Radical vs. Sensible
Hospital medicine had grown rapidly and provided the platform for change in our nation’s hospitals long before there was any meaningful healthcare legislation in Washington. With President Obama’s appointment of an innovator—Don Berwick—to head the Centers for Medicare and Medicaid Services (CMS), there is increased opportunity to ramp up revisions, large and small, to provide the incentives and the impetus to create a healthcare system for the 21st century.
With that in mind, I thought I’d offer a few ideas that Don could institute on Day 1, which could start us in the right direction, or throw us all into chaos, depending on how it plays out. While most of my attention is directed to the Medicare population, all of these ideas would be equally applicable to the commercially insured population.
Advanced Directives
We all know that too few people in this country have taken the opportunity to discuss with their families and their personal physicians how they want their care managed at critical junctures, whether it comes on suddenly with an accident or with aging. The suggestion that Medicare would pay for an office visit with your doctor to discuss this imploded with the news media’s fanning of the “death panel” flames first stoked by Sarah Palin, which sidetracked all rational discussion.
Besides setting up people for unwarranted and unwanted assaults and protracted misery, mismanaging the end stages of life leads to an enormous misallocation of physicians’ focus at a time when we all need to be mindful stewards of our limited healthcare resources.
It is acceptable if, after careful consideration, anyone chooses to not have any advanced directive, but it should be a cognitive directed choice, not just a failure to engage.
Therefore, I am proposing that Medicare offer an incentive (e.g., waiving co-payments or deductibles) to have all Medicare beneficiaries complete an advanced directive annually, or sign a form indicating they were offered an advanced directive and declined to have one invoked. In addition, Medicare could set up a system that would allow physicians (or facilities) who would manage the patient’s healthcare to have access to the conditions of the advance directives. The forms could be attached to individual Medicare profiles, possibly on the Web, in addition to being held by a patient’s PCP or medical home, if they have one.
Personal Health Records
Most people in this country can access most of the information about their personal financial status in real time from any computer in the world. Less than 10% of Americans can retrieve meaningful personal medical information. This is in spite of the prevalence of Web-based personal health record (PHR) software from Microsoft, Revolution Health, and other software vendors, along with Kaiser Permanente and a handful of insurance companies.
PHRs allow for an initial baseline set of data to be recorded and updated as new tests, diagnoses, and medications are employed. It allows for a composite knowledge of what has been tried in the past and what is being utilized in the present. This can be under patients’ control, but it would allow for appropriate access at times of acute need (e.g., an ED visit or a hospital admission).
Too often, patients with a long-term relationship with a local PCP present to the hospital and all of the healthcare professionals are forced to make critical decisions in the first few hours with insufficient or inaccurate information. This leads to needless repetition of tests or inability to compare current data with previous data (wouldn’t it be nice to have the last EKG or labs?), or in retrying a treatment regimen that hasn’t worked in the past.
