Apr 17, 2020
In this podcast, Dr. Nicholas Schneeman, a family medicine physician specializing in geriatrics, and chief medical officer for LifeSprk, presented at Ridgeview Medical Center's Live Friday CME Series - Annual Dr. Lehmann Lecture Series, on February 14, 2020. At this annual event, Dr. Schneeman talked about value based care for the elderly, as well as moving away from the confusing, unfruitful and sometimes dangerous fee for service model we are currently practicing.
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Dr. Nick Schneeman is a family medicine physician who specializes in geriatric medicine, and has a keen interest and expertise in value based care for the elderly, as well as moving away from the confusing, unfruitful and sometimes dangerous fee for service model we are currently practicing in. Dr. Schneeman is currently the chief medical officer of LIfesprk, and had over 30 years of clinical experience caring for this very special patient population. He joined us on February 14, 2020, for the annual Dr. Jim Lehmann lecture covering a variety of geriatric topics. Dr. Lehmann served his patients for many decades. Joining him and others in the audience today was the Spanus Family who helped fund this endeavor. Do sit back and enjoy the program. It is sure to make you think about how you fit into this complicated dilemma, but more importantly, how you can be part of the solution.
The way in which to fix the geriatrics dilemma is to understand the quality and cost factors on a very deep level. We will have 1 billion elderly patients in the world in the next several years. In the 1930s, only 3 to 5 % of the population was seniors, now we are at 20+%. To further complicate this statistic, senior citizens age 85 and older have a significant cognitive impairment rate of 50%.
In the U.S., Medicare is the single payer system for our senior citizens. There are segments inside of Medicare where the costs are exorbitant, including the last 2-years of life where they go up 6-to-7 times what they were up to that point. Put another way, half of an individual's Medicare budget is spent in the last 6 months of life. Much of these costs unfortunately are very wasteful. Medicare is not sustainable in its current form; and it is going to continue to threaten our national economy.
Edith is 86 years old and lives in her own home by herself. She has a doctor who she loves. Mild ailments have ensued and she no longer drives. Her son and daughter check in periodically and neighbors lend a hand at times.
Dr. John Goodparent and his partner Dr. Rachel Cakeandeatit are partner physicians who take care of Edith. They are a different kind of physician than the physicians of old, though, mostly working for large health systems with maximally loaded schedules. In addition, they are working either in the clinic or hospital, and no longer both.
Lately, Edith's daughter, Connie, has concerns and has been calling Dr. Goodparent. So, he sees her in the clinic and determines she has had some chronic cerebral ischemic changes, so refers her to a neurologist who performs a battery of tests with no resolution. Sinemet is tried for what is felt to be some Parkinson's issues. Connie comes to the house and finds her in a bit of disarray. She takes her to see Dr. Cakeandeatit who determines she's depressed, so givers her a sample of an SSRI. Her UA is dirty although no symptoms of UTI, but antibiotics are started nonetheless. Connie takes time with her at home. Edith improves a bit. Up until now, her care has been paid for my Medicare financial driver domain clinic. Physician incentives are pretty bad in this model. No value in the extra phone calls, etc., and you can't crank this kind of patient through the clinic in a 10-minute appointment slot. Not to mention having to juggle and address all the calls from Connie and other concerned parties.
Connie leaves town for a bit, and about a week later, Edith's son visits and sees her in a disheveled state. Now she's brought to the ER and meets Dr. Saverlife. Weakness and low grade fever are noted. Parkinson's history is acknowledged, with Lexapro and Sinemet on board, as well as a bunch of other new medications in the past several weeks to months. Final ER diagnosis is recurrent UTI and mild CHF. So a little more diuretic and now a fluoroquinolone are added.
Well, a short while later when a neighbor finds that she now has stacked newspapers on her front porch and Edith is found to be stool-stained and stuck between the wall and her toilet. 10-days in the hospital ensue, with a new diagnosis of C diff colitis. She is in A-fib with RVR. Multiple consultations happen. Abd CT and colonoscopy are performed due to a Hgb drop. SNF is recommended but the patient and family refuse. So its back to home again; her medications are tweaked to now include a PPR and Seroquel.
This current care is driven by domain hospital, and the hospital is paid a value-driven lump sum of money called a DRG. Administratively, we are pushed to get patients through the hospital and turn beds over. As providers, we are incentivized by part B, which is volume driven. See more patients and get paid more. Quality is not as rewarded.
Edith now falls down at home, has a hip fracture. Ativan is given, and more Seroquel due to increased delirium. IV fluids are given throughout her care. She's discharged now to a SNF. The 10-day old H and P is noted and her d/c orders, but there is no d/c summary yet from this hospitalization. Due to the hyperregulated state of SNFs, a lot of documentation must take place, orders, Q/A parameters, etc. The nurse calls the on-call doctor who has no prior knowledge of this patient. This care is paid under Medicare nursing home domain, which is a split system. The SNF gets a daily rate based on how much therapy the patient needs. Just recently this has transitioned to payment based on the patient's diagnoses. While we should be incentivized to help manage the patient under this system, we ae still driven by fee for service and volume on Medicare part B, meaning uncompensated calls and no resource management incentives either.
Edith doesn't really participate in rehab, demonstrates increased confusion and another urine is checked off the foley. Because it looks infected, she is restarted on Levaquin and an increase in Seroquel is also ordered. Big surprise here she continues to deteriorate, leading her down any number of etiology pathways for her further decompensated state. Edith is now back in the ED. And has entered the revolving door of rescue, rehab and relapse. Unfortunately, quality of care in this paradigm is suspect as best. It becomes a bit of a crap shoot, and there's little respect for consideration of patient autonomy. We've all experienced this, right? How do you have a meaningful "goals of care" conversation with patients and family when they're figuratively "stuck in the mud" of dilapidated care. There's obviously significant difficulty in obtaining informed consent. Drug cascading is highly prevalent. And as Dr. Schneeman eloquently illustrates for us, this is a complex issue made more complex by polypharmacy, limited time with our patients who are elderly with multiple comorbidities and multiple silos of care weighing in to crate a low quality, hyper expensive healthcare delivery model.
How has the healthcare industry responded? We've done a lot of work-arounds. Care coordination being one big "fix"! This notion started in the 1990s. CMS has funded a number of trials looking at the topic of Care Coordination. Many different strategies exist, but nothing has worked. In 2011, there was an initiative from private industry to fi healthcare for example.
Dr. Jeff Brenner attempted to find a way in which we can use date to coordinate care for the 3-to-5% of hyper expensive patients within the Camden Coalition. But unfortunately this endeavor yielded no results. They couldn't fix things, per a recent follow-up article in the NEJM. There was a further attempt to tease out what could be of value in the 15 studies looking at care coordination. 1. Comprehensive d/c planning; 2. Timely communication of information; 3. medication reconciliation; 4. patient caregiver education with teachback; 5. open communication b/w providers; 6. prompt f/u visits with a provider.
As Dr. Schneeman points out, medication reconciliation does not really improve risk benefit discussion and the truth is many of the drugs our senior patients take are in fact problematic and dangerous most of the time as well. It does not teach us how to unwind the drug list. Big pharma has had a heavy hand in how these drugs have been used over the years, including off label use. The intermittent confusion our senior patients have is not due to asymptomatic bacteriuria. C-diff colitis in a fail old person is potentially life-threatening, not to mention the other adverse effects brought on by antibiotics given for this reason. Patient education with teach back doesn't really teach us anything. Open communication about cancer screening with limited life expectancy does not validate the notion of open communication. Prompt follow-up does not address the fact that blood pressure medications are not getting deescalated, nor the fact that the marginally functioning demented patients will still have an unavoidable and predictable decline regardless of what we do. Finally, per Dr. Schneeman, comprehensive discharge planning does not address the lack of science to help guide us in treating our patients with the comorbidity of progressive dementia. These very patients are in fact excluded from the trials that originally brought these drugs to market!
So what's going on here? Well, we're part of the problem as clinicians, for one. Secondly, we're living in a country where being multimorbid and elderly is not a good thing when it comes to quality of health care.
On a positive note, we have an opportunity to be part of the cure. In other words, we have the opportunity to begin thinking and acting on the real cost of the care we're providing, as though we are paying for every penny of it. The selling-off of primary care clinics has been an issue for physicians and has taken them out of the discussion of the bottom line. There is poor accountability for cost and quality, due to lack of peer review within our silos let alone across silos. Compensation is not equated to value, and unfortunately there are still some unscrupulous techniques from industry to try and inform our practice. We're also taught in a way that doesn't fit with the Edith's of the world nowadays. The "chief complaint" from Edith is a syndrome and not a single complaint. We can all relate to this.
Medicare Advantage is a platform that allows physicians to get paid based on quality of care. Dual eligible programs are also out there. As well as new payment options on the horizon, such as the Independence at Home demonstration project. Basically compensation for providing complex, in-home care.
Medication delivery devices, sensors and other tech that is out there to help us provide more care is proliferating. New brick an mortars are also popping up and are attaching Medicare Advantage to the underserved elderly communities. And then of course, there are more and more Dr. Schneemann's out there who want to provide complex, in-home care.
So what can we do? 1. Accept that we participate in low value care; 2. Subspecialty care needs to be just that, and no longer the primary care providers for these elderly patients. Ultimately the core solution is team base, flat hierarchy and a cultural shift to one of accountability across silos, thus creating a safety net for our patients.
The physicians are the ones who need to take this bull by the horn, and not rely on guidelines solely. We are in the trenches and must be negotiating the trajectory of care. Getting involved in a value based care and compensation model is imperative. It can be a double-edged sword though. We need to provide the appropriate care when it's warranted, but also not withhold care to save or make more money. The onus falls on us to e the experts and to rebuild the current construct. Let's stop merely ordering a bunch of stuff and begin to have those conversations with patients and families to understand and clarify goals and realistic outcomes before committing to multiple diagnostic tests and polypharmacy. This is made difficult in patients with cognative impairment, but it can be done!
Well, it's a happy ending after all. Edith survives her last hospitalization. And as it turns out there is a geriatric specialist working for a geriatric center of excellence, who takes over her care. She is able to access her care and chart 24/7. Medications are deescalated, and the fog is lifting. Edith is now participating in therapy. While a moderate fall risk exists, she is more independent and now using a walker, and she gets Meals-On-Wheels. Edith is now teed up to move into an assisted living facility. In addition, she has advanced care planning with a team trained to do this. A POLST form is completed and while Edith and her family can consider 911/ER visits, she is DNR/DNI with a tilt toward hospice care in the setting of a major health complication or event. Home based care is the new focus and guess what...people working for Edith actually love their jobs.
Geriatric centers of excellence can be virtual; and they are made up of compassionate people providing personalize care that is also profitable. That's a lot of "P's".
Questions from the audience were
addressed by Dr. Schneeman as follows:
How do we help patient and families make those decisions and changes in care plans. Well, its never easy to make that kind of decision during an emergency. But it is made easier by having a long-term patient relationship in this desirable model, something that spans over months to years, where the home based care team is at the forefront of the patient's care experience. They will help patients and families make realistic decisions and will obviate the option of "let's give it one more try!", suggested by the well meaning son who's visiting from California and hasn't been home in a couple years.
In regards to "how do we fix this?", the new payment and reimbursement programs can and will. Essentially making geriatric care a subspecialty level compensation model. New practitioners and nurses are hungry for vocation and meaning in their work. Bottom line though is that fee for service for this demographic is not sustainable.
Are there local geriatric centers of excellence presently? Not yet, but the pendulum is swinging. Recruiting and employing physicians, nurses, APPs, and others who want longitudinal relationships with patients, and who have the personality and passion for this vocation will help to create such centers. It will be both exciting and game changing.
Thanks so much to Dr. Schneeman for his time and expertise on this topic, and to all who care for this special population of patients in our community.