>>> More people are choosing hospice care and living longer and that's a problem for
Medicare. >>> I look at those pictures and I think where
did they go? >> Yes, yes.
>>> The first time L. C. Danced with Betty, he shoe she was the woman he would marry,
now they look back on a lifetime without regret. >>> Can't explain about nothing.
Really, if I did, I would be a fool. L.C. is 89 years old he's dying, he has stage
4 heart failure, his breathing is labored, it's difficult for him to walk from one room
to the next. The constant pump of the oxygen machine reminds
everyone in this house L.C. is not well. Congestive heart failure is one of the most
common reasons people over 65 are hospitalized. Will you tell L.C. hasn't been to the emergency
room in two years, instead he's chosen hospice care.
>>> How are you doing today, L.C.? >> I'm doin' good.
>>> He gets regular home visits from his family doctor and a team of nurses and therapist.
His symptoms are being palliated, which means they can't cure him but they can make him
comfortable as his heart grows weaker. >>> Deep breath in.
>>> To be eligible for hospice a patient must
have terminal illness and six months or less to live.
When Medicare introduced the benefit back in the 80s, most hospice patients had cancer,
today the most common conditions are those that make predicting death difficult, Suzy
Johnson president of sharp hospice care. >>> The things that make it difficult are
Parkinson's, con guess active heart disease, the trajectory is different, it takes a lot
of time and then they begin to decline and then they go.
>>> Across the country and in San Diego more people are choosing hospice, ten years ago
it was a much smaller number, in 2011 it grew to 2400, there are a growing number who live
past six months, in San Diego county 1 in 9 outlive their six month prognosis in 2011.
Every day they're in hospice costs the government money.
Under pressure to save money and find fraud Medicare wants to know were they really dying?
San Diego hospice, the largest in California has been the subject of a Medicare investigation
for the past two years. Kathleen Tecure is the head of San Diego hospice.
>>> We have narrowed the window because we're look at it through a strong lens of compliance.
>>> They discharge patients they deem as eligible, in other words, not terminal.
Experts are asking whether it makes sense to limit pacare for a growing number of chronically
ill patients who would benefit from it in the last year, even two years of life, it
begs the question: When does end of life begin? >> How do you take care of patients with advanced
illness that may be close to end of life but may not fit into that eligibility perfectly.
>>> Both ladies would like to see a change in the rules allowing the chronically I will
access before the six month period. >>> The course of the disease, would make
more sense. >>> L.C. has been receiving hospice care for
about 13 months. >>> I asked the doctor, how long do you think
I got? And I don't know you don't know.
>>> If I had 100 people in your situation, some would be here, for many months and some
just for a few days. >>> Yeah.
>>> We've got to be prepared. >>> L.C. is allowed to continue hospice care
because his condition continues to get worse and his prognosis has not changed.
>>> He is getting every last breath out of life that his body will give him.
>>> And I think he's slated to turn 90 years old the second of April.
>>> I don't think I'll be here. >>> Well, we don't know, you surprised us
so far. He doesn't know, he's guessing like we are.
>>> My two guests are here to talk more about hospice care, Suzy Johnson and family physician
and chief medical officer for sharp's palliative care, Dr.ÊDaniel Hoefer.
Suzy, what do you think about this issue? >> I think we are needing to extend the care.
>> JOANNE: Doctor, the story is people are growing older, this care can help you at home,
it can help you live longer, what do you do to address the gap if you can't put somebody
in hospice care? >> In the healthcare model there is not a
lot. Patients have to have a Medicare part A skilled
need to get home health or move into an institution to get a level of assistance.
They're called ADLs, they're not covered by any insurance plan and the family has to pick
up those costs and that's part of the national decline for every illness.
Sometimes it happens earlier, like dementia but in other diseases it happens later.
We don't have a good system to fill in the gap.
>> JOANNE: Suzy sharp has created "transitions." Tell us about that.
>>> We took our knowledge of the hospice care and the disciplinary team using progress no,
sir stick indicators and developed a program for those in late stages, heart failure, cancer,
where we are providing a consultation service at home doing disease education and getting
people prepared for what's coming next. It's not "if" it's "when."
We change the conversation and you saw with L.C. and his wife they're prepared for what's
happening next, there aren't specializes. That's what we have done with the program.
There isn't funding for that in traditional Medicare but in the sharp healthcare system
where we manage our own population financially and medically, we are able to provide that
service to our patients. >> JOANNE: What surprised me, when we talked
about hospice care or transitions, these are simple things that you're teaching patients
to do at home that keep them out of the hospital. You're teaching them how to take their medication,
increase their dose, not to retain fluid. Is it simple things like that, having that
home concept that can keep someone out of the hospital?
>> About two thirds of the readmissions, which is the big issue with the affordable care
act for hospitals, we found that those readmissions are based on medication mismanagement.
Guess what? Good medication management improves symptoms
so by going in and helping people manage these issues, we can help them do a better job.
On the other hand I cannot overvalue the response of family, moral resolution that they understand
the pathway that their parents are on because what happens in the traditional system with
these patients decompensate in the E.R. and the family shows up, the distant relative
or son who hasn't been involved in their care except over the phone and moral resolution
occurs while the patient is incubated in the I.C.U., that's a reactive model.
What we need to talk with patients and their families about is proactive management and
the inevitable consequences that the healthcare industry has to offer.
We will do whatever you want us to do but the patients are speaking up and saying "I
just want to be at home with a growth of in home supportive care."
>> JOANNE: We're going to have to end it there. There is more on our web site, Dr.ÊDaniel
Hoefer, Suzy Johnson thank you for being here.