November 16, 2017

Rounds: A message from the President and CEO of VUMC

Over the year, Congress has repeatedly attempted to “fix” healthcare by altering the funding streams between states and the federal government, as well as to commercial insurers. All of this might lead one to think that Congress is focused on the most important problems facing healthcare.

Real healthcare reform

Dear Colleagues,

Over the year, Congress has repeatedly attempted to “fix” healthcare by altering the funding streams between states and the federal government, as well as to commercial insurers. All of this might lead one to think that Congress is focused on the most important problems facing healthcare.

Jeff Balser
Jeff Balser, MD, PhD

Efforts by Congress to repeal and replace Obamacare have also failed to repair the healthcare exchanges which provide the majority of individual health insurance options to Americans. As a result, people purchasing healthcare on the exchanges are experiencing large cost increases. Yet only 9 percent of people in this country purchase individual health insurance. The vast majority — 91 percent, or 290 million — receive health insurance from their employers (56 percent) or through Medicaid (19 percent) or Medicare (16 percent, because they are over 65).

Because of this, despite the relentless news cycle, the vast majority of Americans have not been directly impacted by the country’s problems with its healthcare exchanges. Yes, we’ve been anxious about the annual increases we’ve seen year over year in our deductibles and copays.

But those increases are no higher now than they were a decade ago. As such, most of us are barely aware that behind the scenes, the real cost of healthcare — paid for mostly by companies purchasing commercial insurance for their employees and by the Medicare system — is escalating out of control.

In fact, the expense for healthcare is still growing at 6 percent per year — that’s more than twice the rate of overall annual inflation. And the truth is, many employers purchasing health insurance have reached the limit of what they can afford and still remain in business. Most businesses in the U.S. are now looking at ways to shed significant portions of their employee healthcare costs. As they do, healthcare will become an even larger personal expense for most people — a sizeable chunk of the average American’s household budget.

What does this mean for us at VUMC? While we pride ourselves, with plenty of solid evidence, that we are providing the highest possible quality of care to patients, are we equally convinced that we are doing all we can to deliver the highest value — that is, the best quality at a given cost? A recent survey published by PLOS One affirms the belief held by many U.S. physicians that overtreatment is common, is potentially harmful in some situations and adds waste to the health system.

For example, let’s consider a thorny issue in this realm, the care we provide near the end of life. As many of us know, VUMC’s extraordinary capabilities in subspecialty care cause many patients to come here with serious diseases and few options remaining. Are we effective in managing the balance between giving patients and families hope and providing realistic expectations in those challenging circumstances? And are we as proactive as we could be in helping people understand the limits of treatment, attain relief from suffering, and, when appropriate, secure hospice care, thereby minimizing expense for futile, heroic measures?

The national data suggest otherwise. In the U.S., more than 40 percent of patients who die from cancer are admitted to an ICU in the last six months of life. A Kaiser Family Foundation analysis on end-of-life spending found that Medicare per capita spending in 2014 was nearly four times higher for those dying the same year, at $34,529 per patient, compared to survivors, at $9,121 per patient. In fact, more than 30 percent of Medicare spending goes toward the five percent of beneficiaries who die each year, and one-third of that cost — hundreds of billions of dollars annually — occurs in the last month of life. This massive expense — among the highest of any developed country in the world — is a significant factor fueling the uncontrolled spiral in the cost of U.S. healthcare.

Are we doing all we can to help patients and families make the best possible decisions? A recent report by the National Academy of Medicine found that while outcomes for patients in hospice consistently show better quality of life, not only for the person with serious illness but also for their family, there remain huge geographic variations in the use of hospice care in the U.S.

Moreover, a 2015 Kaiser Family Foundation survey found that 89 percent of adults say physicians should discuss end-of-life issues with their patients, yet only 17 percent of survey respondents said they have had such a discussion with their healthcare provider. Consequently, 44.5 percent of Medicare beneficiaries see 10 or more different physicians during the last six months of life.

As a leader in healthcare, for both the nation and this community, we have an opportunity and an obligation to effect change. An End-of-Life workgroup, led by Dr. Bonnie Miller, Executive Vice President for Educational Affairs, and Dr. Lee Parmley, Chief of Staff for Vanderbilt University Adult Hospital, is already working in support of compassionate care for patients and their families at the end of life. Specifically, we will work to assure that all adult patients have Goals of Care documented in eStar, including preferences for end-of-life care. These goals will be patient-oriented and clinically sound, and available to clinicians and patients at all times. Through different approaches tailored to the unique needs of children and families, we are developing strategies for our youngest patients at Monroe Carell Jr. Children’s Hospital at Vanderbilt.

Already, we have outstanding research and patient care taking place around end-of-life care through the Palliative Care Team led by Dr. Mohana Karlekar. Palliative Care, like Hospice Care, is focused on providing comfort, but applies at any stage of any disease, whether chronic or in the terminal phases of an illness. To provide the most effective care, a full appreciation and understanding of these care models and how they can be most helpful for each patient’s circumstances and prognosis, will be essential.

At VUMC, we are exploring these modalities across an array of care settings. For example, a multi-specialty team just launched a study examining the impact of palliative care services for patients with advanced liver disease, while the Vanderbilt-Ingram Cancer Center, through the Centers for Medicare and Medicaid Services Oncology Care Model, is hard-wiring end-of-life care planning into care conversations.

So as Congress endlessly debates insurance reform, what can we do to effect real healthcare reform? Let’s start by providing the most thoughtful and compassionate care possible for the patients we cannot cure.

Jeff Balser, MD, PhD
President and CEO, Vanderbilt University Medical Center
Dean, Vanderbilt University School of Medicine