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Ensuring Quality Of Life To The End

May 22, 2017
4:16 pm

As the value-based approach to healthcare delivery is gaining momentum, the focus on end-of-life care has moved towards center stage.  The benefits of palliative care and advance directives have proven to increase quality of care while decreasing the overall costs.  Particularly near the end of life, patients can have a wide range of preferences regarding where they want to be, how much treatment they want to receive, and how comfortable they want to feel.  It is important that caregivers and providers are aware of these preferences and have them documented.  Health systems and patient advocates alike have been working on educating both sides of the healthcare interaction – the physicians as well as the patients and their families – in order to help with coordination and communication about the patients’ needs and desires.

Premier, Inc ., a member of the Healthcare Leadership Council,  has been an acknowledged leader in communicating the vital role palliative care plays within the healthcare system.  Its CEO, Susan DeVore, wrote in the Health Affairs Blog about the growth in this area and how Premier has worked to improve the patient experience near end-of-life.  This piece is an excellent example of the private sector bringing value and quality to those who need it the most.  The post in its entirety can be viewed below, and the link to the original post is here.

 

The Humanity In End-Of-Life Care

Susan DeVore
May 19, 2017

Health care is personal, especially when it comes to caring for someone as they approach death. However, half of Americans feel they have too little control over end-of-life medical decisions.

As the industry moves toward a more holistic approach to care delivery, health care organizations are beginning to rethink how they treat patients and starting to embed end-of-life care plans into the overall approach earlier on, sometimes before people even become ill. In a recent report on end-of-life care by the Aspen Health Strategy Group, several principles are discussed that take a broader view around caring for seriously ill patients, helping to ensure that care is sensitive, aligned with patient and family wishes, and always working toward enhanced quality of life. One of the top recommendations in the report to achieving that end is increasing emphasis on palliative care.

Deemed the fastest-growing medical specialty in the United States, palliative care is interdisciplinary care (medicine, nursing, social work, chaplaincy, and other specialties when appropriate) that focuses on improving the quality of life for persons of any age with a serious illness, as well as for their families.

While a relatively new concept, palliative care has been increasing in prevalence, in part due to new value-based care incentives that promote an environment in which payment relies on not only treating the illness but keeping patients comfortable and, when possible, at home.

However, there is a significant misunderstanding about what defines effective palliative care among patients and providers. Palliative care is about proactive care, which can be used at any point in an illness. Unlike hospice, palliative care is not just for those who are dying; it can be delivered to anyone with a serious or chronic medical condition from the time of diagnosis, regardless of whether the patient is terminally ill, expected to recover fully, or facing years of chronic or progressive disease. It is often provided at the same time as curative medical regimens to help patients tolerate side effects of disease and treatment, while carrying on with everyday life. This includes social, emotional, and spiritual support, as well as advising families on how to care for their loved ones.

Effective Palliative Care Improves Patient Experience

In dealing with these illnesses at the time of diagnosis through palliative care, caregivers can greatly increase patient satisfaction and outcomes, while reducing costs. For example, one of Premier, Inc.’s (a health care improvement company) members, Presbyterian Healthcare Services, in Albuquerque, New Mexico, launched palliative care outpatient clinics in 2012 and now offers them at three primary-care offices and two oncology offices. In a 2014 cost comparison of patients’ costs in the six months before their first visit to a Presbyterian outpatient clinic to the six months after, hospitalization costs dropped by 19 percent, use of outpatient hospital services went down by 44 percent, and emergency department costs decreased by 79 percent. All of this was done while maintaining quality. And they’ve continued to expand these services by creating a more robust home palliative program with 24/7 access to trained professionals. Acute care hospitalization rates for these patients are now extremely low when compared to national or regional norms.

Research has also shown advantages in administering palliative care. In a randomized trial of patients with metastatic non-small-cell lung cancer, those assigned to early palliative care not only experienced a better quality of life and fewer symptoms of depression than patients receiving standard care, but they also lived more than two months longer.

Health systems in Premier’s quality improvement and population health collaboratives are sharing their best practices in palliative care and implementing effective models across the continuum to make them available in outpatient settings, nursing homes, and at home. They are also driving ongoing educational initiatives to improve cross-specialty generalist palliative care skills and ensure high-risk patients complete advance care directives. At Fairview Health Services, in Minneapolis, Minnesota, nearly all of the oncology clinic sites have interdisciplinary palliative care teams embedded within them. Physicians, social workers, and nurses work together to ensure cancer patients and their families are receiving timely emotional support and are prepared for future decisions using advance care plans.

These efforts are well-aligned with and supported by value-based care delivery and payment models, including accountable care organizations and bundled payment initiatives that require high levels of care coordination. For instance, last year Medicare began paying for voluntary advance care planning. This creates appropriate incentives for physicians, patients, and family members to spend time discussing patients’ health care wishes, which is just as important as having a life insurance policy.

Plan For The Care You Want

Advance care plans can be created even if you’re not ill. In fact, about 90 percent of people say that talking with their doctors and loved ones about their preferred care wishes is important. This includes writing legal instructions on treatments one would or would not want to receive. Patients who have these plans in place report greater satisfaction with their health care, based on how much treatment is desired, and have been shown to have lower costs of care.

Additional efforts dedicated to helping people talk about their wishes for future care, especially care delivered at the end of life, are underway. One that is focused on ambulatory practices and other sites of care is the Institute for Healthcare Improvement’s program, The Conversation Project. It has developed a starter kit to help people have conversations with family members or other loved ones about their wishes, should they become seriously ill.

However, definitions for palliative care standards and remaining fee-for-service incentives can stand in the way. As addressed in Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life, there are too few standards for professional institutions and other organizations to follow regarding advance care planning. In addition, lingering fee-for-service models incentivize volume over value, which can lead to care that may not be in line with patients’ wishes.

Therapies to treat diseases, especially those that are life-threatening, need to be balanced with therapies to relieve suffering or improve the quality of life in the process.

While progress is being made, we need to continue to think about how we fold standards of humanity into caring for the people we love, should they be faced with a devastating illness. Conversations about serious illness can be difficult to have, but they are essential to ensuring the care delivered is compassionate, wanted, and warranted.

Diving into Genomics at Datapalooza

May 03, 2017
2:15 pm

I had the privilege of moderating a panel at Datapalooza – the annual gathering of hundreds of leaders in health data innovation — that focused on innovations in genomic science, which are rapidly spurring discoveries in personalized medicine.  Clinicians face enormous challenges in keeping pace with evolving best practices in data management and implementing these technologies into routine care.  The panelists focused on how genomic sequencing could be utilized with today’s healthcare information technology infrastructure, and the most effective way to do so.

Keith Stewart, the Carlson and Nelson Endowed Director of the Center for Individualized Medicine at the Mayo Clinic, where he is also a professor of medicine at the Mayo College of Medicine, discussed the importance of understanding genomes.  He said that 24 percent of people who have their genes sequenced discover new medical findings.  Utilizing this information can lead to more precise treatment.  Personalized treatment means that patients have the capability of finding out which drugs will give them more or fewer side effects, and which will be more effective overall.  Different people react to drugs in different ways, and this advanced knowledge can significantly increase quality of life for those who would otherwise suffer from severe side effects.  Dr. Stewart questioned how genome sequencing results can be stored in a way that they can be easily referenced for treatment.  Mayo Clinic, he said, is working on a way to bring genomic sequencing directly to the consumer, without the need for a doctor as a middleman.

Emma Huang, associate scientific director for Janssen research and development, said that the entire health continuum — from prevention to interception to cure — can be pushed forward by genomics.  Models are being developed for integrating genomic data into predictive models in real time.  What the system is lacking is the deep data collection at a population level in order to predict with greater accuracy.  There are currently global initiatives linking human genetics and clinical phenotypes.  Ms. Huang specified that data needs depend on the stage of a patient’s health.  She declared that insights from genomic data need to be available and easily interpreted by patients to achieve results.

A major implementation barrier involves data transfer, flow, and interconnectivity.  Genomics data is rarely generated, analyzed, interpreted, and clinically implemented in the same system.  Mark Dunnenberger, PharmD, program director of pharmacogenomics at NorthShore University HealthSystem, said genomic data needs to be integrated into the system for true value and should be used alongside clinical data.  NorthShore opened the first pharmacogenomics clinic of its kind in 2015, and has recently expanded the offering with an at-home testing program, MedClueRX. Electronic health records were not built to handle the huge volume and complexity of genomic data, and the current method of saving patient information as pdf files does not provide discrete data and tends to get lost in the system.  Pharmacogenomics helps clinicians choose between therapeutically equivalent treatments that benefit unique individuals in varying ways.  Patients grasp the value of pharmacogenomics, Dr. Dunnenberger said, and are willing to invest money regardless of whether it is covered by insurance.

As our nation’s efforts to bring precision medicine the forefront of clinical care accelerate, we must take care to ensure we incorporate this data in ways that will be usable for clinicians and valuable for patients – without creating additional uncertainly or unsustainable costs.  As is often the case, HLC members are forging a path forward for others to follow.

The Power in Planning Ahead

April 17, 2017
4:53 pm

Now that most of us have filed our taxes for 2016, this is an opportune time to review our health planning with the same level of attention.  There is a nationwide effort to make the day after Tax Day “National Healthcare Decisions Day” – a day in which we think about our long-term healthcare needs and make a plan for how we would like to be cared for in our final days.  At one point or another, all families face challenges with advanced illness and must make decisions about end-of-life care, but too few of us have given thought to issues like designating power of attorney or creating advance directives and living wills.  Advanced illnesses cause many challenges for families.  One of the most difficult is when family members become the primary caregiver for their loved ones and are placed in decision-making roles that they never expected.  Advanced care planning is a useful tool that can assist individuals in preparing for end-of-life care, and keeping family members and healthcare providers updated on their wishes.

For individuals faced with end-of-life care decisions, it is important to have conversations with their physicians about their treatment options and their wishes regarding advanced illness care.  Studies indicate that patients and their families are interested in discussing their end-of-life options with their physicians.  However, there is concern that physicians may lack the training or resources to engage in long-term conversations with their patients on end-of-life healthcare decisions.   For instance, a recent survey of 736 physicians, link above, found that less than one-third reported any formal training on discussing end-of-life care with their patients and their families.

The Coalition to Transform Advanced Care (CTAC), a non-partisan organization, is collaborating with the AHIP Foundation on “The Advanced Care Project,” which offers suggestions for how healthcare professionals can help patients make their decisions about their end-of-life care needs.  A combination of education and collaboration on advanced care allows for patients and family caregivers to develop their own care plan that is specifically designed to fit their needs.

Healthcare plans and providers are embarking on their own initiatives to assist and ensure that patients are able to make their own decisions about their healthcare.  For instance, Aetna offers support to its members through its Compassionate Care Programs, in which individuals experiencing end-of-life care are assisted by nurse care managers who are available to provide resources to patients and their family members, as well as assist physicians in managing the care of the patient.   The Franciscan Missionaries of Our Lady Health System in Louisiana is collaborating with the Louisiana Health Care Quality Forum in the Louisiana Physician Orders for Scope of Treatment (LaPOST) initiative on how a patient’s desires and goals into their treatment plan can be medically translated and applied to multiple healthcare settings.

SCAN Health Plan has constructed a new system to make it possible for patients and their families to understand the full array of care options available to them and to receive treatment that best fits their values, goals, and cultural preferences.  This system is called the Program for Advanced Illness (PAI). A palliative-trained nurse case manager serves as the member’s personal advocate.  The nurse will help members and their caregivers navigate care options that reflect patient’s goals and wishes, encouraging articulation and documentation of end-of-life requests while identifying healthcare proxies and making referrals to hospice.  Additionally, the nurse will communicate with all medical staff and other parties to ensure everyone understands the critical decisions being made as well as following up with the family to offer bereavement services.  More program details are available in the Viable Solutions compendium recently released by the Healthcare Leadership Council.

On National Healthcare Decisions Day, let us continue to have the conversation about how healthcare providers can best assist individuals in making their own decisions about their health care needs.  Create an advance directive and talk to your family and friends about the importance of care planning.  Visit www.nhdd.org for more information.

The Mythology of Safe, Cheap Drugs from Canada

February 24, 2017
1:54 pm

In January, the U.S. Senate rejected legislation, as it has multiple times in the past, which would have allowed the importation of prescription drugs from Canada.  Apparently believing that a bad idea can never have too much exposure, some senators are reportedly poised to bring drug importation up for another vote.  The evidence on this issue hasn’t changed and neither should the outcome.

Last month, the Congressional Research Service provided lawmakers with a report on the safety of the Canadian drug supply that should have put this issue to rest once and for all.  The report, compiled by a Senate committee in Canada, illustrated the differences between the rigorous drug safety infrastructure maintained here in the United States and the protocols in other countries which are, well, less extensive.  While both Canada and the U.S., for example, import ingredients used to manufacture prescription medications, the U.S. Food and Drug Administration conducts hundreds of inspections at foreign manufacturing facilities each year.  Canadian authorities conducted only 14 in 2013 and 2014.

This is of particular concern when drug counterfeiting is becoming a global crisis.  Putting a crack in our closed drug inspection-and-approval system with importation legislation will place American patients and consumers at unnecessary risk.

What Congress should keep in mind is that laws already exist to permit drug importation from Canada.  The Secretary of Health and Human Services has the authority to permit drug imports, under the Medicare Prescription Drug Improvement and Modernization Act of 2003, if it can be certified that such action will generate substantial cost savings while protecting public safety.  No HHS Secretary in either Democratic or Republican administrations has ever made that certification.

There’s no doubt that drug importation is one of those crowd-pleasing issues that looks good on paper.  The reality is, though, that it offers very little, if any, gain for consumers while carrying a very high potential cost that is simply unacceptable.

Walden Discussed Repeal and Replace Strategies at HLC Meeting

January 26, 2017
3:06 pm

On January 24 at a dinner hosted by the Healthcare Leadership Council for its members, U.S. Representative Greg Walden (R-OR), the new chairman of the influential House Energy and Commerce Committee, spoke of his panel’s goals for the upcoming healthcare overhaul.  CQ Roll Call published the following article based upon his prepared remarks.


CQ: Walden Outlines Obamacare Strategy to Health Care Executives By Joe Williams, CQ Roll Call

Energy and Commerce Chairman Greg Walden was poised Tuesday night to outline to health care industry executives his panel’s strategy for repealing and replacing the 2010 health care law, including insights on his plans to overhaul Medicaid.

The Oregon Republican planned to use his closed-door meeting with the Healthcare Leadership Council to discuss several measures his panel would consider in the coming weeks, according to prepared remarks obtained by CQ Roll Call.

A pair of hearings to be scheduled for late next week will center on stabilizing the health insurance marketplaces and on Medicaid. Walden is working with Senate Finance Chairman Orrin G. Hatch of Utah on changes to Medicaid, which provides health insurance to more than 73 million Americans.

Walden planned to confirm during his speech Tuesday night that Republicans will model their legislation largely on a repeal bill President Barack Obama vetoed last year.

“We will use our 2015 reconciliation bill as a starting point in order to repeal major portions of Obamacare, such as the individual and employer mandates, and address the Obamacare Medicaid expansion and the failing exchanges,” Walden’s prepared remarks say. They also say a “stability period” would be included in the legislation.

Walden also is expected to say that Republicans will “maintain protections for those with pre-existing conditions” and permit children to stay on their parents’ insurance plan until age 26, two provisions in the current law (PL 111-148, PL 111-152) that President Donald Trump has voiced support for keeping in a replacement plan.

In his prepared remarks, Walden calls on the Healthcare Leadership Council to engage publicly in the health care debate. The group includes executives from hospitals, insurers, pharmaceutical companies, medical device manufactures and other industries.

“We can’t do this alone. But by working together . . . we can reach our mutual goal of helping people live healthier lives and giving every American a new opportunity to get affordable health care coverage,” Walden will say, according to the prepared remarks.

Changes to Medicaid

Walden’s remarks don’t detail how the GOP would address the 2010 law’s Medicaid expansion, but he confirmed to CQ Roll Call earlier in the day he has had several meetings with Hatch to discuss their legislation on changes to the program.

Earlier this month, Walden organized a meeting between Republican lawmakers on his panel and GOP governors to discuss potential changes to Medicaid. He also attended a separate but similar meeting organized by Senate Finance.

A top aide to Trump said earlier this week the president would propose turning Medicaid into a block grant system. Some GOP governors at the meetings last week, however, suggested a per capita approach that would explicitly require the federal government to incorporate enrollment changes when determining reimbursement rates.

J. Mario Molina, president of Molina Healthcare, told CQ Roll Call both Republican and Democratic governors are likely to push for a per capita approach because it would account for potential increases in each state’s Medicaid population.

“This is going to be a debate between the states and the federal government as to how best to continue this entitlement program while trying to rein in costs,” he said in a recent interview.

Others Republican governors, including Gov. John R. Kasich of Ohio, proposed lowering the Medicaid coverage threshold to 100 percent of the poverty level and allowing people with income above that amount to get exchange coverage. The law’s expansion provides Medicaid coverage for individuals up to 138 percent of the poverty level.