getting from roulette to reliable: high value care for the last part of life aging america: a reform...

Getting from Roulette to Reliable:

High Value Care for the Last Part of LifeAging America:

A Reform Agenda for Living Well and Dying WellThe Hasting Center Symposium, Washington, DC

May 20, 2008

Joanne Lynn, MD, MA, MSJlynn@Medicaring.org

(Speaking on my own, not for US government policy)

2

© Copyright 2003, Onion, Inc., All rights reserved.

3

By permission of Johnny Hart and Creators Syndicate, Inc.

4

How Americans Die: A Century of Change

1900 2000

Age at death 46 years 78 years

Top Causes Infection Cancer

Accident Organ system failure

Childbirth Stroke/Dementia

Disability Not much 2-4 yrs ave. before death, <6% die without related bills

Financing Private, Public, substantial- modest in US - 83%

in Medicare ~½ of women die in Medicaid

5

Why target fatal chronic illness?

• It’s bigbig – >1/3 of lifetime expenses, most “being ill”

• It’s badbad – unreliable, often harmful

• It’s uglyugly – little political will for reform – Unpleasant and complicated situations – Inadequate data and methods – Bad manners

6

But – Some Promising Innovations

• Hospice

• PACE (Program of All-Inclusive Care for the Elderly)

• SNP (Special Needs Plans – capitated high-risk)

• Palliative care – now in most hospitals

• Elderly and Disabled Waivers

• CARE and Care Transitions, upcoming from CMS

7

CARE: Continuity Assessment Record &

Evaluation• Beneficiary’s health situation• At critical times, such as transfers• On-line, real-time• Information to “downstream” clinicians• Quality and payment information to Medicare

In demonstration now, in QIO agenda by fall.

8

Care Transitions in Communities

• Build on Dartmouth Data

• Target Seriously Ill Medicare Beneficiaries

• Assure Continuity and Reliability

• Support by Quality Improvement Organizations (QIOs)

• With ALL Clinical Service Providers

• And Community Leaders

How can we learn to improve quality and also deliberately enhance efficiency?

9Lewis and Clark – leaving St Louis, May 1804

10

Pushing for Reform

THE BUSINESS CASE:

THE AIM:

– Social consensus on how to live and die with serious illness

THE STRATEGIES:

– Engender political demand

– Engender the workforce

– Tailor services, payment, quality measures to populations

11

The Business Case

• Pay well only for continuity care

• Make planning ahead standard

• Permit continuity over time and setting

• Change the information flow

– Require feedback “upstream”

– Give relevant information to patients/families

12

The AIM

• Public stories – TV, famous people, other

media

• Honest accounting of costs and benefits

• Include patient and caregiver voices –

in coverage, payment, and quality

• Demonstrations – in substantial regions

• Compare small areas

13

Caregivers – Politics and Needs

• Organize caregivers for political power

• Demand reasonable working conditions

• Demand a role in setting priorities

14

Employee Work Force

• Change the skill mix for physicians

• Leadership positions for nurses, social

workers

• Fair labor practices for aides

15

Tailor Care to Populations…

16

17

18

19

Tailor Care to Populations…

First – short course to dying**Mesh hospice and conventional care

Second – exacerbations**Move services to home, advance care planning

Third – dwindling course**Family support, nursing homes, supportive care

20

We have much to learn and little time

21Map of the US, 1802

22Map of the United States, 1826

23

Maps of the US, 1802 and 1824

Maps from the Smithsonian Institution Collection

24

Some Resources for Reform

Transitions - Transitions - http://www.cfmc.org/value/co/index.htm

Patients and familiesPatients and families • Web – www.growthhouse.org

• Handbook for Mortals (Oxford U Press, 1999)

PolicyPolicy• Sick to Death and Not Going to Take it Anymore! Reforming Health

Care for the Last Years of Life (U California Press, 2004)

Quality ImprovementQuality Improvement • Common Sense Guide to Improving Palliative Care (Oxford U

Press., 2006)