need, physicians feel handcuffed by system ○ The market creates opportunities for niches to be filled → consumer-oriented medicine Complementary and Alternative Medicine (CAM) i.e. natural products, breathing, yoga, prayer, chiro etc. Small percentage of total spending, but ~11% of total OOP costs Most costs go towards using natural products Take Home - Americans consume a lot of CAM, lots of money is spent out of pocket doing so Lecture 18: Prescription Drugs Nick McCarthy-Belash [email protected]  Types of Drugs Brand name drugs Biologics Biosimilars - Original FDA - They’re huge, - Alternate Approval hard to make formulations of - “Tylenol” biologics - built differently but do the same Generic Drugs things - Equivalent drug Specialty Drugs made by a different supplier - Kind of fake distinction made by payers - “-Acetaminophen” - Might be for very specific conditions - Definitely very expensive Key Trends Prescription drug costs are increasing worldwide but much faster in the U.S. Out-of-pocket costs impact patients’ ability to take their drugs as prescribed by their physicians Specialty drugs are the most expensive category of prescription drugs and continue to increase in both sales and development ○ Biologics are a Big part of this  FDA Drug Approval Process 1.5 years preclinical trials - where most drugs get weeded out 6 years clinical trials: Phase 2 is the clinical phase that the fewest drugs make it through: 35.5% Cost effectiveness, etc Dosing, toxicity: Adverse Reactions, Efficacy: How well Rigorous efficacy: How well does How to not poison people does it work, what are the side effects it work really Drug Development and Approval It’s Expensive!!!!! Median cost $985 million Mean cost $1.336 billion Takeaways It’s expensive, multi-year process to develop a new medicine Many phases to testing safety and efficacy of a new drug It’s unlikely (12% chance) for a drug to pass the FDA approval process The R&D drug pipeline is crowded with high-cost specialty drugs Pharmacy Benefit Managers (PBMs) Companies hired by health plans/employers/government/unions PBMs became valuable by introducing real-time electronic processing of drug claims (in the 1980s), helped insurers move to completely paperless system ‘90s: PBM expanded services to Medicaid programs Market has become extremely consolidated, with 3 PBM companies controlling 80% of the market form PBM services  What do PBMs Do? Design formularies - The list of drugs covered by an insurance plan ○ Developed through the “Formulary Development Process” must add/include (value add!) may add/optional (often added low tier) must not add/exclude (none or negative value) ○ Committee of non-employee physicians/pharmacists make the final call on recommendations for drug inclusion on formularies Set up pharmacy networks (like physician networks) Electronically process claims Negotiate rebates How can PBMs Reduce Drug Costs? – Position to negotiate and manage Networks of affordable pharmacies & home delivery Encouraging generics & affordable brand name meds Negotiate rebates from manufacturers & discounts from drugstores Cost reduction specific strategies Step therapy – prescribe cheaper drug A before can try more expensive drug B Prior authorization Indication restriction Rebates Paid by the manufacturers to the health insurance plans via PBM negotiations Manufacturers pay rebates in exchange for maintaining a favorable relationship with the health plan ○ preferred formulary positions ○ exclusive status – lock out competition ONLY in competitive drug classes (aka there are alternatives (it’s a market!!)) Transparency issues. Are insurer-level rebate savings passed to the patient? Vicious Cycle? Higher rebates/ fees to PBMs from consolidation → higher manufacturer prices Insurers’ Price Control Methods Prior authorization Disease management ○ improves outcomes, may or may not reduce costs “Value based benefit design” of plans: cost sharing determined by value not price ○ High value, low cost – low co-pay ○ Effective yet expensive – middle copay ○ Marginal benefit – high co-pay Prescription Drugs and the IRA Allows the government to negotiate prices for some top-selling drugs covered under Medicare Would have saved Medicare 6 billion if the newly negotiated prices had been implemented in 2023 Stuff that makes things more expensive Biologics (and other specialty drugs) Consolidation of PBM companies Research and development process length and rigor Drug manufacturer profit margins Stuff that makes things cheaper Basing drug price and cost sharing on drugvalue PBM’s leveraging their negotiating power to set affordable pharmacy networks and encourage use of generics etc Insurer’s utilizing prior authorizations and step therapy Negotiation directly with drug manufacturers (IRA) Mental Health Break! Let’s take a 5-minute break :) Lecture 19: Hospitals Kate Choi [email protected] Facts about Hospitals Almost ONE-THIRD of all healthcare expenditures in the US are towards hospital-based care There is a decreasing trend of the # of hospitals Health Care is the largest employer in the US Evolution of Hospitals 1. 1800s - “Primitive institutions of social welfare” (Municipal almshouses) 2. Late 1800s - “Distinct institutions that care for the sick” (separate public hospitals/centers created by philanthropists) 3. Early 1900s - “Organized institutions of medical practice” 4. Mid 1900s - “Advanced institutions of medical training & research” 5. 1980s-TODAY - “Consolidated delivery systems” Expansion in the late 1800s to mid 1980s Roemer’s Law (1961): “a built bed is a filled bed” Six major contributing factors to the massive growth of # of US hospitals 1. Advances in medical science 2. Development of specialized technology 3. Advances in medical education 4. Development of professional nursing 5. Growth of health insurance 6. Role of government Important Policies/Acts Hill-Burton Act Hospital shortage following WWII Federal govt. provided states with grants and guaranteed loans for hospital construction Goal: 4.5 beds/1000 people in each state Very successful; allowed small, remote communities to have their own hospitals Allowed the federal govt. to force desegregation in hospitals in the Simkins v. Moses H. Cone Memorial Hospital Supreme Court case ○ Civil Rights Act of 1964 banned segregation at hospitals Medicare and Medicaid (1965) Increased demand → increased number of hospital beds Downsizing since the mid 1980s Main reasons for decline in number of hospitals and beds: Shift from inpatient to outpatient care Prospective payment system & the advent of DRGs Impact of managed care Hospital closures Types of hospitals Public Owned by federal, state, or local government Usually have higher utilization Private For profit: owned by individuals, partnerships, or corporations Non-profit: owned and operated by community associations or other NGOs and receive tax exemptions ○ Have to conduct a Community Health Needs Assessment (CHNA) and implement strategy every 3 years in order to keep tax-exempt status under the ACA ○ IMPORTANT → Nonprofit hospitals DO make a profit, just can’t distribute that to shareholders/individuals Hospital payments Billed charges: the amount hospitals bill an insurer for a service Don’t cover many professional fees Contractual adjustment: discounts negotiated by payers Allowed amounts: the actual payment that a hospital receives Medicare and Medicaid set prices, while private and third-party payers negotiate prices Medicaid and Medicare pay less than private insurance, but are more expensive for hospitals ○ Cross-subsidization: losses from Medicaid/Medicare payments are made up by shifting costs to private insurers Hospital payment reforms Alternatives to FFS: population-based, episode-based, site-based, pay for performance Ultimate goals are to discourage overutilization and focus on quality The Hospital Value-Based Purchasing (VBP) Program Pay-for-performance Budget neutral program: payments are collected from underperforming hospitals and given to high performing hospitals Payments depended on achievement and improvement Hospitals can gain or lose up to 2% of Medicare payments Hospitals have a financial incentive to deliver higher quality care, but safety net hospitals tend to perform worse because their patients have more social risk factors Results so far: no significant impact on quality of care or patient outcome measures Hospital payment reforms Maryland All-Payer Model Site-based payment → all-payer, annual, global hospital budget encompassing inpatient + outpatient hospital services Incentives to limit both volume and costs per admission Greater reductions in total expenditures and inpatient admissions for Medicare beneficiaries, without cost-shifting to other parts of the system Greater increases in admissions severity, strategies to reduce avoidable utilization had mixed results, coordination with community providers following a hospitalization did not improve  Lecture 20: Long Term Care and Nursing Homes Nick McCarthy-Belash [email protected] (Credits to Jedidiah for the fun stuff in the slides) Readings yay 1. Thomas and Applebaum (2015) - Older population w/ disabilities projected to double by 2040 -> today’s challenges are tomorrow’s crisis w/o preparation - Coverage- most funding through Medicaid, low % of older adults receive Medicaid, limited caregiver support, projected low workforce, etc. 2. Harrison and Frampton (2016) - Resident-centered care- shift in culture and improving nursing home quality - prioritize resident autonomy and decision-making, consistent staff assignment, make it more home-like than institution-like, transparency about death and dying 3. Harrison et al. (2021) - Vaccine uptake is a social enterprise. - Concise info from trusted sources i.e. community leaders, seeing people like themselves take the vaccine 4. Grabowski (2022) - Problems of poor staffing and few homelike models - Medicaid reimbursement falls below cost of care - Solutions will need to both increase reimbursement and accountability for spending. 5. Shi and Singh, Chapter 10 (p. 433-462) is also great to look at!) Age and Intersectionality Age is a social construction- has stereotypes, and we decide when it happens, what it looks like, what it means A form of inequality, loss of power and exclusion always, no matter what other social statuses Double/multiple jeopardy (Intersectional inequality) - Higher poverty rates - Physical aging has more severe consequences for women than men Ageism - “old age is bad”- do anything you can to not be labeled as old. - “Stay young while old”- expectation to approximate youth in age As population continues to age, there will be a strain on resources and caregiving facilities. What is Long-Term Care/ Long Term Support Services? Health-related services to maintain/improve optimal level of physical functioning and quality of life - Provided over extended period of time - Not prevention, diagnosing, treatment, or curative purposes - Sets apart from other medical/acute care this way - Not just for older adults - Children with developmental, intellectual, or physical disabilities - 18-65: “adult onset disabilities” (physical), intellectual disabilties, mental health disorders, paralysis, etc. - 65+: physical (heart conditions, arthritis,etc.), cognitive (dementia, Alzheimer’s, etc.) 70% of people who reach age 65 will need LTC!  Long-Term Care: Costs uh oh ~$725 billion spent per year Unpaid caregivers provide majority of care Medicaid is the largest single-payer: covers nursing home, home health, etc. Medicare does not cover - 10% of elderly adults long-term care receive Medicaid - Acute rehab - BUT ⅔ of elderly and hospice adults in nursing are not LTC homes receive Private insurance Medicaid assistance - $$$, complex, - Huge coverage gap lack of motivation A Little More on Long-Term Care Cost ¾ of Americans age 40+ feel unprepared to pay for LTC - Expensive - Private room in RI costs $10,000/month (0.0) - Component of not wanting to think about aging or having to prepare for that inevitability Majority of costs for community-based services are out-of-pocket for those who do not qualify for Medicaid and due to the fact that only about 7-8% of older Americans obtain LTC insurance. - When private funds are exhausted, then would need to rely on government-paid system  Forms of LTC - More on nursing homes later Assisted Living - Not a nursing home! Adult Day Care ○ Housing model with personal care ○ Daytime group program to meet social assistance + medical needs of ○ Variable in all ways, including regulation functionally/cognitively impaired ○ Fastest growing segment of LTC adults Adult Foster Homes ○ Partial respite for family caregivers ○ Personal care services and room & board Home Delivered Meals ○ ~2-6 residents ○ Meals on Wheels ○ Staffed 24/7 by family or commercial entity ○ Funded through Older Americans Act that runs home and Medicaid Home Health Services ○ Provides ~5 meals per week ○ Nursing, rehab, therapy ○ “More than a meal” → Food + social ○ Typically for people who need help with interactions activities of daily living (ADLs) Nursing Homes - For people with long-term needs that cannot be met in their own home - Paid for privately or by Medicaid. - Challenges - Chronically understaffed, High turnover - Low provider reimbursement Used to be “total institutions”- daily rhythm of resident’s life overtaken by central authority - extremely isolating - dysfunctional all around - 1987 Omnibus Budget Reconciliation Act (Nursing Home Reform Act) - BIG changes to nursing homes with improvement of quality of life and care- establishing minimum standards, rights for residents, protection from neglect, emotional abuse, etc. More on Nursing Homes 1990s onward- Culture shift! Wahoo Nursing homes shifting away from being “mini-hospitals” - Resident-centered care! - Eden alternative- one of earliest efforts in culture shift - Against “three plagues of aging”- boredom, loneliness, helplessness - Residents can give AND receive care - Green house- de-institutionalizing - smaller communities of 8-10 residents instead of large facilities COVID-19 People in nursing homes especially vulnerable to social isolation ○ Physical Safety trade offs with quality of life The highest rates of infection and mortality in the US were among skilled nursing facility (SNF) residents and staff Nursing home worker was found to be the most dangerous job in America during the pandemic Even locking down facilities and restricting access to outside visitors, COVID-19 outbreaks in SNFs persisted due to exposure of staff in the larger community  Lecture 21: End of Life and Palliative Care in America (Rudolph) Hamid Torabzadeh [email protected]  Readings JAMA Infographic (2016) for 2014: 4/5 Americans who died in 2014 were covered by Medicare EOL care contributed a fair amount of Medicare spending (13.5%) though declining Medicare spending was higher for people at EOL ($34,000 vs. $9,000) Medicare hospice use/spending has increased Many Americans 65+ have not discussed (70+%) or documented (40%) EOL care wishes 68% of physicians not trained to discuss EOL care Gawande article (2016) Benefits of palliative care must be further studied, but literature suggests that it might improve quality of life + increase survival of patients Awareness about the intricacies/legal documents surrounding EOL care must be improved Many countries are transitioning away from institutionalization/hospitalizations @EOL, including U.S. Vital goal: not having a good death but having as good a life as possible all the way to the very end Tulsky article (2015) Palliative care is high-quality care for people living with serious illness and their families Quality standards should be developed for clinician-patient communication and advance care planning All clinicians who care for people with serious illness must be competent in generalist palliative care skills Health care financing incentives must be restructured to incentivize palliative care We should increase EOL conversations Readings Pt.2 KFF report (2017) Age-Friendly Health System General trends about Americans’ Provides a set of 4 evidence-based elements perceptions/experiences relating to EOL care and of what is high-quality care: What Matters, the healthcare system Medication, Mentation, and Mobility. Most Americans know about hospice care, but most Americans haven’t discussed EOL care wishes with a healthcare provider Perceptions and experiences about hospice care are generally positive WHO article (2020) Palliative care improves quality of life, but only 14% of people who need it currently receive it Palliative care is recognized under the human right to health There is a huge disparity in access to palliative care between higher income and lower income countries All of us Die Causes of death change from youth to older people Older people are more likely to die 20-24 yrs 45-54 yrs 65+ 2014 #1 COD Injury Cancer Heart disease 1940 1900 1980 % Surviving #2 COD Suicide Heart disease Cancer #3 COD Homicide Injury Respiratory #4 COD Cancer Liver disease Cerebrovasc. #5 COD Heart Disease Suicide Alzheimer’s Age (years) Other notes: The world is aging (unevenly - Africa, Asia, South/Latin America expected most growth) The infrastructure to accommodate the growth in older people is going to be stretched These are population-based points; dying is a personal experience Death is Personal, but US Promotes Dying in Hospital Physicians overestimate survival of terminally ill cancer Different courses of death: patients, and cardiologists overestimate survival of people Sudden Death suffering from congestive heart failure Why does US healthcare promote dying in hospital? ○ Discomfort with Death ○ Aging Bias ○ Hospital is Safety Net Recurrent Insults ○ Reimbursement favors Acute Disease and Procedures Lack of needed provider / patient / family discussions regarding end-of-life care Undocumented advance directives and the issue of not honoring documented directives Dwindles across care settings ○ Perception that Hospital Can ‘Save’ People Sites of Death (SOD) Death is Expensive, Vary By Diagnosis Particularly in Hospital Cancer COPD Dementia #1 SOD Home Hospital Nursing home #2 SOD Hospital Home Home #3 SOD Nursing Nursing Hospital home home Palliative Care - Definition: - “Patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.” - Addresses physical, intellectual, emotional, social + spiritual needs - Objective is pain + symptom relief + begin advanced care planning - Includes comprehensive care delivery: medications, day-to-day care, equipment, bereavement counseling, and symptom treatment - Benefits: - Improved quality of life for patient/families - More frequent and timelier hospice referral - Lower acute care utilization for patients with cancer - Lower hospital costs Palliative Care vs. Hospice – Important! Palliative Care Hospice Place MOSTLY in hospitals, some MOSTLY at home (assisted in nursing homes living/nursing homes) Timing NO time restrictions Terminal (6-month prognosis) Election NO active election/choice MUST actively enroll Disease Modifying Care Can receive disease Cannot receive disease modifying care modifying care Payment Insurance (i.e., Medicare Medicare, Medicaid, private Part B visits), patient/family, insurance charity Advance Directives They allow persons to convey preferences for future healthcare treatment. Types include: - Durable Power of Attorney for Health Care - Person designates someone to speak for him/her - Living Will - Person documents values, goals, and preferences for treatment - POLST / MOLST documents - Translate preferences into doctor’s orders - Legislated by states and follow persons across care settings Medicare Hospice Benefit (Part A) - Comprehensive care for dying (type of palliative care) - Interdisciplinary team/unit of care - Includes: - Pain and symptom management - Emotional + spiritual support (patient, family) - Bereavement support (family) - Hospice is growing: - In 2000, 23% older adults received hospice; in 2019, 51.6% of Medicare beneficiaries - Patients with the longest hospice days are those suffering from dementia; those with the least suffer from cancer - Patients are less likely to be hospitalized, less likely to die in hospital; in some cases, decrease hospital expenditures (not all; think acute vs chronic disease) Hospice is a Business Less Black Americans die in Hospice - $20.9 Billion Medicare compared to Whites: Spending Annually - $13,237 per hospice enrolled beneficiary - Avg. Length of Hospice Stay – 98.9 days - 4840 Hospice Agencies - 71% For Profit - 26% Non-profit - Most Agencies are Small - ADC