Let's pretend everyone in a healthcare-policy working group is handed a government issued folder titled "The Congestive Heart Failure Project." I'm guessing that most legislators would be unable to define CHF despite the fact that it's the loudest knock in the engine that drives the cost of healthcare in America.[1] Imagine if that working group included healthcare professionals who actually understand that CHF patients are medicine's "frequent fliers" who flood medical venues on an hourly basis and boomerang back to hospitals within hours, days, or weeks of discharge.
All Ideas Welcome
"Where do these heart-failure patients live and why are they so ill? " asks one thoughtful committee member, and with that they begin to shape healthcare strategy.
A cardiologist thought leader flashes a slide showing a map of the United States. Dark crimson identifies states with the highest CHF death rates: Alabama, Arkansas, Eastern Kentucky, Louisiana, Mississippi, Oklahoma, Northern Texas, and parts of Alaska are blood red. She points out that lack of secondary education is directly linked to obesity, smoking, sedentary lifestyle, hypertension, diabetes, and coronary artery disease and asks for suggestions to tackle this problem "Don't be shy. Every idea will be considered," she urges.
The first idea voiced is more aggressive statewide smoke-free initiatives—in states where comprehensive legislation has passed, teen smoking decreases.[2] If these future parents spend their resources on a college fund for their children instead of cigarettes, it kickstarts a positive cycle of education, better employment, and better health. A physician and parent suggests, "Instead of discussing dress codes at school orientation, we talk about waist circumference and the Mediterranean diet."
This triggers a plea for an increase in physical education to a total of 45 minutes per school day. An exercise physiologist suggests a more organized approach that includes tax incentives for large and small businesses that monitor and promote daily exercise for their employees. Another member of the working group proposes a revamp of the primary and secondary education curriculum to include health literacy.
A diabetologist at another table suggests a guideline change to encourage HbA1c and glucose tolerance tests for all patients with any manifestation of arteriopathy, noting that a 2-hour glucose tolerance test costs about $49 out of pocket. "Dialysis units are full of patients who were diabetic for a decade before they were diagnosed," he explains. "The goal should not be to control type 2 diabetes, but to cure it." The cardiologist concurs and gives the example of a 58-year-old with a coronary artery calcium score of 1000. "How did it get that high, what are the inflammatory drivers? We should not just throw pills at people to lower their LDL-C and blood sugars. We need to get at the front end of these diseases," she declares. Everyone at his table appears shocked but nods their heads in agreement.
"Fat chance of that happening!" bemoans another physician member, oblivious to the unintended pun, "CMS won't even pay for a basic calcium score that costs about $100 and could save billions in the cost of GI bleed admissions for unnecessary aspirin or statin therapy in elderly folk with a calcium score of 0."
"What's a calcium score?" whispers the congressman from Kentucky. The diabetologist leans across the aisle to explain that it's a test with a little radiation exposure that stratifies heart-attack risk. "Well, why won't CMS pay for it?" he asks, a bit annoyed.
The Empowered Pharmacist, Barber, Dentist . . .
A pharmacist is encouraged to suggest, "Let us participate in treatment. We can titrate meds if the prescriber outlines a clear plan at the time of e-script transmission."
A hypertension specialist pipes up. "Put blood-pressure cuffs in places where people show up repeatedly, like quick marts, hair salons, and barber shops. That study has been done and it worked," he adds emphatically.[3] A legislator recognizes an opportunity to endear himself in the eyes of his constituents and proposes "tax breaks to all merchants that offer blood-pressure checks with an automated machine and chart displays explaining the readings and what to do if the reading is high. We put posters about employee rights in every business. Why not this?"
An advisor to the committee (not from Virginia or Eastern Kentucky) suggests "incentives to promote blood-pressure screenings at the dentist office. After all, strokes are very expensive and uncontrolled high blood pressure drives heart failure."
"Speaking of expensive, let's tackle end-of-life care," suggests the congresswoman from New York, acknowledging that former President Obama got creamed for it. "Could we do some kind of public-service announcement on how to broach the topic of DNRs in the geriatric and terminally ill populations? Who really wants to spend the last few days of their life on a machine?" she asks.
Another thoughtful legislator laments that all of this is well and good, but his clinician constituents complain that tests are repeated because the acute-care provider can't access the patients' medical records. He is emboldened to propose legislation that requires every EHR to allow access by a central server. "If the VA hospitals can do it, why not all? That would cut a chunk of change."
Patient and Clinician Compliance
A nurse suggests asking patients to take home their last progress note. "And by progress note, I mean an easy-to-read list of meds, tests results, and practical follow-up information given to every patient discharged from the hospital, not a confusing series of grids and pages of extraneous information," she laments with exasperation.
For patients with CHF, this nurse proposes a brown-bag review within a week of hospital discharge, where patients are asked to bring in all their meds and explain when/how each is taken. Initiatives like this expose prescription errors and patient confusion early in the process. "Nurses should also call these patients weekly to encourage dietary and medication compliance," she added.
Our cardiologist concedes that providers participate in treatment failure by forgetting to give CHF patients basic instructions on the importance of daily weighing and on how to identify sodium in their diet and avoid overdrinking. These omissions and noncompliance render heart-failure medications as effective as a TV remote with the AA batteries in backward. "Instead of penalizing hospitals for 30-day readmits, let's directly penalize if they fail to document these instructions. That would be more effective," she concludes.
A representative reminds the healthcare professionals that we need to enlist the help of insurance companies. A few physicians mumble that they hope the insurers' "help" won't just be refusing to pay for tests. "Anyone with an ounce of common sense can see that preventing a $30K hospital admission is more effective than denying a $1500 nuclear stress test," rues the cardiologist.
"Are there any representatives from the big three insurance companies here?" No one raises their hand, and the legislator jots down a reminder to invite by the end of the week.
Our pharmacist brings up drug repository programs such as the one in Iowa for poor and indigent patients where deprescribed meds and meds of deceased individuals can be dispensed. He suggests that such drug recycling could help cut readmissions driven by the inability to access meds.[4] He's on a roll now and has another suggestion for boosting compliance: discharge cognition testing in patients over the age of 70. "I read that if a patient couldn't draw a clock, then compliance was deplorable," he explains.[5] Several committee members nod their heads in agreement.
That brings the morning session to a close. "Think long and hard about this $30-billion conversation we're having. Half of all CHF patients will die within 5 years of diagnosis. What have we tried that works and what doesn't. Come back in 1 hour with more great suggestions," challenges the cardiologist thought leader.
"Guess we'd all better order the Mediterranean diet," quips the senator from West Virginia as they all head for lunch. "And to think I had no idea what it was before this morning," he adds, pointing to his information packet.[6]
My plea to our nation's politicians is to give a voice to representatives of all areas of healthcare so a working group like the one described above is not just a figment of my imagination. Using teleconference capabilities and some organization, amazing legislation could be fashioned in a matter of months. That's what we need.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: The Missing Link in Healthcare Policy: Constructive Conversation - Medscape - May 24, 2017.
Comments