Changing demographics and the need for education

Guest blog in Long Term Living Magazine regarding recent demographic study and its implications. Go here.

Five-Star Rating Asked to be Suspended by 31 State Attorneys General

We have written about the Five-Star rating system in the past, CMS's latest attempt at ranking and rating nursing facilities. In an interesting twist, a total of 31 state attorneys general sent a letter to the secretary of the Department of Health and Human Services calling for the suspension and revision of the Five-Star Quality Rating System. The letter stated that the rating system "can be misleading and create significant confusion." What I can't figure out is this is a good thing or bad for the industry and for the consumer. Bottom line - buyer beware of rating systems. There are many other ways to evaluate choices for a loved one. I and others have blogged about many of them. And if you need more guidance, send me an email to cirillo@4wardfast.com and I can send you resources from my book. Keep your eyes on this issue.

Nursing Home Arbitration

Here is an interesting article from Mother Jones about the area of mandatory arbitration. While it does not mention nursing homes it is followed by many.

This article will open your eyes to the issue of arbitration and can help you in your daily life as well.

Healthcare and the Tailor Shop

If you want to understand why healthcare is such dire straits, Atul Gawande's essay in The New Yorker is a great place to start.

My mother slaved in a tailor shop most of her career. She got paid for how many things she stitched in a given day. Guess what, that is how doctors and hospitals get paid. Is it any wonder why there is redundant testing and waste in the system? The incentives are all wrong.

What is great about this article is how a simple question of what should a newly minted surgeon make per year dived into an incredible essay about the healthcare system. Read every word and shake your head in disgust then try to figure out how any of the reform movements afoot will solve any of this.

Life Inside a Nursing Home

This article is a must read. How do you encourage doctors to go into geriatrics? Have them spend time as a resident in a nursing home. Great perspective. Any one trying to change the experience in long term care would be wise to do the same thing. In fact, it would be really courageous for caregivers to try it out when seeking care for their loved one. I have stayed in assisted living facilities overnight but not nursing homes and not for a long enough stay to really matter. Good stuff.

Changing Demographics and the Need for Education

This is a video blog of something we wrote about last week.

A report released recently from the Department of Health and Human Services and the U.S. Department of Commerce entitled An Aging World: 2008 should make people pause. Consider these key findings:

· People aged 65 and over will soon outnumber children under age 5 for the first time in history.

· Most countries show a steady increase in longevity over time, which raises questions about the potential for the human lifespan.

· The worlds population aged 80 and over is projected to increase 233 percent between 2008 and 2040, compared with 160 percent for the population aged 65 and over and 33 percent for the total population of all ages.

· As people live longer and have fewer children, family structures are transformed and care options in older age may change.

Implications? Well watch the video.

Those are my thoughts. What are yours?

Higher Risk of Dementia for Middle Age Smokers, Diabetics and those Hypertensive

Part of the health crisis is the fact that we do not take care of ourselves. Our choices today WILL affect our health and life expectancy later. More proof, in the August 19 Journal of Neurology, Neurosurgery and Psychiatry, it is reported that those who smoke, or suffer from hypertension or diabetes during their middle-age years have a higher risk of developing dementia later.

Current smokers were 70% more likely than those who had never smoked to develop dementia. People with high blood pressure were 60% more likely than those without high blood pressure to develop dementia. People with diabetes were more than twice as likely as those without diabetes to experience cognitive impairment, the study found. Investigators studied more than 11,000 people, aged 46 to 70 years. Patients were followed up for more than a decade to see how many would later develop dementia.

Lesson – do I really have to spell it out?

Age Bias Affects Healthcare for the Elderly

The Pew Research Center released results of its November ’08 study on the increasing generation. Here are some eye opening statistics. When does old age begin? The average American says 68. Those under 30 say it is 60. Those over 65 say it is 74.

Conan O’Brien’s average audience age dropped 10 years from Leno’s and that was considered a good thing because advertisers crave younger viewers even though boomers and elders hold the majority of wealth in the nation.

And then you come to healthcare for the elderly. New interns are starting in hospitals across America. Young fresh faces whose definition of old is highly exaggerated and who have received no training in geriatric medicine. All medical students are required to rotate through pediatrics and obstetrics. There is no such requirement for geriatric medicine despite the fact that a third of physician’s patients are over 65 and almost half of specialist patients are too. Medicare contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on older adults.

There is great essay on this in the New York Times by Rosanne M. Leipzig, a physician and professor at Mount Sinai School of Medicine. She argues that those receiving Medicare money should be required to demonstrate that their trainees are competent in geriatric care, that Medicare should finance medical training in nursing homes, and that state licensing and medical specialty boards require demonstration of geriatric competence for licensing and certification.

Basic geriatric knowledge is preventive medicine she says and I agree. Is it any wonder that mis-handled and diagnosed older patients end up worse off then when they present with their illnesses? And then where do they end up – in the long term care world.

You may require all the things she argues for and people will follow the rules to get paid or licensed but that does not take into consideration the general tone of the culture whose definition of old is warped, where the wisdom of our elders is not cherished, and where their contribution ends at retirement in the eyes of many. We need to change not just healthcare for the elderly but a culture that is obsessed with youth.

AARP Loses 60,000 Members

Here is a case where perceptions cause myths to arise and then actions actually cause revenue to be lost!

As many as 60,000 seniors have canceled their AARP memberships since July 1 because they are angry about AARP's position on healthcare reform. Three bill versions would trim $563 billion out of Medicare's growth rate over the next 10 years while pumping in about $320 billion.

That has translated into a belief that Medicare cuts will lead to long lines, restrictions on care and other problems.

First, you need to know that there is so much waste in the healthcare system that trimming is needed. Second, if a standardized EMR protocol is developed, it will lead to further efficiencies in the system. I think Medicare is a sacred cow that legislators will be hard pressed to mess with too extensively.

All that said, AARP might better spend its time thinking about what it can do to solve problems not play politics. The sad truth is that there is a shortage of primary care physicians in this country and haplessly few geriatric specialists.

There is a larger societal issue around aging, understanding aging, preparing for aging. When younger people think 60 is old that is a problem. When younger people are drawn to specialty medicine because it pays more than primary care, that is a problem. Some of the basic framework of our primary care infrastructure needs to be addressed. Because for young people, perceptions of aging and caring for the aging tranlates into choices that continue to diminish the ranks of those dedicated to our elders.

Perhaps the American Seniors Association, a conservative alternative to AARP, should take the mantle if AARP chooses not to do so.

Older Society Challenging Implications

A report released recently from the Department of Health and Human Services and the U.S. Department of Commerce entitled An Aging World: 2008 should make people pause. Consider these key findings:

· People aged 65 and over will soon outnumber children under age 5 for the first time in history.

· Most countries show a steady increase in longevity over time, which raises questions about the potential for the human lifespan.

· The world’s population aged 80 and over is projected to increase 233 percent between 2008 and 2040, compared with 160 percent for the population aged 65 and over and 33 percent for the total population of all ages.

· As people live longer and have fewer children, family structures are transformed and care options in older age may change.

Some quick implications:

· We live in a society that does not know how to deal with aging. We don’t talk about it. We don’t prepare for it. We don’t value it. Just look at the mass media. Most of the wealth is controlled by the older population and yet most of the programming and advertising is geared toward the younger population.

We need to start talking about aging issues.

· The Asian cultures have long been known for their respect of the elderly. Extended families are the norm. But even for them it is changing. As the global economic situation has made it necessary for both spouses to work, fewer families can take care of the growing number of elderly. And boomers have had fewer children so there is less of a safety net for care assuming the children would chose to provide it.

We need to start educating society on aging choices.

· I sang at a nursing home last week. Two people were celebrating 100 birthdays. In the book, Earth's Elders: The Wisdom of the World's Oldest People, Friedman interviewed 50 of the oldest people on earth about their keys to life. Average age – 113 years old. It could be very possible that the 100 year old may be in a home with a 55 year old.

We must foster intergenerational learning and respect if we are all going to live together, learn from one another and love one another.

Those are my thoughts. What are yours?

Putting Health Care Reform in Perspective

With permission, I am reprinting Larry Minnix's great essay on his mother's experience with the health care system. Contrasting it against the "death panel" rhetoric floating around, he actually shows how current proposals would actually pay for services that have up until now been provided at times for free from providers who at the end of the day have the patient/resident at the heart of everything they do. Thanks Larry and here it is:

My acid test of health care reform is how it will make my family’s life better. I’ve told many stories about my late mother, a real character. She died of cancer almost five years ago. She lived at Wesley Woods, a HUD 202 facility in Atlanta. She was a volunteer there for years. She moved in – her decision – within a year after my daddy died. She was lonely.

Mother’s cancer was rare and difficult. Multiple surgeries, experimental drugs, tended by compassionate geriatricians and oncologists, nurses who came to her apartment without compensation, her great-great niece Ashley, a pediatric ICU nurse who spent three nights per week at the Towers, her great nephew Steve, a staff member who did chores (probably on a cash basis, but I’m not sure), and Chaplain Woody. And there were numerous friends like Doris, Peggy and Lynn. And she had my wife Kathleen and me. Kathleen stayed close in Atlanta, while I lived in Washington, D.C. Our own long-distance caregiving story.

Mother was middle-class poor. She worked for the county government for 40 years. She earned a couple of thousand dollars a month in retirement and Social Security and had $130,000 in the bank after selling her house and receiving the payouts from my late father’s insurance policies.

She had Medicare Part A, took advantage of Medicare Part B (a voluntary opt-out program) and supplemental insurance offered by the county. She had a car, which she sold when driving became difficult and the upkeep a strained expense. The sale put $3,000 in her bank account.

Mother died at Emory Hospital while living at Wesley Woods. Of course, we had to think about the prospect of nursing home care. Fortunately, she had enough to pay for the great care she would have received at Budd Terrace or A.G. Rhodes at Wesley Woods. When that money ran out, she had too much income for Medicaid at the time in Georgia, so my wife and I would have supplemented. That made me rehearse in my mind about difficult choices of state school tuition for my sons instead of private college tuition versus nursing home care for Mother. Fortunately, we didn’t have to make those choices, but we did have bigger choices to make.

The bigger choices: how aggressively does the cancer get treated at various stages? Who decides?

A few years earlier, my mother, father, wife and I decided to update our wills, living wills and durable powers of attorney. Mother and Daddy switched their care to a couple of wonderful geriatricians at Wesley Woods, who gave them great attention and wise counsel. We had the same attorney, an old friend, help us draw up the documents. Mother and Daddy had different ideas about the conditions related to aggressive treatment, but both agreed that final decisions would rest on my shoulders if they were unable to decide. Before their lives were over (he died of heart disease), both documents had to be invoked so my father could avoid aggressive/liability-driven treatment at a local emergency room, and my mother could be comfortable with clinical quality versus quantity of life as she faced the inevitable.

My mother, my wife, Mother’s oncologist and I sat in the doctors’ office a few months before she died. The cancer had returned, this time inoperable, and experimental medications weren’t helping. The doctor explained the options: much more aggressive chemotherapy, with side effects, and low probabilities of cure, though always a chance, versus comfort care.

Her position: “I don’t want to die because I don’t want to miss anything. So, if treatment can get me several months or more, I’ll try it. If not, I don’t want to suffer. So, Doctor Lawson, we all know the score. You and Larry decide. Now, I’d like to talk about something else. I believe I’ve put that in writing already.” Comfort care and quality relationships became the objectives after more than an hour with the doctor.

The second choice came a few weeks later. She began to smother. Fluid around the heart and lungs—internal lesions from the cancer. The hospital drained them. The question: how many times do we anesthetize her to drain them? Very soon, it would need to be done every few hours. Temporary relief through a painful procedure. Mother’s great-great niece, Ashley, along with Woody, the doctor and my wife were her “panel” at the bedside. The conclusion: enough is enough. She passed a few hours later.

Now, how would health care reform ideas floating around Washington improve my mother’s experience? After all, Medicare already offered her choice of doctors and hospitals. Those doctors and hospitals had choice in terms of whether they wanted to serve Medicare patients, which, thankfully, they did. My mother’s drugs were covered by the combination of Medicare and supplemental insurance. No one ever questioned those doctors’ orders—even the experimental. The time her geriatrician and oncologist spent with her related to their wise counsel was not totally covered. In fact, geriatricians and family practice doctors are grossly under-reimbursed for encounters where the interaction is not for a procedure rendered.

The services delivered to my mother in her apartment were not covered by anyone. They were either given freely by friends and committed professionals or paid in cash by my mother. I later found out she needed more of these support services than I knew or she led me to believe. She could have been more independent and comfortable, but she didn’t have the money. Fortunately, she had friends and family from whom she bootlegged attention in her own endearing way. But what if she was a person without those precious assets of friends, family and charm?

The various health care reform proposals airing in Washington today would do the following to improve my mother’s experience:

* Actually pay the physician for the time he/she spent with my mother, wife and me to reach ethical, responsible decisions from time to time.

* Provide for a daily cash benefit to help my mother cope more comfortably and easily at the Towers without imposing on friends.

* Allow her choice of trusted providers in her community.

* Cover more drugs if she had needed them.

* Pay for care management to help her – and me – see that her care had continuity. She might have avoided a couple of emergency room visits. Reduce the possibility for spousal impoverishment if both of my parents had lived longer, had become more disabled and if one had needed Medicaid.

* Allow her to purchase insurance without being excluded for pre-existing conditions. Currently, my family cannot get insurance because of pre-existing conditions.

* Assure that her therapy wouldn’t have been capped, if needed.

* Allow me to bring my mother to Virginia from Georgia with consistent eligibility requirements and, again, a daily cash benefit to help us help her in our home or in another setting.

Your AAHSA staff is in the middle of health care reform. We meet a lot of policymakers and review a lot of drafts of possible language for health care reform bills. It is now a seven-day-a-week responsibility. The summary above is what the basics of health care reform would do (or would have done for my mother), if many of the provisions being discussed are enacted.

Some people are calling such provisions “socialized medicine,” government interference in our lives and “death panels.” They don’t know what they’re talking about.

My mother’s “death panel” would have continued to be her doctors, my family, a chaplain, a great-great niece and a lawyer. No one from the White House, the House of Representatives, the Senate, HHS, or even the Politburo would play a role other than to make sure she was assured of more choices, guaranteed coverage and more peace of mind.

No reputable policy maker here is advocating for socialized medicine or death panels. There will be things we like – and some we don’t – about a final health care reform bill. We’ll be vigilant about that and keep you informed. But don’t be a victim of unintended, or even manipulative, rhetoric.

We all have the responsibility to filter the rhetoric through personal experience and facts. I begin with the question: Does any proposal make it easier on people like my mother or yours?

Is Quality Better in Not for Profit Nursing Homes

See our guest blog at Long Term Living Magazine.

Is Quality Really Better in Not for Profit Nursing Homes?

Canadian researchers published a study in the British Medical Journal in which they examined 82 studies carried out in the United States and Canada from 1965 to 2003 comparing quality between for-profit and not-for-profit nursing homes. Forty studies showed significantly better quality in not-for-profit homes and three showed the quality was better in for-profit homes. The remaining studies, however, had mixed results. Quality was judged on overall and quality of staffing, incidence of pressure ulcers, use of restraints and inspection surveys. The analysis found that nursing home residents in the United States would receive 500,000 more hours of nursing care per day if all not-for-profit institutions provided all nursing home care.

The mission versus margin argument in health is a long and complex one. And I am not here to debate that. What I do encourage is dialogue especially from for-profits that have good indicators. Unless you start telling your story, studies like this will continue to paint the wrong picture. A more systemic issue in all this is staffing. All the other indicators can eventually be traced backed to good or poor staffing. Part of the problem is that the lowest tier worker in long term care mostly views this as a job. And if Target paid a buck more an hour they would be gone. The industry needs to create a culture where these are not jobs but mission driven careers. Of course salary becomes part of the attraction and recruitment. That we have two separate bodies representing nursing homes tells us something about how un-united we are and how far we need to come. Lets start the dialogue.