THE HIGH COST OF SAYING GOODBYE Ifeoma Aguanunu

THE HIGH COST OF SAYING GOODBYE Ifeoma Aguanunu HPA 430 4/15/13

The Issue National Health Expenditure (NHE) has continued to increase substantially and Medicare is a large portion of this growth. Over the past 30 years, Medicare per capita spending has grown at a faster rate than the GDP. Further, though the ACA will help to decrease Medicare spending other factors – such as technological advancements, changes in health coverage, rising prices, reimbursement structures, and an influx of Baby Boomer enrollees – led to a report by the Medicare Trustees predicting that the hospital trust fund will run out of money by 2024 unless serious action is taken to address spending. 1 ØHealth care services delivered near the end-of-life consume a large portion of healthcare dollars. Ø

Definition of End-of-Life Care Best practice in end-of-life care focuses on supporting both the dying patient and their family. End-of-life care attends not just to the physical but also the psychosocial and spiritual concerns of patients and their families, and extends into the bereavement period. Physical problems that must be anticipated and proactively addressed for the comfort of the dying person include pain, delirium/agitation, dyspnea, respiratory secretions, mouth and skin care, bladder and bowel care, and nausea and vomiting. Burdensome interventions which do not improve the dying person’s comfort should also be ceased whenever possible. - Current treatment regimen - Life-saving medical interventions (i. e. surgery, ACLS, life support, etc. ) - Hospice & palliative care services - In-patient and out-patient care (i. e. home health)2

Quick Facts 101 Ø Ø Putting everything into prospective, 2011: - National Healthcare Expenditure (NHE) - $2. 7 trillion or $8, 680 person; 17. 9% GDP - Medicare - $554. 3 billion; 21% of NHE - Medicaid - $407. 7 billion; 15% of NHE - Out of pocket - $307. 7 billion; 11% of NHE 3 97% of elderly are covered by Medicare 4 5% of beneficiaries die each year use about 30% of Medicare expenditures in the last year of life (aprox. 1/3 of budget) 5, 6 The elderly (65 years and older) consume more than 33% of all health care spending. 5

Medicare Began in 1965 Federal entitlement to provide health insurance coverage for those 65 years and older 4 parts: - Part A: hospital care and is financed primarily from payroll tax - Part B: physician care and other types of outpatient care and is financed jointly through general income taxes (75%) and premiums paid by beneficiaries (25%) - Part C: Medicare Advantage - Part D: Prescription drug benefit 7

Aging Population Growth 4

4

Expenses Non-terminal Terminal $37, 581 $7, 365

Terminal vs. Non-terminal year expenses Non-Terminal years All expenses: $7, 365 - Medicare: $3, 775 - Non-Medicare: $3, 590 Expenses by services: - In-patient: $2, 040 - Hospice: negligible 5 Terminal year All expenses: $37, 581 - Medicare: $23, 739 - Non-Medicare: $13, 842 Expenses by services: - In-patient: $15, 461 - Hospice: $7355

Take Home Points Whom? - All tax payers How? - Medicare program looks to today’s workers to pay the cost of today’s retirees. Why? - The number of active workers per beneficiary is projected to decline from 3. 5 in 2009 to 2. 4 in 2030. - If cost per beneficiary remains constant then the tax burden on each worker will increase by about 70% in the next 30 years. - Unsustainable 7

Life saving medical treatment at the end of life http: //www. youtube. com/watch? v=N 8 Qkw. ED-z. U 8

Code BLUE!!! Basic Life Support - CPR + defibrillation Advanced Care Life Support (ACLS) - BLS + Medications (i. e. epinephrine, atropine, etc. ) Overall survival rates: - Out-of-hospital arrest 6. 4% - In-hospital arrest 17. 6% Consequences: - Brain damage - Broken bones 8

Policy Action Plan 2 Prong Approach to decrease costs at the end-of-life

Allow Natural Death (A. N. D) 1. Broad Public Education Campaign Educational campaign aimed at healthcare practitioners, terminally ill patients and their families, and the general public to increase public awareness of end-of-life care including hospice and palliative care services, DNR/DNI (Do not resuscitate/incubate) guidelines, living will provisions, advance directives, etc. 9 2. Re-introducing Section 1233 of HR 320011 Establish a national workgroup to spear head. -Follow Maryland model: Workgroup on hospice care, palliative care and end-of-life counseling 9 Support HR 1339 – Palliative Care and Hospice Education and Training Act - Amend Public Health Service Act 10 Reimbursement for Advanced Care Planning Consultation: - advanced directives (i. e. living wills and durable powers of attorney) - health care proxy - national and state specific resources - hospice and palliative care services - DNR/DNI orders, AND orders - life sustaining treatments (i. e. surgery, ventilation, antibiotics, feeding devices, etc. ) Every 5 years → Every 2 years Include in Medicare & You Handbook

Section 1233 of HR 3200 (ACA) ‘Advance Care Planning Consultation’ (hhh)(1) Subject to paragraphs (3) and (4), the term ‘advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years 2 years. Such consultation shall include the following: (A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to. (B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses. (C) An explanation by the practitioner of the role and responsibilities of a health care proxy. …

(4) EFFECTIVE DATE- The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2011 2015. …

(c) Inclusion of Information in Medicare & You Handbook- (1) MEDICARE & YOU HANDBOOK- (A) IN GENERAL- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall update the online version of the Medicare & You Handbook to include the following: (i) An explanation of advance care planning and advance directives, including-- (I) living wills; (II) durable power of attorney; (III) orders of life-sustaining treatment; and (IV) health care proxies. (ii) A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives, including-(I) available State legal service organizations to assist individuals with advance care planning, including those organizations that receive funding pursuant to the Older Americans Act of 1965 (42 U. S. C. 93001 et seq. ); (II) website links or addresses for State-specific advance directive forms; and (III) any additional information, as determined by the Secretary. (B) UPDATE OF PAPER AND SUBSEQUENT VERSIONS- The Secretary shall include the information described in subparagraph (A) in all paper and electronic versions of the Medicare & You Handbook that are published on or after the date that is 1 year after the date of the enactment of this Act.

Policy Paramour: Eliot Engel Democrat NY-16 (Bronx and Westchester) Sponsor HR 1339 – Palliative Care and Hospice Education and Training Act Energy and Commerce Committee - Subcommittee on Health - Subcommittee on Energy and Power House Foreign Affairs Committee Founder and Co-Chair of the House Oil and National Security Caucus Championed energy independence, affordable housing, real healthcare reform and education for all Americans. - created the Dependence Reduction through Innovation in Vehicle and Energy (DRIVE) Act - ALS Registry ACT (P. L. 110 -373) - Paul D. Wellstone Muscular Dystrophy Act (P. L. 110 -361) - Public and Teaching Hospital Preservation Act (P. L. 110 -252) - President’s Emergency Plan for AIDS Assistance (PEPFAR) (P. L. 110 -293) – Stop Tuberculosis Now Act

Co-sponsors of HR 1336 Lois Capps (CA-D): Energy and Commerce Committee (Health), Congressional Nursing Caucus, House Cancer Caucus James Mc. Govern (MA-D): Rules Committee and Agriculture Committee Bobby Rush (IL-D): Energy and Commerce Committee, Congressional Black Caucus Earl Blumenauer (OR-D): Budget Committee, Committee on Ways and Means (Health and Trade) Tim Ryan (OH-D): Appropriations Committee, Budget Committee Tom Reed (NY-R): Committee on Ways and Means (Human Resources and Oversight) Corrine Brown (FL-D): Veterans Affairs Committee, Congressional black Caucus, Older Americans Caucus Sam Farr (CA-D): Appropriations Committee Bruce Braley (IA-D): Energy and Commerce Committee

Stakeholders Governmental Center for Medicare and Medicaid Services (CMS) Congressional Budget Office (CBO) Medicare Advisory Payment Commission (Med. PAC) Agency for Health Care Research and Quality (AHRQ) US Department of Health and Human Services (HHS) Non-Governmental National Hospice and Palliative Care Organization (NHPCO) American Association of Retired Persons (AARP) Center for Medicare Advocacy Medicare Rights Center Medicare Advocacy Recovery Coalition (MARC) American Medical Association (AMA) American College of Physician (ACP) American Health Care Association Committee on Responsible Federal Budget

Which do you prefer? Option 1

Option 2

References 1. Med. Pac. (March 2012, March). Report to the Congress: Medicare Payment Policy. Retrieved from http: //www. medpac. gov/chapters/Mar 12_Ch 11. pdf 2. Care Search Palliative Care Knowledge Network Website: http: //www. caresearch. com. au/caresearch/tabid/738/Default. aspx 3. Centers for Medicare and Medicaid Services website, National Healthcare Expenditure. http: //www. cms. gov/Research-Statistics-Data-and. Systems/Statistics-Trends-and-Reports/National. Health. Expend. Data/Downloads/tables. pdf 4. Centers for Medicare and Medicaid Services website, Medicare Coverage. http: //www. cms. gov/Research-Statistics-Data-and-Systems/Statistics. Trends-and-Reports/The. Chart. Series/downloads/35 chartbk. pdf 5. Hoover, D. R. , S. Crystal, R. Kumar, U. Sambamoorthi, and J. Cantor. 2002. “Medical Expenditures during the Last Year of Life: Findings from the 1992 -1996 Medicare Current Beneficiary Survey. ” Health Services Research 37 (6): 1625 -1642 6. Zamosky, L. The Bogey Man Hiding in the Affordable Care Act. http: //blogs. webmd. com/health-insurance-navigator/2012/07/no-death-panels-in-theaffordable-care-act. html 7. Barr, B. A. Introduction to U. S. Health Policy: The Organization, Financing, and Delivery of Health Care in America. 3 rd ed. Baltimore, MD: John Hopkins University Press; 2011: 131 -136. 8. Copper, J. A. , J. D. Cooper, J. M. Cooper. (2006). “Contemporary Reviews in Cardiovascular Medicine: Cardiopulmonary Resuscitation. ” American Heart Association Journal 114: (2839 -2849) Retrieved from: http: //circ. ahajournals. org/content/114/25/2839. full 9. Workgroup Report on Hospice Care, Palliative Care, and End of Life Counseling. (2009). Retrieved from http: //www. oag. state. md. us/Healthpol/Hospice_and_Palliative_Care_Workgroup_Report. pdf 3. Rapheal, C. . , J. Ahrens, and N. Fowler. 2001. “Financing end-of-life care in the USA. ” Journal of the Royal Society of Medicine 94: (458 -461). 4. Vincent, G. K. and V. Velkoff. 2010. “The Next Four Decades: The Older Population in the United States 2010 to 2050. ” U. S. Census Bureau Current Population Reports P 25 -1138. 5. Mc. Clanahan, Carolyn. The Health Care Reform Post. http: //www. forbes. com/sites/carolynmcclanahan/2011/12/16/not-ready-to-die-who-should-pay/ 9. Center for Disease Control and Prevention website. http: //www. cdc. gov/nchs/fastats/hexpense. htm 10. Congress. gov website: http: //beta. congress. gov/bill/113 th-congress/house-bill/1339/text 11. Govtrack. us website: http: //www. govtrack. us/congress/bills/111/hr 3200/text

12. Maryland, H. a. (2009). Testimony for HB 1090. Retrieved from http: //www. hnmd. org/library/resources/documents/Committee_Activities_Legislative/2012 Legislative. Positions/Testimony. HB 1090 Palliative. Carein. Hospit als. pdf 13. Crowley, R. (2012). American College of Physicians Position Paper on Reforming Medicare in the Age of Deficit Reduction. Retrieved from http: //www. acponline. org/acp_policy/policies/reforming_medicare_in_age_of_deficit_reduction_2012. pdf 14. Vernon, S. (2012, December 18). How raising age for Medicare would affect seniors. Retrieved from CBS News: http: //www. cbsnews. com/8301505146_162 -57559633/how-raising-age-for-medicare-would-affect-seniors/ 15. Bronson, D. (2013, February 15). Letter to Senator Hatch regarding his Medicare/Medicaid reform proposal. Retrieved from American College of Physicians: http: //www. acponline. org/advocacy/where_we_stand/assets/letter_to_sen_hatch_regarding_entitlement_reform. pdf 16. Silva, C. a. (2011, January 10). Medicare about-face on end-of-life planning pay. Retrieved from American Medical News: http: //www. amednews. com/article/20110110/government/301109961/2/