Monday, December 27, 2010

"Death Panels"

I read this yesterday. It's interesting to see how alarmed people can be when they think that the government is going to get involved in end of life decisions for patients. Conservatives worry that it is a way to "kill grandma." Economists hope that it will help save money be decreasing the costs of excessive care at the end of life (which only serves to make conservatives worry more). Some proponents of physician assisted suicide may even see it as the beginning of legalization of PAS. But from my perspective, none of those views are correct.

I spend half of my time in nursing homes and half of my time in the office. I also spend 10 weeks a year doing inpatient medicine in the hospital where I supervise residents and medical students. I probably spend about 2-5 hours per week talking to patients about end of life issues, mostly without being reimbursed.

End of life issues are tricky. It goes far beyond whether someone wants to be full code (CPR, intubation) or DNR/DNI. Most people I know are inbetween: do CPR/intubation if there is some chance of recovery but not if it causes permanent impairment (which is a medical impossibility to know). But even more than that, patients have ideas about everything from how often they want blood tests, to whether they want to continue mammograms to chemotherapy, major surgery, nursing home placement and how often to see a specialist. What I tell patients when I ask them about their goals of care is that every patient has different desires, goals, values and limits and there is no way I can tell what a patient wants by looking at them. So instead of guessing how aggressive a patient wants me to be in pursuing therapeutic care, I ask them what they want. That's it. I ask some further questions to clarify issues ("You don't want dialysis because...? What is your impression of chemotherapy?"). Currently, this type of conversation is not reimbursable (i.e. I don't get paid for it).

So what happens if this type of care is not reimbursed? Physicians often don't engage in this type of conversation. What happens when physicians don't engage in this type of conversation? Physicians guess what the patients want and often guess wrong. Sometimes physicians assume the person wants aggressive care and the patient ends up suffering through invasive procedures. Sometimes the physician assumes that patient would not want to tolerate anything and the patient is denied treatment options without their knowledge.

So from my perspective, what would be the result of reimbursing physicians for talking to patients about end of life issues? Patients would more precisely get the level of care that they want. What's wrong with that?

Now in all honesty, when it comes to most people, most people get more interventions done on them than they want and end up having to suffer more than they want to because they get talked into procedures/treatments or even yet physicians just do them without any meaningful consent. While more end of life discussions may lead to less aggressive care, increase use of hospice and cost savings, to me that is not the main goal or benefit. I would frame the benefit in terms of helping to increase the autonomy of patients be giving patients a greater voice in their end of life decisions rather than this being an intervention what would limit autonomy or coerce/impose patients to do things they don't want to do.

Here's a good commentary.

Wednesday, December 15, 2010

Medicare fee fix

As you may have heard, every year Medicare has to "fix" the medicare physician fee reimbursement to avoid having physicians get a pay cut. Every year we hear physicians voice concerns that if Medicare cuts physician fees by 25% or more, no physician will take Medicare patients anymore or that physicians will go bankrupt taking care of Medicare patients. Medicare patients and advocacy groups voice concern that doctors will limit their access. Deficit hawks argue that passing the "fix" will only make Medicare insolvent faster and/or increase the already alarming federal deficit.

Geriatricians are in a somewhat in a unique position among physicians in that our reimbursement is much more dependent on public health insurances than others. For example my patients are predominantly (>90%) Medicare and Medicaid (most nursing home patients have Medicaid). Without any question, a physician fee cut would hurt geriatricians more than any other specialty. Geriatricians are already the second lowest paying specialty next to pediatrics.

A little bit of math....If a geriatrician's net revenue is $300,000 and overhead is $150,000 and the physician is 100% dependent on Medicare and there is a 25% cut then while the net revenue will decrease by 25% ($75,000), if the overhead remains the same, income will be cut by 50% ($150,000 to $75,000). Now if a nephrologist has net revenues of $500,000 and an income of $250,000 and have 30% of their revenue come from Medicare, they would have a salary cut of $37,000 or 15% of income. Their salary would decrease from $250,000 to $213,000.
While a 15% cut in income is no small cut, it is hardly career ending when the starting salary is so high.

So what is my conclusion? A medicare cut would be devastating for the field of geriatrics which already has fewer and fewer new physicians each year (less than 250 in the country), while having a much smaller impact on other specialties. It would also affect primary care disproportionately as well. But part of me feels that the cuts ought to happen. The deficit can not be quickly wished away. The shortage of geriatricians and primary care doctors will just be prolonged and masked by the 1 year fixes. I would rather have the crises come to a head quickly and dealt with decisively rather than have 1 year fixes that prolong the financial disincentives that keep geriatrics to such a small field. In the long run, it is better to deal with the problem now, even if it is painful, rather than to drag it on slowly and painfully year after year.

My 2 cents.