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Study links Medicaid fees, use of feeding tubes

Financial incentives for nursing homes seen
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Mirrored here for historical purposes.

Study links Medicaid fees, use of feeding tubes Financial incentives for nursing homes seen

By James Collins, Globe Correspondent, 7/2/2003 

Thirty-four percent of US nursing home patients who suffer from Alzheimer's disease and other forms of  dementia receive their food through a stomach tube, even though the practice is of dubious medical value,  according to a study published today in the Journal of the American Medical Association. 

The study suggests the economics of Medicaid reimbursements favor the potentially harmful practice  and that large, for-profit nursing homes were more likely to use the devices. In addition, the study found  that nonwhites were more likely to be given feeding tubes than whites. 

Sufferers of Alzheimer's and other neurological diseases gradually lose the ability to swallow. Yet critics  say feeding tubes can agitate patients and takes away much of the dignity associated with dying. The  other method, feeding people by hand, often is more time-consuming and requires more staff attention.  ''Staff time required for hand feeding is expensive,'' according to the study. Nonetheless, Medicaid,  the government-run healthcare system for the poor and disabled, tends  to pay more for tube feeding than for feeding people by hand. So for-profit homes may have a  concrete financial incentive to feed their patients by tube, said Joan Buchanan, a Harvard healthcare 
policy analyst. 

''Right now we've set up a situation where it's often advantageous for nursing homes to tube-feed their  patients,'' Buchanan said. ''People feel like, the more you do for a patient to prolong life, the better.  That may not be true  for end-of-life care.'' The Department of Health and Human Services, which administers Medicaid and  Medicare, the federal health insurance program for the elderly and the disabled, says that feeding people  by hand can be less expensive but that patients in need of this level of care often have other problems  that justify the higher reimbursement rate, said Bill Pierce, a department  spokesman in Washington. 

''It's based on the acuity of the illness of the individual,'' Pierce said. ''If you need to be tube fed,  you're likely much more ill than those who do not need to be tube fed, and therefore you require a greater degree of care.''

Pierce said the health department aggressively investigates for-profit nursing homes that exploit  the difference in rates to increase profits. 

Harvard Medical School professor Susan Mitchell, the study's lead author, said patients often pull  out their feeding tubes and display other signs of discomfort. She urged the government to reconsider its payment schedule. 

''It would be very nice for Medicaid to pay for some kind of conscientious hand-feeding program,'' she said. ''I think there's an opportunity to change policy.'' 

When Lillian Raymond, 89, could no longer feed herself because her Alzheimer's disease had progressed  so far, Raymond's daughters decided to abandon a feeding tube in favor of three-times-daily hand-feeding. 

Raymond, who has lived at the Hebrew Rehabilitation Center for the Aged in Boston for almost four years, now appears more comfortable, said Joyce Cassidy, her oldest daughter. 

''She's 89 going on 90, and we decided if it was -- God forbid -- time for her to go, it's time for her to go,'' Cassidy said. ''We're a family that always eats together, so it was very hard to have her on a feeding tube. Now, we can at least feel that she is enjoying something.'' 

Cassidy, 54, said she or one of her three sisters feeds Raymond her dinner. Nursing staff usually take care of breakfast and lunch. 

Mitchell practices at the Hebrew Reabhilitation Center. Her study examined 15,135 US nursing homes with 186,635 patients, using 1999 data. 

Often when a patient stops eating, it means he or she is getting ready to die, Mitchell said. Because many nursing homes do a poor job of educating family members about the dying process, many wrongly assume that they should always extend a relative's life through tube feeding, she said. 

Mitchell said that a larger percentage of nonwhites than whites don't use do-not-resuscitate orders that would prevent tube feeding in many cases. In addition, Mitchell said, African-Americans are often particularly unwilling to consider hand-feeding because of preexisting fears about the medical profession. 

''There's some apprehension or mistrust of the white medical establishment,'' Mitchell said. ''People are worried that they're not going to get the best care, so they go for it all.'' 

James Collins can be reached at

This story ran on page D1 of the Boston Globe on 7/2/2003. 
Copyright 2003 Globe Newspaper Company.