From bone marrow cancer breakthroughs to drug development to treat blood cancer, medical research finds new ways, daily, to keep sick patients alive longer.

But the American obsession with having “the best health care” is not only costing billions annually—it is often taking the dignity out of a patient’s end days.

The system is broken, according to Richard Meyer, executive director for Online Strategic Solutions. Most patients want to spend their last days at home, but 75 percent either die at a hospital or nursing home. Meyer’s research study, conducted with cancer patients, found that many terminally ill patients “do not want to go through extensive treatments that have horrible side effects if there is no hope of a better quality of life.”

The problem, according to a Dartmouth Medical School’s Dr. Eliot Fisher is supply and demand. Fisher noted in Meyer’s research that hospitals need beds full of paying patients to bill their bills. And Medicare is restricted by law from denying patients the treatments required, based on cost.

“The real problem,” Dr. Fisher notes, “is that many of the patients that are being treated aggressively, if you ask them, they would prefer less aggressive care. They would prefer to be cared for at home. They’d prefer to go to hospice. If they were given a choice. But we don’t adequately give them a choice.”

Meyer notes that patients are too quickly sent from their overloaded GPs to hospitals, where they see a flurry of disconnected specialists who order tests, needed or not.  The result is patients receiving all kinds of costly and often unnecessary treatments for the underlying complications to their disease.

Last year, $55 billion was spent for doctor and hospital bills in the last two months of patients’ lives. Of that amount, research shows that 20 to 30 of the treatments had “no meaningful impact.” 

Dr. John Schumann, an internist with University of Chicago, calls hospitals “factories” and no place for the dying.

 “Hospitals are like giant factories where all the focus is on process: diagnosing, treating, rehabbing, and discharging. Death, while a natural endpoint, is still too frequently viewed as medical failure. Nothing could be further from the truth.”

Schumann argues that the patients and their families need to advocate loudly for the patient’s wishes:  to listen to their desire for how they want to end their life.

“I’d like to empower the folks … especially their family members and loved ones, who will be called on to help with decision making, to take the initiative and die at home. Or in hospice. Or on a mountain top in bright sunshine.”

Though the bill allocates in the neighborhood of $27 billion, it does not add to the deficit as the money generated by spending cuts and by closing a business tax loophole will cover the cost. The measure was approved by a 61 to 39 vote in the Senate last week. The majority was comprised of 57 Democrats, 2 Independents, and the ladies from Maine – Republicans Susan Collins and Olympia Snowe. 39 Republicans voted against the bill, many on the basis that it is a breach of ordinary federal-state relations.

The House has been called back early from its six-week August recess to vote on the measure tomorrow. Democratic Party leaders expect the House vote to go smoothly with an easy approval. However, though the bill does not increase the deficit some representatives whose districts are vulnerable this fall feel they’re again being asked to “walk the plank” with their party on an unpopular economic-stimulus issue. Vulnerable Democrats are especially irritated at being called back from vacation given they’re already defending their seats because of Senate inaction during the dragged out healthcare debate and budget debates. As a result of this many House Dems have become less responsive to party whips, making estimating a vote count difficult.

Though most legislators agree that states burdened with budget gaps desperately require the funds to keep teachers employed and Medicaid enrollees in the program, Republicans contend that calling House members back from recess to vote on a bill that stalled after two weeks of partisan posturing will reinforce popular perception of Dems as ineffective leaders. This narrative that Dems are haphazard and not unified in their approach to the recession and unemployment will likely be reinforced by Friday’s monthly jobs report, GOP spokespeople argue.

State Aid Bill Extends Funds for Medicaid

Conversely, House Democratic leaders see the bill as a win-win worth the admittedly messy passage as it will create jobs and respond to urgent budget concerns without raising the deficit.

Unfortunately, a new problem has arisen for nurses and those who depend on their care. This year though there aren’t enough nurses out there to care for the sick, there are also many new RNs standing in unemployment lines. How can there be such a huge demand for nurses and simultaneously a crowd of nurses with nowhere to work?

As a result of the recession the job market is flooded with more experienced RNs who’ve come out of retirement, delayed their retirement, or moved from part- to full-time employment in order to stay above water during hard economic times. These experienced nurses have therefore taken many of the jobs and hours which would in normal years be available to new nursing school graduates. One survey of new Arizona RNs revealed 21% licensed in the last year lacked nursing jobs with most respondents citing “not enough jobs for new RN grads in the area” as the reason. Because experienced nurses have taken (or are not retiring as planned from) the better-paying hospital jobs they would normally have applied for, new nurses are instead applying to nursing homes and home health care positions. New nurses are also having to be flexible about location and shifts when applying for the few nursing positions open. Alternatively, many have wound up in non-nursing jobs like waitressing, just happy to have employment and some have even switched careers out of nursing entirely.

New Nurses Can't Find Work This Year

When the economy improves health industry experts expect a wave of retirements, opening the job market to young nurses. Industry experts are hopeful that once the recession passes, new RNs will see a job market like that of the early 2000s where graduates could choose between multiple job offers.  However, they further say it is critical for policy leaders to find ways to keep newly minted nurses in the profession through the recession so that projections for nurse shortages in the future won’t get even worse.

Entitlement Reform: What happens when Medicare and Social Security Are Bankrupt?

This threat has been looming in the background for years, and though successive administrations have “kicked the can” down the road we must confront the fact that the financial health of our two major entitlement programs has withered more during this recession than at any time since the mid-1990s. Though the economic downturn has contributed significantly to the programs’ rate of decline given the fact that worsening unemployment figures mean fewer workers are paying into the trusts’ funds through payroll taxes, the pressure of baby-boomers aging into the programs has pushed their financial health to the breaking point independent of current economic conditions.

These facts point glaringly to the need for entitlement reform. Obama administration officials have suggested that if the legislature were to act the programs’ insolvency could be bridged in three ways: by raising workers’ Social Security payroll taxes by 2 percentage points, by reducing benefits by 13 percent, or by a combination of the two.

Electronic Medical Records On the Rise

Doctors are notorious for their messy, often illegible handwriting that can often produce doctor errors.  One optometrist, Meera Sutaria, reported that investing in such technology increased her office’s efficiency.  Because there were fewer issues with paperwork, Sutaria was able to spend more quality time with patients. Computerized records save paper, and make it easier for other doctors to read and access patient information, especially in the emergency room, where doctors often have limited access to patient information.  One Wisconsin doctor, Dr. Ashok Rai, has waited for hours just to receive faxes for his out-of-network E.R. patients, which could easily have been avoided had other doctors outside his hospital made use of electronic records.

Proponents of EMRs point to the reduction of paperwork and increased readability as a great way to streamline and manage healthcare. In a world where health care costs are exploding, saving money is incredibly important.  Kaiser Permanente, a company that revolutionized medical records, found that computerized records helped track vaccine safety in a study of young children. In this society, where patients can be seeing multiple doctors and specialists, it is necessary to have a way to quickly share information with other providers.  Electronic medical records can improve quality of care for patients, ensuring that they do not undergo duplicate or unnecessary procedures. Plus, electronic medical records might be able to streamline the insurance claims process, paying doctors instantly in real time.

Not all doctors or hospitals make use of computerized records today.  In fact, electronic medical records are in the minority rather than the majority.  Providers who do use such medical technology may use it in different ways or to different extents. However, I feel that an expanded, unified system will truly be able to streamline care if (and only if) it is executed properly.

Opponents of Health IT argue that the shift from paper to computer may actually result in higher costs. Providers may charge patients to afford new health information technology. Other providers, including Kaiser Permanente—a Health IT leader—fear that they won’t qualify for subsidies under the government’s new meaningful care standard, which may be too strict to start off with. However, so long as the government places guidelines that ensure high quality of care for patients, poor quality can be avoided.  Servers and databases must be guaranteed secure in order to prevent hacking and identity theft.

Ultimately, I feel that widespread adoption of electronic medical records will only be helpful for the health care industry. First of all, the government must ensure the safety of patients’ personal information. And providers need to step up their efforts in modernizing now so that they can benefit from the subsidies.

CVS Pharmacy Subpoenaed Regarding Discount Drug Program

CVS and the Connecticut Attorney General’s office have sparred on this issue once before. Last session, when CVS officials disagreed with the state’s interpretation of the law the General Assembly passed a bill which clarified the requirement that pharmacies charge CT Medicaid the lowest price offered to consumers. But even now, with little ambiguity left in the law, CVS claims it should not be required to fulfill this obligation because the program was originally developed for uninsured and underinsured individuals, not with Medicaid recipients in mind. Because CVS on its member enrollment forms reserves the right to cancel the voluntary program for any reason, and because it is not required to continue the program by law, the company may indeed terminate the program if Blumenthal continues to push CVS.

CVS has until July 9 to comply with the Attorney General’s subpoena for information on CVS’s threat to cancel the program in Connecticut, which Blumenthal claims is inconsistent with the company’s practices in other states where CVS and other pharmacies have extended their discount drug program to Medicaid beneficiaries. Blumenthal – currently a candidate for Senate to replace retiring Senator Christopher Dodd (D-CT) – hopes his office will be able to force CVS to comply with the law and its practices in other states, as extending this program to Medicaid enrollees would save thousands of pharmaceutical cost dollars, helping to rein in out of control health care costs.

If Blumenthal is unsuccessful, the thousands of uninsured under-65′s and Medicare beneficiaries who rely on the program to stay out of the donut hole coverage gap may find their discount prescription drugs in jeopardy.

The following are considered “unsolicited contacts and in violation of MIPPA:”

• Generally, use of old lists or consents to satisfy the new MIPPA rules regarding unsolicited contacts
• Referrals of beneficiaries and/or their contact information resulting in an unsolicited contact are prohibited by the new guidance.
• Members who are voluntarily disenrolling from a plan should not be contacted for sales purposes or be asked to consent in any formant to further sales contacts

Provider Marketing

It is “inappropriate for providers to be involved in any of the following actions”:

• offering sales/appointment forms,
• mailing marketing materials on behalf of plans,
• making phone calls or steering beneficiaries, in any way, to a limited number of plans

In addition to making draconian cuts to the Medicare Advantage program, the bill largely increases the number and cost of beneficiaries in Medicare. For example, both the House and Senate bills reduce the coverage gap, or “doughnut hole” in Part D coverage by $500 beginning in 2010. Other additions include increased benefits for dual Medicare-Medicaid eligible and eliminating cost-sharing for preventative services (beneficiaries will not have to pay for any of the cost). Such great cost reduction is certainly an enormous benefit for any senior, but puts a new strain on the need for more Medicare funds.

Additionally, the Senate bill plans to tax companies receiving prescription drug subsidies. Since 2003, companies that continued to provide their own prescription drug benefits qualified for a 28% tax-free subsidy (about $600 per year per retiree). The advantage for companies was the ability to list the subsidy as a reduction to their retiree health liability. The Senate bill will tax the subsidy, thus increasing companies’ tax liabilities and companies will be required to register the change as a loss in earnings.

The response expected from these companies will be to no long provide prescription drug benefits on their own. Thus, the cost falls back on Medicare who will see a dramatic increase in Part D beneficiaries. Increasing the number of Medicare eligibles will only add fuel to the fire: these change merely bring the day of reckoning for Medicare closer than 2016.

The members of the council would be given the authority to make broad recommendations about Medicare, but they would focus on setting appropriate payment rates for Medicare Part A and Part B. The council would give two annual recommendation reports: the one due by October 1st of each year would deal with Medicare Part A and the one due by December 31st of each year would address Part B. These recommendations would be sent to the White House for the president’s approval before being brought before Congress. This legislation, if enacted will go into effect after Obama’s first term as president on September 15, 2014.

Other proposals are also being given consideration with respect to Medicare. In particular, the Obama administration wants to give the Medicare Payment Advisory Commission (MedPAC) the authority to determine cuts and makes other changes to Medicare.