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)

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

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By permission of Johnny Hart and Creators Syndicate, Inc.

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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

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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

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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

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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.

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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

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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

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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

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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

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Caregivers – Politics and Needs

• Organize caregivers for political power

• Demand reasonable working conditions

• Demand a role in setting priorities

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Employee Work Force

• Change the skill mix for physicians

• Leadership positions for nurses, social

workers

• Fair labor practices for aides

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Tailor Care to Populations…

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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

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We have much to learn and little time

21Map of the US, 1802

22Map of the United States, 1826

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Maps of the US, 1802 and 1824

Maps from the Smithsonian Institution Collection

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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)