How will CCM be affected if Obama's health care plan becomes a reality?

[RussianJoo]

I am interested in anesthesia and was planning to do a cardio-thoracic fellowship and then a CCM fellowship so that I could split my time between the OR and the CT-ICU. The only intensivists I know are emplyoed by the hospital so it doesn't matter what they bill for they have a salary, how are intensivists that are in private groups reimbursed for their work? How is the medicare reimbursement rate compared to private insurance rates? How negatively do you think Obama's health care will impact those reimbursement rates? I am asking because everyone predicts that the field of anesthesia is going to be screwed if/when Obama's plan comes into action, so if I chose to do critical care will that be impacted less?

I know no one knows for sure but what are people thinking, what are the rumors in the CCM field?

thanks for your replies.

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[josephf1]

actually from what ive heard reimbursemetns are so low for CC already they wont get any lower. If anything other specialists will make more in line with critical care. What might hurt CC is if Obama gets the death panels in to ration health care and then they say after a certain age no dialysis, no ICU, etc like in Europe. Then 1/2 all of critical care bilable cases are history, since most of it is spent on the last year of some gomers life, many of whom would be economically better off in hospice care (at least thats how the bean counters think).

 

[RTrain]

All you have to do is read SDN to see how intensivists will be affected by health care reform: our children will starve to death, our homes will be bulldozed to make room for statues of Lenin, our brains will be repossessed, and our patients will be summarily executed by "death panels." It will be hell on earth, exactly like Denmark or Canada. Duh.

 

[souljah1]

What is going on now in our government with regard to health care is NOT health care reform. It is health insurance reform. Providing insurance to people who don't have it and to partially regulate private insurance companies will do little to affect the lives of intensivists.

If you look at the critical care health services literature, there is a huge difference between the care delivered by multi-disciplininary care teams led by intensivists in a closed ICU compared to open ICUs where internists and surgeons manage their patients in a private fashion. The future of critical care organization and delivery MUST take on the fact that the baby boomers are aging quickly and will do so in a system with a projected shortage of critical care physicians. Intensivists will be desperately needed!

We do have a responsibility for health care reform, though. A substantial amount of our GDP is spent in the ICU - where we often treat the trees with little attention to the forest. Additionally, there is a large variation in resource consumption with no effect on outcomes. Physician behavior plays a large role in health care waste. Critical care is no exception. With a mortality rate ranging between 15-30% in ICUs, we need to better predict who will benefit from critical care resources and who will not. That is not a death squad. The strain on health care resources by treating patients who derive no benefit from our treatments will only grow and tax our system more.

 

[The right Path]

What is going on now in our government with regard to health care is NOT health care reform. It is health insurance reform. Providing insurance to people who don't have it and to partially regulate private insurance companies will do little to affect the lives of intensivists.

If you look at the critical care health services literature, there is a huge difference between the care delivered by multi-disciplininary care teams led by intensivists in a closed ICU compared to open ICUs where internists and surgeons manage their patients in a private fashion. The future of critical care organization and delivery MUST take on the fact that the baby boomers are aging quickly and will do so in a system with a projected shortage of critical care physicians. Intensivists will be desperately needed!

We do have a responsibility for health care reform, though. A substantial amount of our GDP is spent in the ICU - where we often treat the trees with little attention to the forest. Additionally, there is a large variation in resource consumption with no effect on outcomes. Physician behavior plays a large role in health care waste. Critical care is no exception. With a mortality rate ranging between 15-30% in ICUs, we need to better predict who will benefit from critical care resources and who will not. That is not a death squad. The strain on health care resources by treating patients who derive no benefit from our treatments will only grow and tax our system more.

Amen. I would place more of the "blame" for expensive, futile "care" (care defined as continuous painful, diginity lowering treatments and procedures with very little mitigation) on the attitudes and misguided intentions of healthcare proxies. That's why "death panel" hype has such effective emotional appeal.

 

[souljah1]

Amen. I would place more of the "blame" for expensive, futile "care" (care defined as continuous painful, diginity lowering treatments and procedures with very little mitigation) on the attitudes and misguided intentions of healthcare proxies. That's why "death panel" hype has such effective emotional appeal.

I do find it interesting that over the past 50 years or so we have moved from a strong paternalistic view in medicine (fanatically) to patient autonomy (fanatically). The right thing to do is somewhere in the middle. What is implicit to patient autonomy success is an informed patient. That isn't all that difficult to do when counseling someone on blood pressure. When someone is in the throws of critical illness in the setting of terminal disease it becomes much more difficult. It is even more difficult when the patient is too sick to communicate for themselves and has a proxy to speak on their behalf. I've watched family members actively choose to treat their own fears and grief by saying "we want everything done" or "do whatever you can" and not do their job of making an informed decision based on what the patient would want. Patients and their surrogates make poor decisions when they are paralyzed by their emotions. Physicians make poor decisions when they rush not to abandon patients therapeutically at the end of life, but abandon them prognostically.

Physicians often do terrible jobs in informing patients. For example, how many patients with metastatic solid organ malignancies, relapsed AML s/p allo-BMT, decompensated cirrhosis and not a transplant candidate (etc) have meaningful and multiple discussions with their outpatient doctors on their goals of care, what they never would want to have done to them, and where they want to die? Far too often, goals of care discussions and end-of-life decisions are made in the ICU when someone is at the end of their life. To me, that is our system failing. That is way too late. It also leads to needless suffering for both patients and families - prolonging the dying process. For some, their ICU stay occurs in the setting of no significant PMH (pregnant/H1N1/ARDS, new diagnosis of AML in DIC, etc). But for many, their ICU admissions occur as part of a lengthy repetitive inpatient process spent aggressively seeking cure when in fact their prognosis argues strongly for palliation.

There have been some interesting studies that have looked at post-ICU satisfaction among families of patients who had ICU stays. The families of ICU survivors where less satisfied compared to families who had a relative pass away in an ICU or transitioned to hospice. Perhaps that suggests regret? Maybe when they go visit their loved one at an LTAC with their Trach, PEG, and post-ICU depression they begin to think that they made the wrong choice. Who knows..

 

[The right Path]

From my experience, I would have to say for the most part that the physicians I work with are quite clear and realistic about expectations for functional recovery let alone short or long term survival. It's the family members just not wanting to hear/accept it. There is unfortunately, a lot of pressure for physicians to cater to family member's wishes regardless of how unrealistic their expectations are. I'm all for primaries to be reimbursed to discuss end of life issues with their patients. I think a bigger barrier than insurance and legislation issues are peoples' attitudes. They just don't want to address it- not when there is the time and presence of mind for rational thought, and not when they or a loved one is in extremis.