Clinical Corner : News

Health Care Reform and LTC: Part V

Carol Kleinman — Wed, 25 Nov 2009 15:32:00 GMT

For patients, employers and payers to make well-informed health care decisions, they must have access to meaningful and easy-to-understand quality and cost data; such transparency is critical to overall health care reform.

Strategies to involve patients and families are essential. Examples of important patient feedback include:

An "experience mapping" program that gathers patient perspectives on the care they received
Patient and family advisory councils
Multiple opportunities for patients to provide candid feedback, including follow-up surveys, forms online and a patient relations hotline
Physician quality ratings that show consumers how often a physician meets certain targets when caring for their patients

Providing quality and cost information to the public will complement reforms in the payment system and help improve the access and affordability of health care.

Health care reform and LTC: Part IV

Carol Kleinman — Fri, 06 Nov 2009 16:47:00 GMT

Health care reform is not possible without health insurance coverage. It comes as no surprise that health insurance decisions are not always made in the best interest of the patient. As Michelle Obama related, in some states it is still legal to deny a woman coverage because she's been the victim of domestic violence. Health care premiums have doubled since 2001 and the cost of care for the uninsured has skyrocketed.

We should consider supporting public policy initiatives that:

Achieve universal coverage through market-based solutions while avoiding a one-size fits all approach
Encourage patient responsibility and financial accountability for lifestyle and health care decisions
Provide employers and individuals with access to affordable, high quality coverage options
Establish the expectation that each American will maintain some form of insurance coverage

Health care reform and LTC: Part III

Carol Kleinman — Tue, 27 Oct 2009 18:49:00 GMT

While health care reform has long been a topic of discussion in Washington, D.C., it has become a leading policy issue for the Obama Administration and Congress. Health care reform is no longer perceived as peripheral to our larger economic condition. Instead, it is viewed as an integral element to our long term economic stability as a nation.

As lawmakers debate health care reform proposals, it is critical that reform measures promote seamless integration within systems as well as between health care providers and insurers. Specific actions might include:

Promoting widespread adoption of interoperable health information technology systems to reduce errors and maximize provider collaboration
Developing policies to encourage a "medical home" or physician office responsible for coordinating the overall care for patients and to encourage patient care management
Accelerating applied clinical research and demonstration programs which give patients access to advances in science and innovative treatments
Supporting medical education, residency programs and other training efforts that prepare an adequate number of physicians, nurses and other health care workers for growing patient needs

Often "universal health care" is misconstrued as government-run health care, leading to passionate debate on all sides. In reality, universal health care means ensuring every American is covered by affordable and effective health insurance. This is a goal embraced by Spectrum Health and one our nation must aspire to for meaningful health care reform.

Health Care Reform and LTC: Part II

Carol Kleinman — Thu, 15 Oct 2009 18:56:00 GMT

Issues of long-term care have dominated public concern since President Clinton proposed his health care reform plan in 1993. Efforts towards a universal long-term care policy address priority areas of aging and disability in various ways such as the use of Medicaid waivers. Problems of long-term care, such as the nature of entitlement programs, are now the major concerns of the Administration on Aging and the Department of Health and Human Services. Long-term care policies at state and local levels are necessary to meet the compelling needs of an aging population.

As the White House and Congress debate ways to cut costs and improve quality in the nation's health care system, it is essential that those in the industry keep a close eye on the details and ensure that vulnerable citizens are not marginalized in the process. Significant cuts in Medicare nursing home funding would be catastrophic. Hundreds of key frontline care jobs would be eliminated, quality improvement programs would lose vital funding and, ultimately, important long-term care facilities that are already struggling due to chronic underfunding would have to close.

According to the Census Bureau, the world's 65-and-older population is projected to triple by 2050, growing from 516 million today to 1.53 billion. During the same time span, the 85-and-older population is projected to increase more than fivefold, from 40 million to 219 million.

With these projected numbers, it is not difficult to see why those looking for ways to cut health care spending would like to consider cuts to long-term care. Health care spending increases after the age of 50 and continues to accelerate. The financial per capita burden at age 85 and older is nearly six times as high as the burden at ages 50 through 54. Costs of care for people during their last two years of life account for 40 percent of all Medicare health expenses.

Adequate, stable Medicare funding and patient outcomes go hand in hand, and our ability to maintain sufficient work force levels, to sustain comprehensive quality improvement programs and to continue caring for our patients and residents now and in the future is at stake.

Health Care Reform and LTC: Part I

Carol Kleinman — Fri, 09 Oct 2009 13:21:00 GMT

If you suffer a massive heart attack and need expensive medical care in your golden years, it is likely that Medicare will cover your bills. But if you have the bad luck to contract Alzheimer's disease, sorry, you're on your own.

Howard Gleckman's new book Caring for Our Parents could not be better timed. It looks at all the places-nursing homes, assisted living, home care-in which most of us, frail and lonely, will spend our final years.

We may say, "Shoot me first," but nobody ever does. We may pray for a sudden stroke, or a heart attack that takes us in our sleep, but four out of five of us won't leave this life so neatly.

Congress is tackling health care reform and Gleckman makes a persuasive argument that any new plan needs a strong long-term care component. After reading Gleckman's eloquent mix of compelling real-life stories and stunning statistics, you will come away with the firm conviction that any health care legislation that does not address the issue of long term care is, on the face of it, a failure.

Gleckman doesn't just address our failings; he looks at how other modern industrial nations cope with aging populations. It is hard, after reading his book, to not believe that a new social insurance program, like Germany's, built along the lines of Medicare and Social Security should be part of whatever health care reform leaves Capitol Hill.

If you're a conservative, and don't like the idea of federal entitlement programs, then a universal mandate to purchase long-term care insurance from the private U.S. insurance industry may sound more appealing.

In either case, it is something we will need to address.

Health Care and the Common Good

Carol Kleinman — Mon, 31 Aug 2009 16:58:00 GMT

So, the basic debate in the U.S. over healthcare is not really about costs or the freedom to choose one's own doctor. The facts are clear: The World Health Organization rates the U.S. 37^th (!) in healthcare while we spend a much higher percentage of our Gross Domestic Product on healthcare than Canada, Europe, New Zealand, Australia, or other industrial democracies for this lower quality coverage. A universal, single-payer, health insurance program would both increase the choices of physicians available to most Americans and would, after initial start-up costs, lower healthcare costs overall. These facts have been known for decades.

The real issue is whether healthcare is a right (as most progressives believe) or a privilege for those who can afford it (as most conservatives believe). If healthcare is a right, then universal healthcare is mandatory. But if healthcare is simply another consumer commodity to be sold to the highest bidder, then we should simply leave things to be influenced by market forces.

These alternatives come down to basic convictions...basic ways of looking at the world. The "privilege" position sees human life as competition between autonomous, individuals, each looking out for her or his self interest only. But the "healthcare as a right" position sees us all as interconnected and validates the benefit of ensuring the common good.

What about quality of life?

Carol Kleinman — Fri, 14 Aug 2009 14:52:00 GMT

We now save people who would have died 30 years ago. People with severe trauma, stroke, heart attack, brain damage, and so on. We save preemies who would never have survived even 20 years ago. We see people living with severe chronic illness, people in nursing homes unable to care for themselves, people with severe birth defects and disabilities whose conditions would have dramatically shortened their lifespan as recently as two or three decades ago.

But thanks to technology, medication, early intervention, intensive care, first responders, organ transplant, a vastly expanded continuum of care, sophisticated treatments that are now available in the home, and much more, many of these people are able to survive.

Notice I said survive...not live. What about quality of life? What about the emotional, physical, and financial costs to the families? So we are all asking ourselves...what are people really entitled to? Just because we CAN provide healthcare services...does that mean we should?

I find it astounding that an inmate in prison for a life sentence may receive a heart transplant--and be higher on the list than a working father of four--all paid for by our tax dollars.

Health Care Supply & Demand

Carol Kleinman — Wed, 05 Aug 2009 13:45:00 GMT

While most goods and services adhere to the basic economic principle of supply and demand, in many ways healthcare does not. The principle of supply and demand describes a balance that develops between the supply of an item or service and the demand for it. The variable is that of price. There is a simple balance in which as price goes up, demand goes down, and vice versa. Generally, supply reflects demand as who would continue to develop a product or supply a service for which demand has dropped?

The problem in healthcare is that the consumer often pays little or nothing for services, despite the current reality of deductibles and copayments. When this is the case, price stops being a factor in demand and demand increases to virtually unlimited levels.

There was a time when my health insurance cost me nothing (100% of the premium was paid by my employer), I had no deductible and no copayment. So I had no out-of-pocket expenses whatsoever associated with healthcare. Now I really don't like going to the doctor, so it did not matter to me all that much, I still did not use a great deal of care. But many people, when costs are not a factor, use services at the drop of a hat.

This is the reality that triggered the current healthcare crisis. Even now, despite out-of-pocket costs, utilization is at record levels. People even tend to feel that since they are paying more for premiums (though nothing close to what employers are paying), they should get their money's worth. There is little to stop them from using services except the managed care initiatives that have been implemented in the last 20 years to address this situation. People in the first half of the 20^th century paid for healthcare themselves and were cautious about what services they used. When cost (price) stopped being a factor, desire for the product exploded and we have the runaway train that is currently eating up over 15 percent of our gross domestic product.

So, how do we deal with this situation? How do we provide the comprehensive care for everyone indicated in this week's question?

More importantly, how will we pay for it?

Is Health Care a Right or a Privilege? Part 1 - Pro

Carol Kleinman — Mon, 20 Jul 2009 19:03:00 GMT

Once upon a time before the Military-Industrial-Government Complex, Americans were mostly rural and relied on direct sources of food, water, fuel, and shelter. Personal involvement in and responsibility for those needs has decreased with the transformation from direct personal sourcing modes to control of sourcing by corporate operations.

That transformation happens without anything one can reasonably consider as adequate citizen or government oversight. All too often, lack of transparency is intentional with the result that American citizens have woefully inadequate awareness of the long-term cost/benefit picture. With the advent of "globalization" this sorry state of affairs is now being propagated abroad by corporate entities in the form of WTO, NAFTA, World Bank, etc.

While some aspects of quality of life improve for some populations, it is undeniable that tragic consequences have befallen segments of populations with little or no opportunity for them to correct the wrongs of the larger society and improve their lot. Medical statistics have shown that degraded diet, water, and air quality are responsible for billions of dollars in AVOIDABLE health care costs. That degradation has happened largely without citizen involvement in the decisions that brought it about.

So one must ask, if YOU had cancer-right now-would you consider medical treatment a privilege?

Considering the above, one must conclude that

Health care is a human right
Preventive care must include broad revision and oversight of all commercial activity that has human health implications
Federal level controls must be implemented to protect citizen health and quality of life, at least until citizens are equipped to take on that responsibility

Behavioral Medicine, Part II

Carol Kleinman — Wed, 27 Aug 2008 15:33:00 GMT

Why is it effective?

A growing body of research has documented the benefits of behavioral medicine in the treatment of acute and chronic illnesses. The interventions of behavioral medicine include behavioral or psychological strategies, which directly influence physiological states. The methods are best implemented using individual interventions with concomitant daily practice. Clinical experience indicates that patients who use behavioral self-help strategies have better medical outcomes and improved self-efficacy in managing symptoms than those who rely on medical intervention alone.

Outcomes research indicates that patients have improved prognoses and feel more cared for when behavioral medical interventions are integrated into their treatment plans. In addition, behavioral medical consultation-as opposed to psychiatric or psychological evaluation-circumvents patient concerns about being labeled as having a mental health issue or psychiatric diagnosis.

Improved outcomes appear to be based on patients' active participation in treatment, decreased feelings of passivity in response to their illness or injury, and improved perceptions about the probability of recovery of function or quality of life, regardless of actual recovery potential. Family members, who are often included in behavioral medical approaches, find greater comfort with the care received by patients and are aided in their own adjustment to the challenges faced by their loved ones. It has been documented that patients and families often experience a sense of "false despair" that negatively impacts their prognosis when they believe they are powerless to influence health care outcomes.

Who else benefits?

The addition of a behavioral medical professional to the health care team provides several benefits in addition to those experienced by the patient. Physicians and nursing staff find patients are more cooperative and in better compliance with their treatment regimen when behavioral medicine strategies are integrated into the treatment plan.

The facility benefits as there is promising research that behavioral medical interventions may result in shorter lengths of stay, allowing the organization to realize significant savings in prospective payment system reimbursement.

An appropriate use of the model would be to offer a behavioral medical consultation to all new patients as soon as possible after admission so an appropriate set of therapeutic interventions can be identified and implemented.

The challenge of living with a serious illness mandates that health care providers explore all options available to their patients. There is a great deal that can be done to help patients help themselves manage symptoms, improve their quality of life, and promote their well-being. Behavioral medicine can make a significant contribution to a comprehensive treatment approach.

Behavioral Medicine, Part I

Carol Kleinman — Wed, 27 Aug 2008 15:29:00 GMT

What is it?

Behavioral medicine is an interdisciplinary field of medicine concerned with the development and integration of psychosocial, behavioral, and biomedical knowledge relevant to health and illness. It focuses on the contribution of psychological and behavioral factors to the onset, progression, and management of disease. Behavioral medicine deals with what people do that affects their health and the way in which different illnesses affect their behavior.

Behavioral medicine is a discipline that uses a biopsychosocial model to motivate and mobilize patients to greater levels of participation in their own care. Treatment typically involves changing habits. These may involve thought patterns, how one deals with emotions, stress, time management, and their own body's functions. Successful integration of behavioral medicine techniques into a comprehensive treatment plan improves patient outcomes by

Increasing patients' participation in their care
Mobilizing the body's resources for recovery
Creating "learned optimism" by redirecting beliefs and attitudes
Changing negative health behaviors and improving treatment compliance
Reducing the negative influence of anxiety, anger and depression
Increasing patients' sense of control and responsibility for their own health

Who needs it?

Behavioral medicine can be integrated into the care and treatment of patients with a diverse range of conditions; however the approach is most useful with patients with acute or chronic responses to the following conditions:

Cancer
Cerebrovascular disease
Spinal cord injury
Cardiovascular disorders
Cardiopulmonary disorders
Traumatic brain injury
Immune system disorders
Tension and vascular headaches
Irritable bowel syndrome
Sleep disorders
Eating disorders

Patients can also be aided with focused symptom resolution through the use of behavioral medical techniques which are especially useful in the non-pharmacologic treatment of

Pain
Sleep disturbance
Hypertension
Delayed healing
Difficulty with ambulation
Drug regimen side effects
Surgical recovery
Coping difficulties
Depression
Anxiety
Dependence on analgesic medication

Many specific interventions are available as part of the practice of behavioral medicine. Patients must be evaluated individually to assess their current physical and mental state and to identify personal strengths and limitations. A specific treatment plan is then designed that incorporates and capitalizes on each patient's unique response to his or her illness or injury.

Among the techniques that may be used include:

Stress management
Relaxation-rehabilitation exercises
Guided imagery and cognitive-behavioral techniques for pain management
Immune system improvement through guided imagery
Brainwave neurofeedback
Neuromuscular retraining through cognitive rehearsal
Cognitive retraining for depression, illness perception, and anxiety
Hypnosis
Sleep management techniques
Motivational interventions
Thought modification
Problem solving therapy