A study of spending patterns finds end-of-life healthcare spending begins far earlier than the last few months of a patient's life. Nearly half the Medicare patients studied had high spending throughout the entire final year of life.
Nearly half of Medicare patients' end of life healthcare spending begins a full year before their deaths rather in the few months prior to death, a study by University of Michigan researchers shows.
"We were expecting to find the most common pattern to be explosive healthcare spending in the final months of life. In fact, only 12% of older adults in our study showed this 'late rise' pattern of healthcare spending," said lead author Matthew A. Davis, PhD, MPH.
He is an assistant professor at the U-M School of Nursing and member of the U-M Institute for Healthcare Policy and Innovation, said in a news release.
The spending pattern was tied to multiple physician visits and regular hospitalizations for care of multiple chronic conditions rather than one specific disease.
After analyzing data from the Centers for Medicare & Medicaid Services, which included a sample of nearly 1.3 million Americans aged 66 to 99 who died between 2011 and 2012, Davis and his colleagues identified four end of life spending patterns:
High Persistent
Nearly half the Medicare patients studied had high spending throughout the final year of life.
They also had the highest Medicare costs—around $59,394—with twice as many outpatient visits to medical specialists as the three other groups.
They were more likely to spend time in hospitals, skilled nursing facilities, and use life-prolonging treatments like dialysis or feeding tubes.
Moderate Persistent
This group (29 % of patients studied) began their final year with moderately high amounts of spending, then spending dipped for a period of time, and then rose again in the last few months of life.
Their cost of care during the final year was $18,408.
Progressive
Only 10% of those studied fell into this group, but these patients had the second-highest costs, with a median of $37,036.
Their spending was very low at the beginning of the last year of life, but rose steadily throughout the year. They were also most likely to use hospice care.
Late Rise
This group (12% of those studied) spent just $11,166 in median health care costs in their final year.
They had very low health spending until a few months before they died, far lower numbers of physician visits and hospital stays, and no or few chronic conditions.
They were more likely to die during a hospital stay that included time in an ICU and had the second-highest use of life-prolonging treatments.
Conclusion
"Our research points to having to do a better job taking care of people who have multiple chronic conditions in a way that maintains or improves the quality of care they receive, but with cost in mind," Davis says.
Frustrations and disappointments are reported on both sides of the employment coin. Not running a practice doesn't necessarily translate to fewer administrative responsibilities.
Job satisfaction among employed versus self-employed physicians is virtually tied, at 72% and 73% respectively, according to Medscape's Employed Doctors Report 2016.
The nuances of what pleases and irks physicians in both camps, however, depend partly on where physicians practiced before and their expectations around new opportunities.
The national survey of 3,960 employed physicians and 1,027 employed physicians across specialties.
While 27% of employed physician respondents to the latest survey were previously self-employed, just 13% of self-employed respondents were previously employed.
This gap speaks not necessarily to a lack of interest among physicians in regaining autonomy over their practices, experts note, but to the difficulty of switching back to independent practice after signing employment contracts, many of which involve non-compete agreements.
Although 47% of respondents plan to stay in their current positions for at least another year, in part because of the aforementioned hurdles of leaving, the remaining 53% are contemplating some sort of change.
Among previously employed physicians who overcame such challenges to become self-employed, 71% say the move has increased their job satisfaction.
Conversely, only 40% of physicians who switched from self-employment to employment report greater happiness, perhaps skewed by the 13% of employed physicians who said it wasn't their choice to become employed (i.e., they were forced to sell for financial reasons or by being out-voted by partners).
Just 15% of employed physicians said they chose the route as a means to cut down on their administrative responsibilities, compared to 29% in the 2014 survey.
This drop may illustrate physicians' realization that not running a practice doesn't necessarily translate to less paperwork, as employed physicians still have to manage referrals, EHR documentation, and quality reporting, sometimes even more so than in private practice.
While a combined 40% of employed physicians frequently (7%) or occasionally (35%) disagree with their employers about patient care, a total of 61% report disagreements with employers about workplace policy, particularly regarding hiring and firing, according to the report.
Nonetheless, almost two-thirds (63%) of employed physicians report a good relationship with leadership, possibly due to more physicians getting a seat at the table themselves as organizations increasingly recruit doctors into leadership roles.
Changes in benchmark premiums vary widely from market to market, ranging from a decrease of 13% in Providence, RI, to an increase of 18% in Portland, OR, analysts say.
Benchmark silver plan premiums will increase an average 10% in 2017 across 14 major metropolitan areas, according to a recent Kaiser Family Foundation analysis.
Savvy price shopping by consumers could blunt much of the impact, however.
The analysis is based on proposed rate filings in 13 states plus the District of Columbia where complete information is currently available.
The focus was on premiums for the second lowest-cost silver plan, the basis for enrollees' tax credits. About two-thirds of the Patient Protection and Affordable Care Act marketplace enrollees choose silver plans.
The projected 10% average increase, weighted by 2016 state marketplace enrollment, is higher than in the previous years.
The report notes, however, that most health insurance marketplace customers who receive premium subsidies under the ACA can lower their costs by moving to one of their market's lowest-cost plans.
Changes in benchmark premiums vary widely from market to market, ranging from a decrease of 13% in Providence, RI, to an increase of 18% in Portland, OR.
As in past years, the current report finds insurers are again reordering themselves in terms of cost. In nine of the 14 major cities, at least one insurer with one of the two lowest-cost silver plans in 2016 isn't among the two lowest-cost silver plans in 2017.
Consumers receiving tax credits must pay attention to those shifts to avoid inadvertently paying a larger share of their income on premiums.
Increases of 10% or more are significant, but they do not necessarily have to hit a consumer directly.
The Kaiser report offers this example of how the rate changes and other factors can affect an individual and sometimes result in no negative effect: In 2016, a 40-year-old single enrollee making $30,000 per year would have paid about $208 per month in most areas of the country, and a similar person would pay approximately the same in 2017 even with premium caps increasing.
The poverty guidelines are also changing such that a single person making $30,000 would be at a slightly lower percent of poverty than he or she would be this year, the report explains.
The two changes cancel each other out, leaving monthly payments for the benchmark plan very similar from year-to-year.
The report stresses, however, that such stability in premium payments may require enrollees to switch plans. Staying with the same plan from one year to the next is more likely to result in paying higher premiums without receiving additional benefits, but consumers are likely to shop for a lower-cost plan.
The report cites a research brief from the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) which found that about two-thirds of Healthcare.gov enrollees actively shopped in 2016, including 43% of renewing enrollees and all new shoppers.
The number of insurers participating in 2017 ACA marketplaces in half of the states studied, plus the District of Columbia, will hold steady or increase relative to the beginning of 2016, the analysis finds.
The other states will see a net decrease, often as a result of the withdrawal of UnitedHealth.
Complete 2017 rate information isn't yet available for all states, and plans' final rates may differ from the proposals as a result of each state's rate review process. Kaiser intends to update the analysis as more rate information becomes available.
The 25 bicycles in the Free Cycle program and all bike stands prominently feature the Colorado hospital's logo. Bikes are available to the entire community.
The Castle Rock, CO-hospital is subsidizing the local bike-share program, enabling all eligible community members to rent a bike for free all summer.
"When we initially came into the community, we wanted to try to offer and subsidize wellness programs that are free," Christine Alexander, director of marketing and public relations for Castle Rock Adventist Hospital, told a local news outlet.
"We didn't want cost to be a barrier to offer wellness programs."
The Castle Rock FreeCycle program, which is in its fifth year, reportedly cost about $20,000 to launch by purchasing bicycles, bike racks, and a website, and costs $2,500/year to maintain.
In addition to promoting good health, the initiative boosts the hospital's brand awareness. The bikes, bike stands, and website all prominently feature the organization's logo.
"We think our role as a hospital is not just to provide healthcare services, but also to help the people in our community," said Todd Folkenberg, Castle Rock Adventist Hospital CEO. "This way, it's accessible and available to the entire community."
The program has 25 bikes that are available at four locations throughout the city. To help keep maintenance costs down, the hospital partnered with local bike shop, which has agreed to make repairs for free.
"Everyone knows that being physically active makes us look and feel better, but did you know that it helps you fight off illness, stress and fatigue as well?" reads the copy on the hospital's webpage promoting the free cycling program.
"It is our goal to provide our associates and the community with many different opportunities for physical fitness in order to meet each individual's needs and goals."
Since the program's inception, it has serviced 400 unique users, many of whom rented a bike multiple times throughout the summer.
This season, new signs have been added to the bike racks to promote and explain the program.
Viewers are driven to thosegreenbikes, which is hosted by Navigators Marketing Group, another program partner.
Chicago judge rejects FTC claims that the merged health system would stifle competition and violate antitrust laws.
A federal judge on Tuesday cleared the way for a merger of two of Chicago's biggest health systems.
U.S. District Judge Jorge Alonso rejected the Federal Trade Commission's bid to block the merger of Advocate Health Care and NorthShore University Health System.
In a six-day hearing last month, FTC lawyers had argued that the proposed merged system, to be called Advocate NorthShore Health Partners, would enjoy a near monopoly that would stifle competition and result in higher costs for healthcare consumers.
The FTC had sought an injunction to stop the merger so it could hear the issue in an administrative court.
In a brief statement, Debbie Feinstein, director of the FTC's Bureau of Competition, said: "The Court's ruling is disappointing and we will be considering our options."
Alonso's full ruling remains under seal because of "competitively sensitive information," but a public version will be released later this week, the judge wrote.
Executives from the two health systems were clearly pleased by the ruling.
"Judge Alonso's decision reaffirmed what we have wholeheartedly believed since day one—this merger is a big win for consumers and for healthcare in our country as the shift to value takes hold," Advocate CEO and President Jim Skogsbergh said in prepared remarks.
"We look forward to rolling up our sleeves and getting to work together to deliver on our commitment of making healthcare more affordable while raising the standard of care."
NorthShore President and CEO Mark Neaman said that by "bringing together our two very strong and complementary institutions we are creating a patient-centered 'system of systems' that will deliver exceptional care and unprecedented access for those who matter most–our patients."
If finalized, ANHP would serve more than 3 million patients annually, making it the 11th largest not-for-profit health care system in the United States.
Skogsbergh and Neaman will be co-CEOs of ANHP for a designated time. The ANHP Board of Directors will be comprised of an equal number of members from both Advocate and NorthShore. The organizations are consolidating financial statements.
Advocate and NorthShore first announced the merger in September 2014. After a 15-month review, the FTC opposed the merger in December 2015 setting the stage for a federal court hearing this spring.
Evidence has been found linking disparities in post-operative management with poor recovery, quality of life, and mortality outcomes.
Evidence links disparities in post-operative management "with worse functional recovery, quality of life, and mortality outcomes."
But more research is needed into the links between post-operative care and healthcare disparities for surgical patients, researchers affiliated with the American College of Surgeons conclude.
"Few studies have investigated longitudinal outcomes after surgery," the authors write in a study published on the website of the Journal of the American College of Surgery. They reviewed 328 studies.
In the past, researchers had focused on three categories of factors linked to disparities: patient, provider, and systemic.
For this study, they also considered two more: "…the quality of care across hospitals and the impact of variation in hospital quality on surgical outcomes."
Some researchers found that racial and ethnic minorities receive less palliative care, but noted that more research into disparities in end-of-life care is needed.
Looking beyond the operating room, evidence was found linking disparities in post-operative management with poor recovery, quality of life, and mortality outcomes.
'Significant Gaps'
Researchers also concluded that "even in an inpatient setting with equal access to rehabilitation care, racial/ethnic minority patients experience [fewer] functional gains when compared with white patients."
Still, they called research in this area "scarce."
The findings "suggest that, despite significant advances in identifying the presence and etiologies of disparities in surgical outcomes, significant gaps in the literature remain."
Hospital characteristics found to be associated with improved surgical outcomes include:
Use of quality improvement strategies
Application of clinical guidelines and surgical protocols,
Use of supportive technology such as electronic health records, and
A patient-centered culture that focuses on patient satisfaction and shared decision-making
In April, that National Institutes of Health announced a program to support research into disparities in surgical services.
Projects include an evaluation of the benefits of regionalized care versus "strengthening" of safety-net hospitals.
Researchers will also look at evaluating the long-term effect rehabilitation support on functional outcomes, as well as seeking patient opinions on the quality of surgical care.
Nine out of ten solo practices plan to minimize Medicare volume to avoid filing quality and clinical practice improvement reports or cost performance reports to CMS, survey data finds.
Federal legislation that aims to improve healthcare quality and reward those improvements with incentives tied to reporting bodes ill for the dwindling supply of small physicians practices that accept Medicare.
The culprit is the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA), which passed in 2015.
A BlackBook Research survey of 1,300 physician groups of five or fewer clinicians found 67% of such physician practices believe their independence will end with MACRA.
Solo practitioners make up 17% of physician practices; 22% of physicians work in practices of no more than four doctors, according to the AMA.
The Centers for Medicare & Medicaid Services is in the midst of reaching out to small practices get up to speed with MACRA, which will begin to affect Medicare payments in January 2017.
Despite this, the BlackBook survey, conducted in May, found that 89% of solo practices plan to minimize Medicare volume to avoid filing quality and clinical practice improvement reports or cost performance reports to CMS.
More than three out of four (77%) of physician practices are struggling financially, the BlackBook survey found.
"Physician payment based on 2017 performance isn't scheduled to kick in until 2019," said BlackBook managing partner Doug Brown in a media statement.
"That's far too long to maintain operations for the most-stressed practices to hold on with outmoded technology and scarce billing support."
Before 2019, 78% of independent primary care physicians surveyed expect to join a bigger group or integrated delivery network (IDN) to access reporting and revenue cycle tools and support, BlackBook found.
Of practices with 10 or fewer practitioners, 63% remain unsure which health information technology and products meet their needs for meaningful use, clinician usability, interoperability and coordinated claims and billing, the survey found.
A full 55% plan not to make any technology shifts or purchases until they decide whether to be acquired by larger practices or IDNs.
Comments on CMS's proposed rulemaking on MACRA are due to CMS on Monday, June 27. CMS is accepting comments electronically.
Some of the solutions proposed to make health IT safer for patients revolve around improving clinical documentation, health IT workflow, interoperability, and medication management in EHRs.
Five years after the Institute of Medicine concluded that the market has failed to keep patients safe with respect to potential safety hazards introduced by health IT, the HHS Office of the National Coordinator has published its first report surveying evidence of health IT safety concerns.
ONC, which commissioned the 2011 IOM report, includes with its report a survey of recommended corrective action from sources around healthcare and the healthcare IT industry.
The findings, described in an ONC blog post last Friday, aggregate health IT research conducted over the past several years by the AMA, AHIMA, AMIA, AHRQ, the VA, The Joint Commission, the National Quality Forum, academic journals, and HHS itself.
Some of the solutions proposed to make health IT safer for patients revolve around improving clinical documentation, health IT workflow, interoperability, and medication management aspects of electronic health records.
Both were prepared for ONC by RTI International, a nonprofit research institute based in San Francisco.
In the evidence report, the most common reason cited for placing orders for the wrong patient was interruptions while writing the order.
Other contributing factors included incorrect entry of patient name or number, small font sizes, failure of one provider to exit the system before another logged on, and choosing the wrong patient from a list of patients.
The 2011 IOM report recommended that all health IT vendors be required to publicly register and list their products with the ONC.
It further suggested that ONC specify the quality and risk management process requirements which health IT vendors must adopt, focusing on human factors, a culture of safety, and usability of health IT products and technologies.
Last year, ONC released a five-year plan to create a federal Health IT Safety Center. Despite this detailed Obama administration proposal, Congress has yet to fund the creation of such a center.
Reductions in deaths from cardiovascular and cerebrovascular disease are likely to drive spending on mental disorders even higher, as more people survive to older ages when mental disorders become more prevalent.
An estimated $201 billion was spent in 2013 on mental disorders in the United States, more than any other medical condition, according to a study released by Health Affairs.
Behind mental disorders in order of spending from high to low are heart conditions, trauma, cancer, and pulmonary conditions, which round out the top five. Next are osteoarthritis, normal birth, diabetes, kidney disease, and hypertension.
The study estimated health spending by medical condition for the entire United States population. The estimates were developed under contract to the Commerce Department's Bureau of Economic Analysis.
They include health spending by the military and institutionalized populations and are benchmarked to the National Health Expenditure Accounts.
Spanning the period 1996 to 2013, the study updates a 2009 Health Affairs study that used the same methodology and covered the period 1996 to 2005.
The 2016 study highlights the low rate of increase in spending on heart conditions and cerebrovascular disease during this period.
The slow spending growth is explained by reductions in smoking and better control of risk factors such as hypertension and hyperlipidemia, credited with declining death rates for these conditions.
Spending on Mental Disorders Expected to Rise
The author, Charles Roehrig, PhD, founding director of the Center for Sustainable Health Spending at Altarum Institute, in Ann Arbor, MI, noted that "reductions in deaths from heart conditions and cerebrovascular disease are likely to drive spending on mental disorders even higher, as more people survive to older ages—when mental disorders, such as dementia, become more prevalent."
This spending may only be the tip of the mental health iceberg, however. Approximately 1 in 5 adults in the United States—43.8 million, or 18.5%—experiences mental illness in a given year.
Only 41% of adults with a mental health condition received mental health services in the past year, however. Among adults with a serious mental illness, just 62.9% received mental health services in the past year, reports the National Alliance on Mental Illness.
"Because our system is so broken, only 40% of people who actively have mental health issues are getting treatment," John Santopietro, MD, FAPA, DFAPA, chief clinical officer of behavioral health at Carolinas HealthCare System recently told HealthLeaders magazine.
Expansion continues as Dallas-based Catholic health system takes controlling stake in Hopkins County Memorial Hospital.
CHRISTUS Health will own a controlling stake in Hopkins County Memorial Hospital, a 96-bed general surgical hospital in Sulphur Springs, TX in a deal that could be finalized by July 1.
The agreement announced jointly with the Hopkins County Hospital District puts hospital operations under a new organization called CHRISTUS Hopkins Health Alliance. CHRISTUS Health will own 51% of CHHA and Hopkins will own 49%.
Financial terms of the acquisition were not disclosed.
The hospital's name will change to CHRISTUS Mother Frances Hospital-Sulphur Springs and the clinics will change to CHRISTUS Trinity Clinic-Sulphur Springs and CHRISTUS Trinity Clinic-Emory.
Hopkins Memorial CEO Michael McAndrew said the hospital district has invested more than $36 million in capital improvements and expansion of services over the past decade that include a medical office building, an acute rehab unit, a wound care center, and enhanced specialty surgical and cardiac services.
"Even with all of these wonderful things, we knew that if we didn't find a strong partner we would not be able to continue our mission," McAndrew said in prepared remarks.
"After a lengthy process the Board has signed a joint venture agreement with CHRISTUS Health. It will be an exciting new beginning, rich with promise. It will ensure our viability, irrespective of the monumental changes in healthcare, for generations to come."
Hopkins Board Chair Tim Kelty said an affiliation with a larger provider was needed because the healthcare landscape is shifting toward population health and value-based care and "rural healthcare organizations need a partner in order to continue to meet the healthcare needs of their community."
CHRISTUS Health CEO and President Ernie Sadau noted that the venture with Hopkins comes weeks after plans were announced for the creation of CHRISTUS Trinity Mother Frances Health System in Tyler.
"Our mission for the last 150 years has been to extend the healing ministry of Jesus Christ, and with the finalization of this agreement, we are continuing to build upon and strengthen our mission for years to come," Sadau said.
CHRISTUS Health, a Catholic, faith-based, not-for-profit health system, is headquartered in Dallas and includes more than 50 hospitals and long-term care facilities, 175 clinics and outpatient centers and other health ministries and ventures in Texas, Arkansas, Iowa, Louisiana, New Mexico, Georgia, Mexico, and Chile. The system has 35,000 employees and nearly 14,000 physicians on staff.