Knowing about such considerations in advance would be helpful and would allow physicians to tailor care to the patient and family in an efficient and sensitive way. An even more direct tactic would be to approach the local Medicaid carrier to find out what accommodations it might be able to provide. For example, the carrier might be willing to subsidize advance care planning or care management. Physicians could also ask the local quality review organization to study the practices and possible opportunities for improvement. Ultimately, working to help mobilize political forces to change Medicare and Medicaid reimbursements is a key to achieving better care.
Physicians can start by writing letters to their representatives and professional societies.
Moreover, not every nursing home can take on the level of care that such improvements might require. Change of any sort may be troubling or threatening to colleagues, and even strong efforts by physicians may prove ineffective. Physicians, however, are often in a unique position to identify problems and they have real power to effect change. A physician's ethical obligation as a patient advocate extends beyond individual patients. 1 Physicians also have a responsibility to help improve health care delivery systems that disadvantage or devalue patient care.