Diane Meier made a compelling case for the PC provider to be involved in the policy process.
“The original sin”- of health care is that providers and patients determine what care is necessary with no regard to cost vs. benefit.

We spend 16.2% of GDP on healthcare, but rank 40th in quality indices worldwide. And that said, we spend 7.2% of resources on Paperwork/Admin, while the rest of the world is 3.2% We spend more on tests, hospitalization, etc.

So
WHY IS PC IMPORTANT TO HEALTH CARE REFORM (HCR) and Why is HCR impt to us?
Our patients (Chronically ill) account for majority of $ spent (but they have poor care and don’t get what they want (see teno Jama 2004:291:89-93) Medicare’s sickest 10% spend 37% of resoursces. Sickest 10%=$44,200 /yr vs 7,000/yr on rest. But the pts who get highest intensity of care report the lowest quality of care. (teno Jags 2005:53 1905-11.)

Does PC improve quality? Yes.
Per Casarett in Jags . If the patients with cancer recall Occurrence of Prognosis /goals of care they have better quality care, better grief process, lower cost.

If Rural patients with advanced cancer in NH and Vt received Telephone PC support from nurses, there was improved quality of life, symptom and less utilization. Survival interesting was longer but too small to be significant Bakitas M Jama 209 302 (7)341-9.

SO PC leads to better resource use, reduced bottlenecks in high cost units, and improved throughput (key to Hospital Directors) . We are the solution to this.

Here is one Conceptual model: Dedicated team=Focus + time= Decision making/clarity/follow through.
But this is Hard for administration. They think it’s happening. We need to make the case that it is not, and we can do this.
Email from CEO- “you mean no one is in control” YOU GOT IT.

And what is the Impact of PC Health affairs 2009

2% is the annual death rate in hospital
PC at minimum should do that. But ideal upstream and dc.

At 6% we can save a 300 bed hospital 3.15 million dollars

Here is the key:
Why HCR critical for PC
1. No GME dollars for fellowship
Cards /geri/ fellowship paid for by medicare
Pc fellowship paid by philanthropy ##1 threat to field
2. No loan forgiveness
Students with $140 K debt
3. No career dev support for junior faculty in medcal/prof schools
Geriatric career award is a model of how we can move forward

4. Inadequate NIH inv in ev base0.8% is invested from NIH in PC research
5. No compensation for distinct effort/skill of pc practitioners
Ex. Critical care codes get well compensated multi-organ, distraught families (hey those are our patients too)

6. No financial incentives (and have a neg incentive) for hospitals/NH, providers to deliver PC.
Some have even said won’t refer to hospice because they lose a lot of money (back to the original sin-
7. No reg requirement for PC services

Policies we need: Access and quality
To improve access we need a workforce (MD and nurses)
Financial incentive (positive reward)

No work force= no quality
we need Facuty to teach the next generation. So we need a PC training act
We need evidence base, therefore NIH must invest.

All of this is logical and simple, but to accomplish this is 10 yr process on Hill.
And the legislators really care about the local constituent. You need to be involved.

See the next post for how.
Paul Tatum