Sunday, 9 June 2013

Liverpool Care Pathway - The Communitarian Supremacy

Through a mirror darkly do we perceive ourselves and, in that grim reflexion, do perceive each other.

A target-driven, incentive approach does not necessarily produce the desired or even desirable outcomes. In the field of clinical governance, those outcomes, as we well know from the experience of Mid-Staffs, may prove to be calamitous and catastrophic.

This is East of England NHS Clinical Quality and Public Health website on QUIPP -

The NHS QUIPP challenge: an introduction for clinicians (DH)
The quality, innovation, productivity and prevention (QIPP) challenge is our opportunity to prepare the NHS to defend and promote high quality care in a tighter economic climate. We know we have one more year of guaranteed growth in 2010/11, but the NHS needs to be making efficiency savings of £15-£20 billion per year by 2013/14. Frontline NHS staff will play a crucial role in this work because they have first-hand experience and knowledge of the areas where QIPP will start to make a difference.

How to achieve the impossible by making it desirable.

Cutting cost means cutting care means downsizing care means downsizing care expectations, achieving the impossible by making it desirable.

The idea is catching on across the pond -

Patients with severe heart problems and pneumonia tend to decline quickly and often move in and out of hospitals, said hospice marketing specialist Rich Chesney, who proposed the idea.
It might be better, Chesney said, if a hospital CEO hired people to talk to family members about hospice, instead of a doctor, who is more focused on not losing a patient. Chesney made his proposal recently at a conference sponsored by the National Hospice and Palliative Care Organization, an industry trade group.
A quality outcome is achieved through downsizing care expectations. Downsizing care expectations permits downsizing care means a quality, evidence-based outcome.

USA Today continues -

Good hospices have been working with hospital CEOs for years, said Carolyn Cassin, president of the National Hospice Work Group, a coalition of the 25 largest not-for-profit hospice organizations. But the goal, she said, was to make sure patients received the care they needed. She said she was surprised to hear it characterized as a marketing approach to cut costs.
While hospice care costs less than hospital care, at $151 a day for Medicare patients, it's meant for people who are going to die. In hospice care, patients agree not to seek care to improve their health, such as more surgeries, hospitalizations or chemotherapy. After a doctor certifies that he expects a person to die within six months, Medicare covers hospice care.
Experts say they fear patients will be sent to hospice before their time and miss the proper care that could restore their health. 
Say that again?

It used to be about diagnosing a terminal illness; it's now about diagnosing a terminal patient.

Think about that. This sounds extraordinarily like what's going on this side of the pond.

The idea is catching on. The Communitarian legacy is gaining supremacy.

Baroness Neuberger is appointed 'independent' chair of the Review into how the Liverpool Care Pathway is used in practice.

Julia Neuberger wrote an article in 
The Washington Post  in 2010 in which she confirmed the Communitarian ethos and values of the Complete Lives system.

The Washington Post article argues that end of life care in no way rations health care in the United Kingdom.

"What it does is to recognise that, at some point, we must die, and that heroic measures become pointless and cruel if they are not working."

Hospice-care patients
agree not to seek care to improve their health, such as more surgeries, hospitalizations or chemotherapy. [USA Today]
These are "heroic measures".

This is NCPC:
End of life care accounts for a high proportion of NHS spending. The Demos think tank has estimated it as at least a fifth of NHS costs and a total of about £20 billion
There is considerable scope for improvement using interventions such as early identification triggers, advance care planning, co-ordination of care and effective multi disciplinary team (MDT) working.
[Commissioning End of Life Care]

The EoLC Programme in the UK, described by the NCPC as an umbrella but which is more like a web, is all about selecting and identifying via numerous methods recorded in these pages - from the GP 1% campaign, to the Six Steps To Success, to Psychometric testing - candidates for grooming [The article calls it counselling] to accept palliative care and deny themselves the possibility of curative care. 

They need to do this to secure a viable and financially stable health service. 

The EoLC Programme is all about grooming patients into accepting palliative in place of curative care options. This will save the NHS £billions and secure the NHS an "Affordable and Sustainable" future.

"Affordable and Sustainable." These are the buzz words everyone who is anyone is using. 

Simon Stevens was Tony Blair's advisor on NHS reform. He now heads up United Health.

Published on 28 Jan 2013
Forbes contributor Bruce Japsen interviews Simon Stevens, president of global health for UnitedHealth Group. From the Forbes Healthcare Summit in New York City.

Bruce Japsen questions Simon Stevens who quickly moves to set the agenda of the interview.

He jive talks Bruce, talking about a national consensus:

there's a national consensus developed that it's time to move away from paying for the components of care and instead paying for quality and for outcomes of care.

The question though is how do you move from here to there?

…and responds with questions of his own that roll the interview along.

The pressure is on because the government estimates that two point eight trillium will rise to four point eight trillion uh... by the end of the decade.

And so the question is…

Saving 100s of billions of tax dollars is going to be achieved by eliminating those components of care which the medics and the CMS deem to lack a good quality of life outcome. Say no more.

This is United Health -

Working together, we can ensure that quality health care is accessible to all Americans, and that it is affordable and sustainable - not a burden to future generations.

"Affordable and Sustainable." The web the NCPC calls an umbrella is international.

United Health is buying into Medicare policies.

This is US liberal commentator and blogger Matthew Yglesias writing on Slate 

"...not only is this health care spending on the elderly the key issue in the federal budget, our disproportionate allocation of health care dollars to old people surely accounts for the remarkable lack of apparent cost effectiveness of the American health care system. When the patient is already over 80, the simple fact of the matter is that no amount of treatment is going to work miracles in terms of life expectancy or quality of life."

Here's more Communitarian reasoning from Mr. Yglesias -

"Read Frakt for a bit of an account of how this arises operationally, but what I think is more important is that it arises on a meta-level because we have such a fragmented health care system. When your health care spending is all in one bucket, then at any given level of spending you face a question about how to allocate it. And when allocating spending between young and old, you're cross-pressured. On the one hand, older people have more need for health care services which militates in favor of allocating spending to them. On the other hand, providing health care services to younger people generally offers better value in terms of years of life and quality of life saved. A 25 year-old who's in a bad car accident can, if found in time and treated, still live a very happy and healthy life. If you're 95 and get into the same car accident, then treatment is going to be much more difficult, recovery will be much less complete, and in the grand scheme of things you're not going to live very long anyway."

This is from Accountable Care featured in the AHIMA Thought Leadership Series -

What Is Accountable Care?

The idea of accountable care—an approach emphasizing provider assumption of
risk for the quality of care, the cost of care, and patientsatisfaction—is relatively
new to those in the healthcare industry.A variety of models are emerging around
the country, and mostshare the following characteristics or goals:
» Patient-centered, well-coordinated care for a designated population of patients
» Local decision-making
» Focus on patient satisfaction
» Real costsavings as a result of the above

The grooming has it.

CMS has it.

To determine which hospitals have higher than expected risk-adjusted readmission rates and are subject to the Readmissions Reduction Program payment adjustment for FFY 2013, the policy compares hospital’s 30-day risk-adjusted readmission rates (Predicted Readmission Rates) for heart attack, heart failure, and pneumonia to average 30-day risk-adjusted readmission rates for the applicable conditions for all hospitals participating in the program (Expected Readmission Rates). The result of this calculation is an Excess Readmission Ratio. If a hospital performs worse than average, the ratio will be greater than 1.0 and the hospital will be subject to a payment reduction under the program. The analysis includes step-by-step detail on how the readmissions adjustment factor is calculated. []

- CMS.Gov (Centers for Medicare & Medicaid Services)

Formulas to Compute the Readmission Payment Adjustment Amount
Wage-adjusted DRG operating amount* =  DRG weight x [(labor share x wage index) + (non-labor share x cola, if applicable)]
*Note, If the case is subject to the transfer policy, then this amount includes an applicable payment adjustment for transfers under § 412.4(f).
Base Operating DRG Payment Amount = Wage-adjusted DRG operating amount + new technology payment, if applicable. 
Readmissions Payment Adjustment Amount = [Base operating DRG payment amount x readmissions adjustment factor] - base operating DRG payment amount. 
*The readmissions adjustment factor is always less than 1.0000, therefore, the readmissions payment adjustment amount will always be a negative amount (i.e., a payment reduction).

The complicated calculations parallel the CQUINs

This is an article in JAMA, The Journal of the American Medical Association -
First page PDF preview

The strategy of using financial incentives to improve quality and lower costs is firmly embedded in the Affordable Care Act and the hospital value-based purchasing program launched nationwide in October 2012. The Affordable Care Act not only stiffens penalties for hospitals with high readmission rates but also uses risk-standardized 30-day mortality rates (RSMRs) for patients diagnosed with pneumonia, congestive heart failure, and acute myocardial infarction as a criterion for rewarding or penalizing hospitals. As currently designed, these incentives set a new benchmark for hospital quality and functionally establish a 30-day “warranty period” during which hospitals and physicians are held accountable for patient outcome.1 However, 2 questions are worth asking: (1) are RSMRs an appropriate measure of hospital quality; and (2) does linkage of incentives to RSMRs for the 3 highest-volume hospital conditions increase the potential for early misuse or overuse of hospice or palliative care measures for patients whose risk of death is higher than expected but by no means certain?

Another article in JAMA -

Interest in accountable care organizations (ACOs) has increased dramatically with the passage of the Affordable Care Act, which establishes ACOs as a new payment model under Medicare and fosters pilot programs to extend the model to private payers and Medicaid. Proponents hope that ACOs will allow physicians, hospitals, and other clinicians and health care organizations to work more effectively together to both improve quality and slow spending growth.1 

Skeptics are concerned that ACOs will focus narrowly on their bottom line and either stint on needed care or use the leverage they achieve through local integration to demand unreasonable prices from payers.

KHN (Kaiser health News) reports -

Despite a three-year-old order from Congress, Medicare has yet to begin an experiment to expand hospice services to allow beneficiaries to continue potentially lifesaving treatments to see if it would save money while improving the patients' quality of life.
The demonstration project would eliminate one major reason that people are reluctant to take up Medicare's hospice benefit: they have to first agree to forgo curative treatments such as chemotherapy. 
Many rapidly declining patients delay entry into hospice until their final days as they exhaust their treatment options, according to studies. 
Others end up dying in hospital intensive care units, which are expensive and generally not geared to making the terminally ill as comfortable as possible.

These are those components of care which the medics and the CMS will deem to lack a good quality of life outcome.

They are neither affordable nor sustainable.

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