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Insurance type tied to dying dementia patients' care

By Andrew M. Seaman

NEW YORK (Reuters Health) - The chance that nursing home residents with advanced dementia will receive inappropriate care may be related to their insurance coverage, a new study suggests.

Fewer dying people with dementia were moved to the hospital for possibly unneeded care when their insurance coverage paid on a per-patient basis, rather than for every test and treatment, researchers found.

NYU School of Medicine's Keith Goldfeld said so-called managed care organizations are motivated to stop people from receiving unnecessary and costly care.

People with advanced dementia won't usually benefit from being hospitalized during the last months of life for acute ailments like pneumonia, Goldfeld, the study's lead researcher, said. The focus should be on making the person comfortable.

"When the focus is on comfort, the idea is to try to limit the type of care that could be burdensome for the patient and costly," he said.

Nursing homes may want to send very sick residents to hospitals because it shifts the cost of treating them from the homes to the hospitals and Medicare, the government-run health insurance for the elderly and disabled.

Traditional fee-for-service Medicare pays doctors and hospitals for each service provided.

On the other hand, managed care organizations receive a lump-sum payment for each person they cover. That encourages them to keep patients in nursing homes where costs are lower.

Using data from an existing study, the researchers compared 133 nursing home residents in managed care organizations to 158 covered by traditional Medicare.

They analyzed each resident's care during an 18-month period between 2003 and 2009.

Compared to people on standard Medicare, patients covered by managed care organizations were more likely to have do-not-hospitalize orders, the researchers found. Those notes prevent nursing homes from sending people to the hospital at the end of life.

Overall, about 4 percent of managed care beneficiaries were hospitalized compared to about 16 percent of those on traditional Medicare.

Medicare files showed 19 out of 20 people with each type of coverage died by the end of 2010.

"It turns out that they may not live longer even if you send them to the hospital," Goldfeld said.

People enrolled in managed care organizations also had about three times as many primary care visits with nurse practitioners, who may be stationed at nursing homes by the organizations.

"There is no question that the care that was provided in nursing homes was superior to the care they got in hospitals," Dr. William Hall, who wrote an editorial accompanying the new study in JAMA Internal Medicine, said.

Goldfeld said managed care organizations could have been motivated to initiate discussions with families about end-of-life care.

"To the extent managed care organizations are incentivized to have these conversations, they will increase the number of people with (do-not-hospitalize) orders and decrease the number of people sent to the hospital," he said.

Hall, a professor of medicine at the University of Rochester Medical Center in New York, said people should not switch to managed care organizations solely based on these findings.

He also said families should understand the nature of diseases like Alzheimer's and what can be done for the patient.

"One thing they should know is that the aim here is death with dignity. That rarely means putting someone in the hospital at the end of life," he said.

SOURCE: http://bit.ly/16CpZ1b JAMA Internal Medicine, online September 23, 2013.

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