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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, [email protected]
(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?
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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
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21Map of the US, 1802
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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)