Curative+Palliative=New Hospice?

Prior to health reform, Medicare (federal program for 65+ and disabled) only covered palliative (non-curative) care for individuals on Hospice care.  Hospice is both a type of care and a philosophy for terminally ill patients, focused on management and alleviation of pain symptoms and spending the end of one's life with friends and family in a manner of dignity and peace.  The focus is on quality of life, rather than lengthening duration of life, or providing cures, and occurs on one's home or a hospice facility.   


With health reform becoming law, Medicaid (state-federal program for the poor) must now provide both palliative care and curative care for children with terminal health conditions.  Additionally, Medicare is instructed to start approximately 15 demonstration projects around the US (rural/urban mix) to test this palliative and curative combination.  Basically, the demonstration projects will be 3-year programs allowing individuals to receive all currently covered Medicare services while simultaneously receiving hospice care.  If the demonstration projects show benefits (defined as the impact on patient care and quality of life) without increasing costs, this could become a new policy for Medicare.  It is listed as Section 3140 of the Patient Protection and Affordable Care Act (PPACA) (and its reconciled Healthcare and Education Reconciliation Act) and is called the Medicare Hospice Concurrent Care Demonstration Program.  


What do you think the outcome will be?  Will this combination of therapies work?  Will costs increase?  Does the addition of curative therapies confuse the point of hospice care (to end life peacefully and with dignity)? Will this make the end of life easier or more difficult for families? 

Health Reform Makes History - What Does it Mean?

The House voted late Sunday March 21, 2010 (219-212 vote) in favor of sending the Health Reform Bill to President Obama. In addition, the House Democrats made some changes to the Senate's health reform bill (220-211 vote) which now goes back to the Senate. They must pass word-for-word reconciliation. As I post this blog entry, Obama is signing this long-awaited bill for the health of our nation.

32 million uninsured will now have health insurance. Excluded in this number are: illegal immigrants (who are also banned from purchasing in the health insurance exchanges), those eligible for Medicaid who won't enroll until they seek care, and those choosing to pay the fine instead of purchasing health insurance.

Here is a breakdown of (some of) what is included in this historical piece of health legislation.

Effective Immediately up to 6 Months From Now:
1) Insurers can't deny coverage to sick children (due to preexisting health conditions)
2) Free preventive care--screenings and preventive care must be excluded from annual deductibles on any new plans (all other plans affected in 2018)
3) No caps on lifetime benefits and restrictions on annual limits on coverage
4) Young adults allowed to stay on parent's insurance until the age 0f 26
5) Medicare Advantage (Medicare benefits delivered by private firms) gets cuts in spending in 2011
6) Children on Medicaid or state CHIP can't be dropped from now until 2019
7) Excise tax on tanning beds (10%)--"sin" tax
8) Individuals without coverage because of preexisting conditions can purchase it from high-risk pools (to be combined into exchanges in 2014)
9) Rebate of $250 for Medicare seniors in the "donut hole" for prescription drug benefits. First of incremental steps to close the hole (half-closed next year)

Effective in (or just prior to) 2014:

1) Individual Mandate--Everyone must purchase health insurance or pay annual fine of $95 (rises to $695 in 2016) unless they can prove financial hardship.

2) State health insurance exchanges--marketplace of insurance plans--goes into effect
3) Insurers can't deny coverage to adults with preexisting health conditions
4) Insurers required to cover maternity care same as medical procedures
5) Tax credits will start helping pay premiums for working families with incomes up to $88,000 per year
6) Medicaid expanded to cover more low-income people, up to 133% of federal poverty level
7) Medicare payroll tax increase of 1% for individuals making >$200k and couples making >$250k
8) New Medicare tax on unearned income of 3.8% (in 2013)
9) "Donut Hole" closing--Medicare Part D prescription drug coverage gap to be fully closed by 2020

Other items:

In 2018, "Cadillac health plans" are taxed 40% of value of the plan above thresholds (of $10,200 per individual or $27,500 per family)

The bill maintains longstanding federal funding restrictions (known as Hyde Amendment) on abortions. The exception would be in cases of rape or incest, or when the life of the woman would be endangered.

It is estimated by the nonpartisan Congressional Budget Office to cut federal deficits by $143 billion over the next decade. This bill is a landmark piece of legislation to improve the health of our nation's people. In my eyes, this is an incremental step (and focused on health insurance reform), but an amazing step nonetheless.

What are your thoughts about this this historical event, the passing of health reform?

Monkeys, Music, & Health Reform

Apologies for the absenteeism. Summer has been filled with passing my PhD Comps (hooray), traveling (e.g. Costa Rica & Panama), and working at AHRQ. No excuses really, but I give them nonetheless...

Here are some of my favorite recent stories from the Summer of 2009:

Eat Less and Live Longer. A team at the University of Wisconsin found that caloric restriction in monkeys was associated with reduced diabetes, cancer, and heart and brain disease. How did they do it? Reduce caloric restriction by 30%, and add a vitamin and mineral supplement to ensure adequate nutrition.

Internet Therapy. A recent study published in the Lancet says internet-based psychotherapy for depression works. Specifically, the used cognitive-behavioural therapy (CBT) in real time via the web. Will insurers pay for this type of therapy? Although recent trends say a push in therapy trends for depression is heavy on pharmacotherapy, psychotherapy may be more effective or less costly for those receiving treatment.

Pleasure from Music? Not for Depressed. It appears that the lack of interest and pleasure in depressed individuals is actually visible in neural brain activity. Functional magnetic resonance imaging (fMRI) shows that individuals with depression have less neural activity than non-depressed, even for simple activities like listening to music.

US Life Expectancy at All-Time High. The CDC's Center for Health Statistics revealed new mortality stats in their National Vital Stat Report. The United States life expectancy is now 78, all all-time national high (Japan, Australia, Italy, Canada all still live longer than us). Women are still living longer (life expec is 80.4 yrs) than mean (75.3 years), but the gap is narrowing. Deaths due to the 8/15 leading causes of death have dropped (e.g. flu, heart disease, stroke, diabetes), but raised for Alzheimer's, Parkinson's, and liver disease. Not to play devil's advocate to public health and prevention of disease (i.e. promotion of longer lives), but does prevention actually cost us more money in the long run?

Health Reform. Will it occur this year? Questions? Check the facts and falsities behind the bills and debates here.