Nutrition in Clinical Practice

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The Congressional Budget Office (CBO) released a set of reports6-8 recently in which it compared compliance with various mandates. Childhood immuniza-.

Nutrition in Clinical Practice

Change Is in the Wind Charles W. Van Way III Nutr Clin Pract 2009 24: 433 DOI: 10.1177/0884533609339035 The online version of this article can be found at:

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The American Society for Parenteral & Enteral Nutrition

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Invited Commentary

Nutrition in Clinical Practice Volume 24 Number 4 August/September 2009 433-435 © 2009 American Society for Parenteral and Enteral Nutrition 10.1177/0884533609339035 hosted at

Change Is in the Wind Charles W. Van Way III, MD Financial disclosure: none declared.


nless you’ve been locked in a cabin in the north woods for the past year or so, you’ve heard about the Great Healthcare Crisis. Your Editor, Jeanette Hasse, has asked me to dust off the old crystal ball and peer into the future. What will we see this year, and what will we see over the next few years? To begin with, recall that we’ve been here before, and more than once. When Europe and Canada were adopting government-run healthcare in the early 1950s, the United States turned it down. Harry Truman tried hard, but he didn’t have the votes. Lyndon Johnson had a run at it, with some success, notably Medicare and Medicaid. The Clintons tried and failed. And now the Democrats are back in, and the trio of Obama, Reid, and Pelosi are going to give it another try. Or as the newspapers put it, “consensus is growing for action this year.”1 As an indicator, the American Medical Association is allying with business, hospitals, and consumer groups to come up with a plan. Their group is called the Health Reform Dialogue, and it may well craft a middle-of-the-road approach that will appeal to enough people to actually work. At the same time, the Democrats are setting up to use parliamentary maneuvers to jam through a more ambitious program with their current majority in Congress. Still, while they’re doing that, they have recently failed to commit the funds that would be needed over the next 10 years.1 Money is very, very tight, and there’s no guarantee that the Blue Dog Democrats are going to roll over to get their bellies scratched. So let me make one very safe prediction: it’s going to be a wild ride. Hang on to your seats, colleagues. The arguments of those who advocate healthcare reform are persuasive. Consider an editorial by Victor Fuchs, published last fall in the New England Journal of Medicine, which advocated strongly for a complete restructuring of our system.2 Fuchs pointed out 3 “inconvenient truths.” First, healthcare costs are rising at 2.8% per year, considerably faster than economic growth, and have been for 30 years. The present level of costs—about

one-sixth of the Gross Domestic Product—is becoming unsustainable. Second, advances in technology drive about two-thirds of the increase, yet produce better treatments for diseases and increased longevity.3 Third, there is no way to insure everyone unless governments subsidize people who cannot afford insurance and compel all who can afford it to have some sort of insurance. “Truths” 1 and 2 are quite accurate, whereas 3 is simply an opinion. To many pundits and politicians, the term inconvenient truths simply means “things we can’t prove but still want you to believe.” Thank you, Al Gore. There are 3 other points to consider. First, too many people, largely low-income working people, are out of the system. They’re hurting. Second, third-party, employerbased health insurance has become frayed around the edges. It costs too much, gives poor service, isn’t portable, and is too intrusive. Third, there is a huge cultural and legal bias toward more and more interventions of all kinds—drugs, operations, procedures. Professor Fuchs’ solution is a universal, government-run health insurance system. Judging from the political winds blowing around Washington, that’s not going to happen.1 For one thing, there’s not enough money left after all the bailouts. For another, many people think that’s a really bad idea. On the other hand, we will probably see some sort of program to insure the uninsured—some of them, anyway. Maybe half. Or a quarter. We will almost certainly get a system for evaluating new technology—devices, drugs, and procedures—in terms of cost-effectiveness. And we are very likely to get compulsory insurance. Compulsory health insurance, usually called an “insurance mandate,” is something of a hot button right now.4,5 At present, people can choose to opt out of employer-based health insurance. Such folks—usually young adults, without much health risk—skew the system. Given that 17% of the population is uninsured, how big a problem is it? Probably less than we think, maybe 3%-4% of the population, or less than a quarter of the uninsured—no one really knows. But universal insurance, whether private or government, depends on the participation of the whole population. If we’re going to make sure everyone has insurance, then those who can afford it will all have to join the system. That means we will need some way of forcing people into the insurance system, to spread the costs as widely as possible.

From the University of Missouri–Kansas City, Missouri. Address correspondence to: Charles W. Van Way III, MD, 2301 Holmes Street, Kansas City, MO, 64108; e-mail: [email protected]


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434   Nutrition in Clinical Practice / Vol. 24, No. 4, August/September 2009

Make no mistake, getting that 17% covered is going to be difficult. The Congressional Budget Office (CBO) released a set of reports6-8 recently in which it compared compliance with various mandates. Childhood immunizations are 85%, auto insurance is 85%, and seat belt use is 82% (although not mandated everywhere). Compliance with the law that requires filing federal income taxes is 86%. Compared with those, 83% of people have health insurance, either government or private. That may be lower than we’d like, but it’s in line with other mandates. Even if we subsidize insurance for low-income workers and require health insurance for everyone, a lot of people are going to fail to sign up. One major problem is that the 17% isn’t stable. At least half of those, maybe more, are on and off. They have employer-based insurance one month, or Medicaid, and then they don’t have it the next.9 Simply passing a law to require health insurance is not going to be enough. There will have to be punishments, and that’s not going to be popular. The CBO reports focus on options available within the present system. Some of the items are startling. Simply replacing the Sustainable Growth Rate (SGR) with the Medicare Economic Index in calculating physician reimbursement will cost $44 billion per year from 2010 to 2019. Now the SGR requires that Medicare cut physician reimbursement by 40% over the next 10 years. If we’re not to run out of physicians to take care of Medicare patients, we need to fix that. But fixing it appears as an additional cost to the system. It’s an example of just how out of whack the present system has become. And increasing coverage? Nearly all changes to increase coverage would cost a lot of money. Just allowing 63- and 64-year-olds to buy in to Medicare would cost $12 billion per year. Drop the age down to 55, as has been proposed, and you’re into $60 billion or more. More ominously, none of the methods being advocated to save costs will save much. Requiring that all hospitals and physician offices have electronic medical records would save surprisingly little, about $3 billion a year by 2019. And above all, just keeping up with the increasing cost of providing Medicare and Medicaid will be very costly, even without increasing coverage.6-8,10 So what’s going to happen? We’ll get some sort of action this year. The President’s budget has been released. It calls for a great increase in coverage, to be paid for by reducing payments to health plans, drug companies, hospitals, and home care providers, as well as by increasing taxes on “the rich.” (Roughly speaking, that’s going to be defined as anyone who can afford to send their kids to college. But that’s another discussion.) What will we actually get? We will see a modest increase in coverage of the uninsured, although reimbursement will probably be lower than Medicare is now. Medicaid for everybody. The coverage will not be especially good, and it’s doubtful that more than half of the uninsured will be covered. Other

good news? Medicare physician reimbursement will not be cut, but it won’t be increased. The National Institutes of Health will get more money for research. And that’s about it. In general, cutting costs will be the order of the day. Private health plans for Medicare will be squeezed and possibly eliminated entirely. Hospital reimbursement will come under new pressure. Drug and pharmacy costs will be pushed down. The new technology assessment center at the National Institutes of Health will start clamping down on some of the more expensive new interventions. There will be efforts to cut the cost of highpriced services, particularly in radiology, cardiovascular disease, orthopedic surgery, and oncology. After all, that’s where the money is. And there’s a lot of faith in health informatics. Despite the low rate of return for electronic medical records noted above, there will be a big push to implement them. There will be much talk but little new action on fraud and abuse. Last, there will be a move to reduce or eliminate reimbursement for unplanned hospital readmissions.11,12 Even the President has noted that readmissions are a Bad Thing.13 Be warned. Everyone concerned is going to go away unhappy, because this will be a classic Washington compromise. You’ve seen these before. The 2 guiding principles will be the most promises for the least expenditure and the least pain for the greatest number. We can hope that Congress won’t scapegoat anyone, but if it does, the insurance industry is probably at the head of the line. At the same time, there is a strong likelihood that the insurance companies are going to fight all of the above, and they will not take kindly to being blamed for the whole mess. This could get ugly. What are the implications for nutrition care? I see 4 consequences. First, hospitals are going to continue to be squeezed. They may get more reimbursement for the presently uninsured, but that’s not going to offset other cost cuts. Salaries and other expenses will be under pressure. Second, there will be little additional money for physicians. That’s going to be unfortunate for efforts to get physicians more involved in nutrition support, not to mention the overall physician shortage. Third, there will be at least some more money available for research. And fourth, there will be an ever-increasing push to lower such complications as wound infections, catheter infections, decubitus ulcers, and so on. That means that nutrition care should actually become more important to hospitals. Or, it will if we do our jobs back at our home institutions. This means that we have to recover our role from years past. We have to become positive advocates for nutrition. Too often, nutrition professionals have justified their salaries and their nutrition teams in terms of control of nutrition support—often, how much parenteral nutrition we’ve prevented. That negative approach won’t fly in the next decade. We have to learn the language of quality. We must look at outcomes of care. We need to be able to

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Change Is in the Wind / Van Way   435

articulate just why patients need nutrition support, and we need to do it in terms of improvement of overall results. And we need to look at safety. If your hospital doesn’t have a catheter care program, then your catheter infection rate is probably higher than it should be. Bet on it. Become advocates for postoperative nutrition support to prevent infectious complications. Work with nursing in their efforts to prevent decubitus ulcers. Consider this example. We know that an enteral formula high in w-3 fatty acids will help patients with acute lung failure, and we’re pretty sure that it will reduce the incidence of infections. What’s better—2 weeks of enteral w-3, or activated drotrecogin alfa (Xigris, Eli Lilly, Indianapolis, IN) to treat sepsis at $8000 per patient? Consider, too, that avoiding readmission will shortly be a priority. It was common to send patients out on zero nutrition, when a readmission actually made money for the hospital. If that changes, we’re going to be chasing after discharged patients, waving canned nutritional supplements for them to take home. Well, there you have it. As my crystal ball fades out, and before I reboot to see what’s going to happen in the stock market, let me summarize. The health system is going to change. The changes won’t be to a full, government-based, socialized system—our healthcare system is simply too large a part of the economy. In fact, more than one-third of all new jobs today are in healthcare. Congress is not going to do tinker with that, especially in the middle of a recession. No, the changes will be more incremental and more gradual. That’s both good and bad. On the good side, slower changes give us a greater chance to get things right. On the bad side, many of the problems we see today will remain with us. It’s true that there’s a crisis. But to quote a previous president, “We face a massive crisis in this area.” That was Richard Nixon speaking of healthcare in July 1969.13 If what we have is a crisis, then it’s been with us for 40 years. We won’t resolve it this year. Maybe we’ll resolve it during this generation.

Change is coming. We can hope it will be good for nutrition care. But we have to change. Think of this as an opportunity and a chance to improve the nutrition care of our patients. Become advocates. We know that 30%-50% of hospitalized patients have nutrition issues, and that those issues typically worsen during hospitalization. We know this but we don’t tell others, and we do little to make things better. The system will get better. We should, as well.

References 1. Connoly C. (Washington Post Writers’ Group). Support grows for care cure. Kansas City Star, March 29, 2009. 2. Fuchs VR. Three “inconvenient truths” about health care. N Engl J Med. 2008;359:1749-1751. 3. Pauly MV. Competition and new technology. Health Aff (Millwood). 2005;24:1523-1535. 4. Van Way CW III. Optional or required? Greater KC Med Bull, September 2007, pp. 4-5. 5. Van Way CW III. Universal insurance. Greater KC Med Bull, July 2008, pp. 4-5. 6. Congressional Budget Office. Two new CBO reports on health care issues. Accessed December 29, 2008. 7. Congressional Budget Office. Key issues in analyzing major health insurance proposals. Accessed May 31, 2009. 8. Congressional Budget Office. Budget options: volume I, health care. Accessed December 29, 2008. 9. Short PF, Graefe DR. Battery-powered health insurance? Stability in coverage of the uninsured. Health Affairs. 2003;22:244-255. 10. Orszag’s health warning: Obama’s budget chief delivers a reality check on costs. Wall Street Journal, December 29, 2008. 11. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare Fee-for-Service Program. New Engl J Med. 2009;360:1418-1428. 12. Epstein AM. Revisiting readmissions—changing the incentives for shared accountability. New Engl J Med. 2009;360:1457-1459. 13. Inglehart JK. Budgeting for change—Obama’s down payment on health care reform. N Engl J Med. 2009;360:2482-2483.

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