Let Mandela Die In Peace!

The 94 year old Mandela is back to the hospital for the third time in four months with recurring infection, presumably pneumonia. After a week in the hospital he is in the ICU in critical condition.

This great man endured 27 years in prison (1), became the first black president of South Africa, overcame adversity, and left office when he could have stayed. He was the master of his fate, and the captain of his destiny, until now that is.

Weakened by disease and old age he is now at our mercy. Yes, at our collective mercy!

We should ask ourselves, what would have Mandela wanted for himself during these days of grave illness. Would he agree with our selfish pursuit of "keeping him alive at all cost"? Or would he have wanted to be allowed to die with dignity and comfort.

His legacy should not have to be his end of life "struggle", but rather his life story, his bravery, and his accomplishments.

He is a great man, but he couldn't foresee the challenges that would face him at the end of life, and so it is now up to his loved ones, which is the entire nation of South Africa, to decide when he can be "allowed" to die. 

Who in South Africa, and Mr. Mandela's immediate family, is brave enough to say "enough", I wonder.

Only lucky people die in their sleep, most elderly die from pneumonia, sepsis, UTIs, complications of chronic diseases, etc. 

When a 94 year is admitted to the hospital three times in four months it is considered an indicator of poor prognosis and often a marker of "end of life"; Failure to recognize this is a major injustice to the greatest man of our times.

I hope, for his sake, that his country will overcome their urge to keep him alive, and step out of the way for his natural death. He deserves a comfortable and peaceful death.

He should not have to fight for it, he should be allowed to die, not die despite our best efforts.

References:

(1)

http://www.pbs.org/wgbh/pages/frontline/shows/mandela/prison/

A Maine Law To Improve Patient Choice--Unlikely To Pass

NOW LIKELY TO PASS!! (As of 4/11/2013)

By: Jabbar Fazeli, MD

Last year, Medicare spent $63.5 billion on post acute care (on patients care after their discharge from hospitals). (http://www.medpac.gov/documents/Jun12DataBookEntireReport.pdf).

With that much money up for grabs, the hospitals in Maine, and elsewhere in the US, do all they can (within the very limits of the law) to refer their patients to service providers affiliated or owned by the hospital. The affiliations and common ownership span the entire healthcare system, from skilled facilities, home health and hospice organizations, to physician practices employed by hospitals and nursing home chains.

These referral pseudo-monopolies are made possible through limiting or discouraging patient choice at every step in the hospital discharge process. Patients leaving the hospitals to go to skilled nursing facilities are often steered to affiliated facilities. Those who go home with home health services also tend to be offered an affiliated provider. Patients arrive to skilled nursing home without knowing who their doctor will be because they were never offered a choice of physicians even when there is available choice.

In such a system, the independent and less connected providers (skilled facilities, home health, geriatric physicians, and hospices) are left at the mercy of unethical referral practices.

Some facilities in rural areas are in danger of being out out business and the communities losing their local nursing home beds.

The few physicians still willing to practice medicine in nursing homes can not expect their name to be given to patients as they are being discharge from the hospital to a nursing home. That lack of choice is especially troubling when patients are preferentially referred to a receiving physician who happens to be either employed by the hospital or the nursing home.

Given that the usurping of patient choice is at the core of this unethical practice in healthcare referrals, a bill (LD-447) was introduced in Maine calling for greater transparency and patient choice at every step of the hospital discharge process.

At the public hearing for LD-447 both the Hospital Association and the Maine Healthcare Organization testified in opposition, citing "administrative burden" associated with providing more transparency and more meaningful patient choice. It was also claimed that existing laws are sufficient, even though providers testified that the current laws are inadequate and hard to implement do to lack of standardization.

The only supporters for this bill came from small and independent healthcare businesses willing to stick their necks out and bite the hand that feeds them, the hospitals.

The Maine Medical Directors Association (MMDA) came in support of the bill as any referral monopolies can create a disincentive for attracting new geriatrician and nursing home doctors to the State of Maine. This bill also strengthens the role of local medical directors in corporate nursing homes.

A survey is now being conducted by the MMDA which shows that nursing home facilities don't necessarily agree with their organization, the MHCA, when it comes to the assertion that the provisions in the bill would create an "administrative burden". Very few think that hospitals "currently" provide patients with adequate choice.

Considering the powerful forces opposed to the bill, and the millions of dollars at stake, it is unlikely that this Maine bill will pass, but some of us will go though the motions and appear at the working session for this bill scheduled for 3/12/2013.

Wish me luck!

Update: 3/12/2013
Bill tabled until April 2, 2013. Stay gunned.

Update: 4/11/2013:
LD 447 passed the DHS committee unanimously today.. Yay!!!

Photo source: aafp.org

Happy Thanksgiving

Healthcare monopolies and referral abuse in the nursing home industry

1. Monopolies in nursing homes are limiting access to financially unaffiliated physicians:

-At least two nursing home chains in the country are now employing their own physician groups, under a separate LLC of course, and are referring all their nursing home admissions exclusively to their own employed physicians, excluding competing providers even when those providers have more training and experience in geriatrics than the employed physicians. Independent providers stand no chance competing in facilities with such monopolistic business practices were patients are not offered a choice. Genesis healthcare in the east coast has been at the forefront of this new model in their nursing homes.

Why should CMS be held accountable for this abuse?

CMS is failing to ensure patient choice of providers, as it does not mandate that facilities with conflict of interest have a process to offer choice, declare potential and actual conflicts of interests, and document that patients were indeed offered a choice. Allowing this exclusive referral practice to continue unabated violates CMS's rule that medicare and medicaid patients should be offered a choice when it comes to healthcare services.

2. Emerging Hospital/nursing home exclusive relationships:

-There is a trend in the nursing home industry where hospitals affiliate, one way or another, with nursing homes and rehab facilities, then patient referrals are preferentially steered, in both directions. In extreme cases, nursing homes or rehab facilities are actually owned by the hospital and are receiving referrals preferentially, and sometimes exclusively, impacting, and sometimes limiting, patients' choice to go to other facilities. There are many examples of this in Maine, and I dare assume that Maine is not alone.

Why should CMS be held accountable for this abuse?

. In this case CMS is failing to hold both the hospitals and nursing homes to existing CMS standards mandating that Medicare and medicaid patients should be given a choice of facility upon discharge from the hospital. CMS is willfully ignoring the lack of choice, and in doing so, is encouraging healthcare monopolies that eliminate competition and encourage the formation of competing monopolies in the same service areas, as the only way for competing healthcare businesses to survive the lack of free market competition.

Needless to say, such monopolies are a result of CMS's failure to enforce long standing rules regarding the protection of patient choice, focusing instead on clear cut black and white billing fraud cases that make headlines, but cost the system far less than the above mentioned systematic abuse practices.

3. Nursing homes referral as a form of kickback to consultants:

Nursing home facilities in some parts of the country are courting consultants (to get their patient referrals) by committing to making mass referrals to the consultants . For example, some facilities reward referrals from wound specialist by referring all patients with wounds to the wound consultant, even in cases where the attending physicians have expertise in the field or when wounds are minimal or healing. I actually have a case example where the referral was made to the wound specialist even though the wound was actually healed. That referral was made because the patient had wound listed on their admission diagnosis which triggered an automatic referral.
Ironically, such complete delegation of all wounds to outside consultants has not been proven to reduce wounds and does tend to diminish the nursing staff's knowledge of caring for such patients, which ultimately has the potential of patients receiving inferior wound care. Another way wound referrals are abused is when nursing homes are referring to a hospital owned wound cent in return for the hospital referring patients to the nursing home, this is often made practical by the hospital placing their own physicians as medical directors of the particular nursing home.

Another example of inappropriate referrals is when facilities institute policies to refer all patients on psychotropic medications to the psychiatry service, even if stable or the attending physician is comfortable managing their issues. Clinically, many of the dementia related psychiatry referrals are better managed by geriatric medicine, especially if the attending is trained in geriatric medicine.

Why should CMS be held accountable for this abuse?

. In this case CMS is failing to recognize and target wide spread referral abuse, where the only currency being exchanged is the patients themselves, in the form of referrals.

. CMS fails to develop and implement procedures and methods to identify referral abuse issues in which facilities, and not physicians, are driving referrals as a form of kickback for referrals backs to the facility, which can only be achieved through limiting patients' choice.

. The CMS survey process does not include training surveyors on potential referral abuse issues, and even if surveyors identify potential abuse they would not be able to include such findings in the survey report, as system abuse is not an elements of the CMS survey process. This should come as a shock to many concerned citizens.

. CMS has a policy of combating fraud and abuse, but it only deals with fraud, and is willfully neglecting abuse occurring in plain sight. There is no excuse for this indifference as CMS already has surveyors in every medical facility in the country at least once a year. Logic dictates that wide spread abuse costs the system much more than the sporadic fraud cases that occupy 100% of the fraud and abuse unit's attention. CMS's indifference towards abuse issues that don't rise to the level of outright fraud, is inexcusable.

CMS is failing to protect nursing home patients from bad care caused by the DEA

DEA issues in nursing homes and role of CMS:

-CMS is mandated to protect nursing home residents from neglect and substandard care, and yet for the past two years regulations by another government agency, the DEA, have resulted in a built-in delay in carrying out doctor orders when it comes to orders for narcotics and other scheduled drugs, such as benzodiazepines used for seizure or panic attacks. This delay is directly impacting quality of care of nursing home residents, as doctors orders can not be carried out immediately by the licensed nursing staff.

-Current DEA rules, prohibit nurses from carrying out doctor orders for scheduled drugs, unless they are coupled with a hard prescription, forcing a delay until the doctor has provided a written script or until the pharmacist confirmed the orders with the prescribing provider (as if the patient was at home, and not in a nursing home). All this involves or is followed by a complex paperwork process. Moreover, the nursing home nurses are not allowed to use the emergency kit in the facility to treat emergencies such as seizures, panic attacks, or pain control in dying patients, despite having a valid verbal order from a dully licensed attending physician in an inpatient nursing home setting. All this is done in the name of protecting all of us from drug diversion by healthcare professionals, at the expense of nursing home patients' suffering for an added 30 minutes or so each time a stat order is given. In case of seizures it is well established that any delay in treatment is potentially life threatening, but try telling that to the DEA.

-It is noteworthy that if facilities happen to document the above mentioned delays in medication administration, CMS can and does in fact hold the nursing homes, not the DEA, accountable for negligence and substandard care. There is no mention of the DEA in the CMS deficiency tags handed to offending nursing homes.

Why is CMS responsible?

. CMS is failing to live up to their own self-declared goals and obligations when it comes to preventing substandard care, simply because this substandard care happens to be caused by a powerful federal agency, the DEA. Instead of addressing the route cause of this particular problem, CMS is robotically holding local facilities accountable for something they have no control over and is a direct consequence of federal (DEA) mandates.

Pay for performance, ACOs, a good idea with terrible consequences

The unintended consequences of the establishment of "Accountable care organizations" on geriatric care and independent providers:

- "Accountable care organizations" get incentive payments for following, CMS established, quality indicators. The rub is that the quality indicators used as a measure of good care are not always applicable to geriatric patients. For example, the standard of putting all stroke patients on a statin (i.e. Lipitor) doesn't necessarily apply to frail elderly over 80, 90, over even 100 years old, and yet in order to keep the quality indicators on target and get CMS bonus money, many hospitals who are part of ACOs are encouraging the application of these standards across the board, regardless of age or frailty. The hospital employed physicians are often given bonuses for meeting quality indicator targets, which adds another incentive to continue this robotic centralized decision making approach.

This point can be further illustrated by the fact that when the statins are stopped by geriatricians or PCPs post discharge from the hospital, the patients gets re-started on the statin upon their next hospital admission, as if nothing else matters except the hospital protocols to meet the quality indicator targets.

Other examples include diabetic patients goals; in geriatric cases the A1c goal is 8 for many nursing home patients, and hypoglycemia is considered a bigger threat to the elderly's well-being than uncontrolled diabetes. These emerging standards in geriatric care are not reflected in the quality indicators used in the general population, and geriatricians can be potentially penalized for doing the right thing while ACOs are financially rewarded for doing the wrong thing (one that happens to be good on paper and is based on CMS standards).

Why is CMS responsible for this?

. By incentivizing the establishment of Accountable Care Organizations, CMS is effectively pushing the health care industry to centralize care and decision making and eliminate the independent provider models as a choice of practice. It's is also promoting centralized rigid treatment protocols, that are based primarily on clinical goals linked to financial interests, and geared towards meeting targets that qualify corporate providers and institutions for bonus payments from CMS. These rigid quality indicator targets are based on information that is constantly evolving, making the system highly communistic in it's design.

. Pay for performance, based on rigid quality measures, is inherently problematic, as government standards are not likely to evolve with the evolution of science, and as ACOs take hold, employed providers would be unduly influenced to practice cookie-cutter centralized care, even when it eventually becomes outdated.

. As CMS pushes for establishment of ACO through financial incentives, it is actually undermining free market principles in healthcare and diminishes the role of physicians in developing a "patient centered" care plan. ACOs are also creating a conflict of interest for physicians as they practically now receive commission for following protocols at bedside.
An example of such care trends based on quality indicators is most obvious in palliative care or hospice patients. There are many hospice patients on comfort measures that leave the hospital on statins for having a history of hypercholestrolemia, or for their recent stroke or heart attack. In such cases the hospitalists are clearly documenting that prolonging life is no longer the goal, and yet they leave these patients on life prolonging medications, that if discontinued, would impact the quality indicators statistics for their institution, and in some cases impact the doctors' own bonuses.

And so we end up with a 90 year old patient on comfort measures being kept on Lipitor to make sure the ACOs stays on target in terms of quality indicators, and the doctors don't put up a fight because their bonuses depend on it.

"Face to face rules", More paperwork to fill out just to cover system abusers in home health care

New home health agencies "face to face" paperwork requirement:

-Recently CMS, in an effort to combat home health abuses and fraud, has offered a change in regulation that requires additional documentation by "physicians". That includes documenting, on a separate form, patients' home bound status, the reasons for home based services, and documenting the date of last physician visit, which has to be within 30 days if recent discharge from rehab or hospital, and within 90 days if patient is already at home.

CMS "suggested" that physicians do the documentation, and so all national home health agencies have now created a new form for the physician to fill out and sign (NPs can't sign it because CMS rules don't mention Physician extenders). This is in addition to what physicians already document in their progress notes and the physician discharge orders, which are already mandated under other rules.

Please note that prior to this regulation, the home health agency had to establish "home bound status" themselves as they accepted a new referral, or on their first home visit. The providers (doctors and physician extenders) wrote orders in patient's charts for the services needed, and the other disciplines i.e. rehab, social services, and nursing did their own documentations of patient status and home needs post discharge from inpatient setting. The other disciplines input was taken into consideration by providers when ordering the post discharge home health services.

With the new regulation, there is a duplication of paperwork, but more importantly, there is a shift of responsibility from home health agencies to doctors in documenting home bound status, which then legitimizes future abuses by home health when they continue to provide services to patients who are no longer home bound, undermining the reason for which this whole new regulation was developed.

There are many patients who leave the rehab facilities "home bound" and cease to be "home bound" in the days and weeks post discharge. Having a signed document by doctors stating that these patients are home bound (until the end of times) absolves home health agencies from making any follow up evaluation of patients' home bound status and in turn absolves CMS from any monitoring of home health agencies on this issue, where prior abuses were considered an issue by CMS.

The duplicative paperwork by the physicians is only serving the purpose of protecting home health agencies from future scrutiny by CMS and does nothing to limit abuse by home health agencies. So why would CMS offer new rules that protects recent system abusers from future CMS citations and add to the physicians' paperwork in the process.

Why is CMS responsible is dead wrong on this issue?

. In this case, CMS maybe violating the 1980s "paperwork reduction act" outright.

Aside from that, CMS is shielding home health agencies from future fraud and abuse claims by allowing them to no longer be accountable for establishing patients' home bound status on their own. It would not be a stretch to assume that CMS based these new home health friendly rules on the advise of home health agencies themselves without any independent scrutiny.

.CMS is also covering its own failure for not monitoring home health agencies adequately in the past, by erroneously concluding that all that was needed is one more piece of paper signed by doctors to make this particular abuse issue disappear.

.CMS does not attach any reimbursement to this added paperwork provision.

.CMS has created a situation where NPs or PAs can order the home health services, but only physicians can sign the associated forms, because in the regulation, the word "physician" was used instead of "provider".

Why are we helpless to fix this CMS error?

CMS is huge, inflexible, and no longer accessible to the average advocate or physician. It's own commissioners quit citing inability to affect change.
Solution, more Transparency, less corporate say at the decision making level at CMS, more independent voices at CMS to see through the boast advise given by corporate healthcare.

Where is the AMA and other professional organizations when all this is going on?
Good question!