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2 posts from April 2019

04/16/2019

Ann Neumann Discusses Mercy Killings or Suicide-Homicides (April 15th)

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In 2017 more than 47,000 Americans committed suicide.  While suicide rates decreased during the 1980s and 1990s, they have increased by 33% over the past two decades.  Today they are one of the top ten causes of death.  Suicide or suicide-homicides, where the spouse or partner kills their loved one and frequently and immediately themselves, are unsurprising for several reasons.  Among others, the US has no universal long term care policy.   (The ACA attempted to create a voluntary long term care provision, termed the CLASS Act, but it was never implemented having found to be financially non-viable - some would say intentionally so.)  Medicare does not provide long term coverage.  The Medicare hospice benefit is de facto time limited (Medicare hospice providers have an annual per beneficiary reimbursement cap, the only Medicare program to impose a spending cap), one has to meet a poverty threshold to qualify for long term care under Medicaid and commercial long term care insurance, if available, is unaffordable for many seniors.  This last fact is largely explained by the reality that a quarter of Medicare beneficiaries have annual incomes below $15,000 and an equal percent have savings totaling less than $15,000 and over half of these have no savings or are in debt.   Concerning medical aid in dying laws, that present their own limitations, currently only eight states (NJ as of this past week) and DC allow for it. 

During this 27 minute conversation, Ms. Neumann discusses her recent  Harper's Magazine essay titled, "Going to Extremes, Are Homicides Among the Elderly Acts of Mercy or Acts _50A9718_HR_4of Malice?"  The conversation begins with Ms. Neumann's account of Philip Benight and Becky Golden's experience around which the essay is focused.  Ms Neumann moves on to discuss how these acts are addressed by prosecutors, what explains a not uncommon precipitating event, that is terminally ill patients being held in acute or in-patient settings against their will, how and why the health care industry fails to meet the needs of seriously/terminally ill individuals and whether mercy killings can be defined as rational suicides or whether they are acts of mercy or malice.        

Ms. Ann Neumann is the author of The Good Death: An Exploration of Dying in America and a nonfiction contributing editor at Guernica magazine.  Ms. Neumann was a visiting scholar at The Center for Religion and Media at New York University until 2018 and has written about religion and health care for Harper's Magazine, The New York Times, The Washington Post, Virginia Quarterly Review, The Baffler and other publications.  Ms. Neumann is currently working on a book about grief and travel. 

Ms. Neumann's February Harper's Magazine essay is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

The Kaiser Health News April 9th report noted in the introduction of this podcast and titled, "Lethal Plans: When Seniors Turn to Suicide in Long-Term Care," is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

04/10/2019

Harold Miller Discusses Improving Medicare's Alternative Payment Models (April 9th)

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Medicare's Fee for Service Alternative Payment Models (APMs), a creation of 2015 MACRA legislation, currently 12 in number with participation largely voluntary, requires Medicare providers to assume financial risk, based on historical spending and quality measurement performance, beyond a "nominal amount."  The flagship APM is the ACA's Medicare Shared Savings Program, more commonly termed Accountable Care Organizations (ACOs).  Though in its 8th year, the ACO program, that currently provides care to over 10 million assigned Medicare beneficiaries, has not produced meaningful savings (estimates are 1 to 2% annually).  Nor have other APMs, largely bundled payment arrangements, produced substantial savings.  The Medicare Advantage program (with one-third of Medicare beneficiaries), defined as administrative pricing, does not formally score savings.  Over the past few years per capita Medicare spending has been limited, however, program growth or beneficiary enrollment (via the aging baby boomer population) is causing Medicare spending, in sum, to increase substantially.  In addition, the soon-to-be-published annual Medicare Trustee's report will show the program will become insolvent within the next few years. 

During this 26 minute discussion, Mr. Miller provides an overall assessment of APM performance to date.  He moreover discusses the shortcomings in APM design or the barriers APM providers face in improving care, e.g., as ostensibly Fee for Service APMs are not reimburse for valuable non-medical services such as social service supports and ways to improve these models.  We conclude the discussion with his views on the ACA-created PTAC (the Physician-Focused Payment Model Technical Advisory Committee), that has reviewed to date over 30 submitted APM proposals, none of which have been chosen by Secretary Azar for testing as a Medicare demonstration.    

Mr. Harold D. Miller is the President and CEO of the Center for Healthcare Quality and Payment Reform.  In this role he has worked in more than 40 states and metropolitan regions to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms.  He is also currently one of eleven HaroldMillermembers of the PTAC.  He also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.  Mr. Miller has written a number of widely-used papers and reports on health care payment and delivery reform.  He has assisted numerous professional organizations in developing alternative payment models designed to support better care for patients at lower cost.  From 2008 to 2013, Mr Miller served as the President and CEO of the Network for Regional Healthcare Improvement (NRHI), the national association of Regional Health Improvement collaboratives.  He served as a member of the Board of Directors of the National Quality Forum from 2009 to 2015.  From 2006 to 2010, Mr. Miller served as the Strategic Initiatives Consultant to the Pittsburgh Regional Health Initiative (PRHI).  In 2007, he served as the Facilitator for the Minnesota Health Care Transformation Task Force.  In previous positions, Mr. Miller served as the Director of the Pennsylvania Governors Office of Policy Development, Associate Dean of the Heinz School of Public Policy and Management at Carnegie Mellon University, Executive Director of the Pennsylvania Economy League - Western Division, Director of the Southwestern Pennsylvania Growth Alliance and President of the Allegheny Conference on Community Development.

For information on the Center for Healthcare Quality and Payment Reform, go to: http://www.chqpr.org/ 

 
Per my mention of Dr. Robert Berenson's recent (February) essay concerning improving the Medicare Fee for Service schedule, go to: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05411