Sunday, December 13, 2009

How Will Pilot Programs Impact Geriatrics and Palliative Care?

In one of the most influential health policy journals of our time - the New Yorker - the surgeon Atul Gawande "calls out" our health care system for not supporting geriatrics:

[Our system] is neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.

This is not an article about geriatrics - Dr. Gawande wrote that article already. This is an article comparing the pilot programs included in the proposed health care legislation aimed at reducing costs to the successful pilot programs that revolutionized agricultural in the early twentieth century. The pilot programs, as I read them, have two aims: improving quality, and reducing costs, maybe not in that order. My question: how will geriatrics and palliative care be impacted by these pilot programs?

Let's focus on bundled payments, of the most promising pieces of pilot legislation. In bundled payments, health systems receive a single payment for all services related to a procedure. Let's take hip fracture repair, for example, and talk about an older patient with Medicare insurance served in a hospital with both a geriatrics and palliative care consult service (rare I know, but it's an example). My understanding - and please comment if you think I'm mistaken - is that all providers and services related to the hip fracture repair would receive a lump sum payment for that service, including the surgeon, the anesthesiologist, the nursing staff, the hospital, and the rehabilitation care. The bundled payment would be the average payment for these services. High cost providers would have incentives to reduce costs, and low cost providers would make money. This pilot is in stark contrast to our current system - fee-for-service - whereby each provider would bill Medicare separately for their portion of care: the surgery, the hospital care, the rehabilitation.

So how might geriatrics and palliative care be impacted by bundled payments? Let's say the post-operative hip repair patient becomes delirious due to poorly controlled pain. As we know, delirium is associated with worse outcomes, including death. What incentives does the surgeon or hospital have for including geriatrics or palliative care? One might argue that paying for a geriatrics or palliative care consult would treat pain more effectively and reduce delirium and it's complications, thereby reducing costs. The system should then self-regulate, and those that consult geriatrics and palliative care appropriately would realize the benefits in terms of reduced overall costs. But the concern is that geriatrics or palliative care might simply be dropped completely in a myopic move to cut costs.

Furthermore, some of our "interventions" do not translate well into reduced costs by way of the bundled payments. For example, a family meeting that results in non-surgical management of hip fracture, obviating the need for surgery in the first place.

I do believe we need payment reform. Fee-for-service is nuts. But I also believe we should proactively consider the practical implications of the pilot legislation on our fields.

I'm interested in the thoughts of others. Am I being pessimistic? Does anyone have thoughts on how other pilot projects - such as accountable care organizations, patient centered medical homes, and reformed payment for home health and rehabilitation care - would impact geriatrics and palliative care? Finally, kudos to Dr. Gawande for supporting geriatrics!

3 comments:

Tim Cousounis said...

"But the concern is that geriatrics or palliative care might simply be dropped completely in a myopic move to cut costs".
Surely, that's a concern. But of greater concern is that presently only a small minority of such patients receive a palliative or geriatric consult. My mother-in-law has just gone through a similar experience, received no such consult while in the hospital or rehab facility, and is now in a long-term care facility. Bundled payments, while not without inherent flaws, will at least encourage more coordiantion and collaboration among providers (institutional AND indivudual). Moreover, bundled payments will encourage greater compliance with evidence-based best practices.

Mike Steinman said...

I think Alex hit the nail on the head. In many circumstances, there is a strong economic case to make for increasing geriatric services, but not always. Thus, our best argument for increasing the role of geriatrics should combine the economic argument with a convincing appeal that it’s the right thing to do for patient, family, and community well-being.

The recent debate over cuts in Medicare payment for home care services comes to mind. That said, it would be a mistake for us to reflexively leap to the defense of current models of care without seriously weighing if we could do things better. For example, I don’t know much about the economics of home care, but I do wonder if there are ways to streamline home care services to reduce the costs while maintaining the benefits. Could we find ways of using less-skilled (read: less expensive) health care workers to meet existing needs? Could we do a better job of targeting services to patients and reducing hours for those with less need, or providing more hours to those for whom an extra boost could have a meaningful impact on preventing hospitalization and suffering? Could we do a better job of partnering with local institutions such as churches and synagogues to fill in the gaps? I don’t know the answer to these questions – and any changes will undoubtedly cause problems for some – but economic realities mandate that we get the most of our limited resources.

Dawn said...

All these pilot programs are too complicated for my simple mind. How about reimburse less for a hip replacement and more for a geriatrics consult? Watch the number of geriatricians rise and orthopods plummet. Or how about as a PCP, I get reimbursed the same for counseling a diabetic as a derm does for punch biopsying a mole? HEalth care reform done.