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September 16, 2007

Right Answer Wrong Question

The New York Times has a nice piece on the City of San Francisco's efforts to provide health insurance to uninsured adults. This is good news because it shows that the system can be changed when principled people put their minds to work on "system change." Still, the San Francisco program is best categorized as a public policy band-aid because it does not address the tremendous difficulties faced even by those who have health insurance.

In other words, while "universal health insurance coverage" is a good thing; "health care as a basic human right" is the best thing.

Posted by Dr. Bill Thomas on September 16, 2007 4:47 PM |Permalink |Comments (0)

September 22, 2007

And the Winner Is...

This arrived in my inbox and it was a nice reminder of all the great work being done by skilled and committed people in the field of long term care.

"Just to let you all know... LaVonda Cathcart from Holly, CO won last night. Her home was either first or second (I think) to become Eden Registered and her home is truly a home. LaVonda has moved her office into the center of one of the neighborhoods. No walls. She truly embraces Eden philosophy in every way. LaVonda had numerous challenges this year such as fierce fire threats, a major snowstorm that paralyzed the area and many cattle died due to impossibility of getting food to
them and getting them out of the snow. Then in March without warning a severe Tornado ripped through the town. The nursing home was slightly damaged, but many of her staff and of course community members lost their homes. There were a few deaths in the community. LaVonda opened her nursing home as a triage center but also helped the community in
every way.

The competition was stiff for this award. All Eden associates, all Eden registered homes and of course Susan an Eden educator, but in light of the tragedies that occurred in Holly and La Vonda's stunning administration at all levels - she was the winner."

Posted by Dr. Bill Thomas on September 22, 2007 3:15 PM |Permalink |Comments (0)

October 5, 2007

Exhibit A: Why Oh Why is Health Care Reform so Hard to Do?

Let's say that Congress decided to get behind some incremental changes in one part of our medical industrial economy. It could even get all optimistic and cool and call its package of proposals the “CHAMP Act.” The bill might, for example, improve coverage and benefits for children, extend Transitional Medical Assistance for people enrolled in “Welfare to Work” programs and, make it easier for elders to continue using community-based Adult Day Service Programs. Well that's exactly what it did and the AMA , AARP and National Association of Children's Hospitals have all applauded this legislation. Nice huh?

Oh, there is one more thing, CHAMP also...

“Takes into account recommendations from the non-partisan Medicare
Payment Advisory Commission, the bill refines payments for a variety of
institutional providers including skilled nursing facilities, rehabilitation
facilities, long-term care hospitals, cancer hospitals and rural and small urban
hospitals.”

It turns out that the nation's for-profit nursing home chains (and their defenders in Washington) are just not that into the cancellation of multi-billion dollar funding increases in their future revenues.

"The CHAMP Act, as it now stands in the House Ways and Means Committee, is highly detrimental to the long term care needs of 'America's Greatest Generation' as well as future generations - contrary to the claims being made by its proponents," stated Bruce Yarwood, President and CEO of AHCA.

So what does a big-time Washington lobbyist do?

WHY%20Ad.jpg
How about running attack ads directed specifically at freshman Representatives who dared voted against the perceived interests of the nursing home industry? Here is the ad being run against Tim Walz in Minnesota's First Congressional District.

Congressman's Walz's is pushing back against the nursing home industry's fearmongering.

“For too long, these private insurance companies and big nursing home chains have reaped the benefits of Medicare overpayments, and when I voted for the CHAMP Act, I voted for legislation that will help the most vulnerable of our community: our low-income children and seniors.

The people of the First District don’t have to buy expensive and deceptive ads. They don’t have to hire expensive lobbyists. People in southern Minnesota can be confident that I have and will continue to cast votes that are in the interest of our children and seniors, no matter how many full page, color ads costing thousands of dollars the special interest groups can buy.”

Read the full text of his statement here.

So what's new? Congress withdraws promised increases in the nursing home industry's funding stream. The industry's lobby lashes out at the CHAMP Act's Congressional supporters (especially freshmen). Little changes. Another battle is won, lost or drawn.

It is easy to see that the American medical industry is huge and exceptionally powerful. Each component of that industry holds a laser focus on its own needs first and foremost. Each component has its own individual war chest that it can you to attack elected officials who refuse to do its bidding.

It is also easy to see that the public supports fundamental change in our health care system. Hundreds of millions of people can see and are appalled by the waste, the injustice and the failure to produce the quality health care outcomes enjoyed by citizens of other industrial nations. Despite the urgent need for reform, nothing happens.

It turns out that attack ad is asking the right question: “Why?”

A few years back, Jonathon Rauch wrote a brilliant book (Demosclerosis) that explained the paradox of popular support for change being stymied by gridlocked inaction.

Scott London captured the the crux of Rauch's argument nicely...

“In a stable, democratic society, pressure groups inevitably form to persuade government to redistribute resources their way... Taken one at a time, these benefits have practically no effect on society as a whole, so no countervailing group arises to stop the waste. But, taken as a whole, group demands gradually sap the effectiveness and flexibility of government to the point where no program can be cut and no subsidy eliminated without arousing vehement opposition from some group or another. As the number of interest- groups in a society increases, and as the benefits secured by groups accumulate, the economy rigidifies. By locking out competition and locking in subsidies, interest-groups capture resources that could be put to better use elsewhere.”

As a physician, I believe that this kind of insightful diagnosis is a starting point for action. I believe that our national health care policy is being held strangled by a powerful industrial complex. The only thing that can break its grip is a counter-force of educated citizens who can see past the spin, the self-serving distortion and the outright hypocrisy--- and are willing to stand together and fight.

When I was in medical school a fellow student started his third year (the most challenging phase of medical school) by posting a sign on his dorm room door. It read: “I must therefore I can.” Today I would amend that statement. “We must therefore we can.” In fact it's already happening. Take a look at VOTER Mel Strand's counter-attack on lobbyist-generated attack ads running in his hometown paper.

Posted by Dr. Bill Thomas on October 5, 2007 8:45 AM |Permalink |Comments (1)

October 8, 2007

And the Beat Goes On

The range and sophistication of non-institutional community-based alternatives to conventional long-term care continue to grow. Many people are glad. Some wish that the status quo would last forever.

David Harlow's Health Care Law Blog picks up the thread with a nice summary of the state of the art. I found the following to be especially interesting.

The latest entrant in this field of alternatives to traditional nursing facilities is the Going Home program in Massachusetts, highlighted in today's Boston Globe story about a four-resident home in West Peabody operated by North Shore Elder Services, which plans to add additional sites. The home provides a residence, a live-in aide, meals, and other services as needed. Per the Globe, services cost another $3,600 to $4,000 per person a month at West Peabody, covered through the Medicaid and Medicare programs, because the residents have medical and physical conditions that would otherwise qualify them for government-paid nursing home care. The total cost per day is less than the $187 average state payment for nursing home care, but more than the state pays for the least-ill nursing home residents.
The story continues:

Because the houses are not subject to state regulation like nursing homes, some question whether residents would be adequately protected. There have been occasional abuses in state-funded homes for the mentally ill.

Organizers say there are multiple checks and balances in the way the houses are run. One of the regular duties of the elder service agencies is to investigate abuse and neglect for the state. The agencies' staff monitors the care provided in the houses. And other professionals, obligated to report abuse, are regular visitors.

The market for these services is likely robust and it will be interesting to follow the growth of this initiative in Massachusetts and elsewhere.

This photo is titled "Going Home" and comes from a collection of images from Randy Putnam's tour of duty with the 174th AHC, circa 1967 -1968. Take a look. If you like what you see, drop a line to JimMcD (webmaster)

Posted by Dr. Bill Thomas on October 8, 2007 8:59 AM |Permalink |Comments (0)

Smack Down

The Gimp Parade lays a smack down on private, for-profit investors who are, increasingly speculating in the nursing home real estate market. Blogger Kay Olsen highlights the following from the recent New York Times article that covered this issue.

"The typical nursing home acquired by a large investment company before 2006 scored worse than national rates in 12 of 14 indicators that regulators use to track ailments of long-term residents. Those ailments include bedsores and easily preventable infections, as well as the need to be restrained. Before they were acquired by private investors, many of those homes scored at or above national averages in similar measurements."

What does she want to do about this?

"One of the demands of ADAPT at the recent sit-in at the Chicago headquarters of the American Medical Association [see the AMA's policy on the use of restraints in nursing homes here-- WHT] was that doctors divest themselves of financial interest in the nursing homes they recommend to their clients."

I agree with and support ADAPT's position on the divestment issue.

"While there is a movement by aging Boomers gaining steam to make nursing and assisted living institutions into communities where people can go to live happily instead of going there to wither of neglect and die, a key factor in the injustices visited upon the people who end up in these homes is that continued institutionalization with minimal service and minimal care financially benefits someone else."

When you get down to it, the paragraph above is the core of a moral argument against health care as a purely profit-driven "marketplace" and for the enlargement and preservation of human dignity and freedom of choice as a fundamental human right.

When the profits of corporations in the medical-industrial sector come to take precedence over the life and death needs of ordinary citizens we have a prescription for disaster.

Posted by Dr. Bill Thomas on October 8, 2007 2:40 PM |Permalink |Comments (0)

October 15, 2007

Social (In)Security

So how have the financial whiz kids who were supposed to take over the operation of a new "privatized" Social Security been doing lately? Let's take a look at how Wall Street has been handling another sacred financial tradition-- the home mortgage. Ummm. I think we'll keep Social Security right where it is. It's the best kept promise America ever made.

Posted by Dr. Bill Thomas on October 15, 2007 8:20 AM |Permalink |Comments (0)

October 18, 2007

A Sermo(n) for Pfizer

The following article is a virtual Master's level course on the VERY dysfunctional relationship between the corporations that make drugs and the people who prescribe them. I am almost always an optimist but, in this case, it's a matter of "read it and weep."

By AVERY JOHNSON
A new Pfizer Inc. partnership with a doctors' Web site could attract fresh attention to how drug companies interact with physicians.

The New York pharmaceuticals maker will announce a partnership today with Sermo Inc., a social-networking site for licensed physicians. Facing financial pressures as some of its best-selling products lose patent protection, Pfizer is looking for more-efficient ways to reach the doctors who prescribe its medicines. Under the arrangement, Pfizer-affiliated doctors will be able to talk candidly with the site's 31,000 members, potentially giving the company insights into prescribing patterns and a way to show doctors data on its drugs.

It is risky territory for Pfizer, though. The drug industry's interactions with doctors are highly scrutinized by regulators and lawmakers for signs that they are offering financial incentives to drive sales or promoting their drugs for unapproved uses. Pfizer plans to discuss the partnership with the Food and Drug Administration.

Many doctors, too, are wary of undue industry influence on their profession. "Often it's looked badly upon by other physicians when you are perceived to have a close relationship with a drug company," says Sermo member Richard Thrasher, an ear-nose-and-throat specialist from McKinney, Texas, who generally welcomes Pfizer to the site.

Sermo, founded in September 2006 in Cambridge, Mass., provides a forum for doctors to seek diagnostic advice from peers. The site earns money by letting clients such as hedge funds monitor doctors' anonymous conversations and thus gain insight into, say, the popularity of certain treatments. Sermo rewards physicians whose input is highly ranked by other members and soon will offer to pay doctors for participating in its clients' surveys.
Avery Johnson discusses how Pfizer plans to reach more physicians through a social networking site, instead of sending sales reps to doctors' offices.

Pfizer has historically fielded the industry's most aggressive sales force, but laid off 20% of its U.S. sales force last year and more than 20% of its European sales team in January.

Pfizer doctors, who will be clearly identified, will be able to ask questions of the Sermo community or respond to posts. If Pfizer doctors were to offer comments others deem biased, the system provides for quick rebuttals.

Sermo chief executive Daniel Palestrant says he initially didn't want to involve drug companies, but changed his mind when physicians on the site started asking for the industry to communicate with them in a medium more convenient than sending sales people to their offices. "It takes a lot of courage for Pfizer to do this, because the response isn't going to be universally positive," Dr. Palestrant says. "Pharma is always in crisis, always under fire for something, and there have been trust issues with physicians."

Michael Berelowitz, Pfizer's senior vice president for global medical, says the company wants to communicate more openly, despite the risk. "We live in an environment where we're closely monitored all the time and have constraints around what we say and how we say it," he says. "Given that this kind of medium is the way forward...we have to learn how to behave in it."

Neither company would disclose financial terms of the agreement.

Posted by Dr. Bill Thomas on October 18, 2007 9:46 AM |Permalink |Comments (2)

October 19, 2007

Ouch... It Gets Worse

A coincidence? I think not...

Oct. 18, 2007 (Investor's Business Daily delivered by Newstex) --

Drug firms closely tied to schools

The majority of department chairs at U.S. medical schools have financial ties with the drug industry, according to a Harvard Univ. study. Health Day News said researchers found that 60% of department chairs said they are paid by drug makers as either consultants or officers. More than two-thirds of department chairs contended that such close relationships with medical companies had no effect on their professional activities. Another study found third-year medical students get, on average, one gift or attend one activity sponsored by a drug maker each week.

Posted by Dr. Bill Thomas on October 19, 2007 5:36 AM |Permalink |Comments (0)

October 22, 2007

Chipmunk Economics

I've been watching the SCHIP tragi-rama and, for me it least, it has all of the overtones of the recent Social Security brouhaha. Its the same story with Medicare, Medicaid, WIC, SSI...etc., etc. etc.

Here is that story:

"Despite all evidence to the contrary, there is no such thing as the common good. It turns out that we are all alone in this world, rich and poor alike--- well not exactly alike. Anyway, again despite all evidence to the contrary, it is best if we learn not to rely on each other. We are, it seems, a race of chipmunks each of us racing alone to toward the creation of our own, individual, pile of nuts. If your stash is big and well-hidden, then congratulations, you deserve to make it through the winter. If your stash is small or not so well hidden, or stolen or ruined, well then that's just too bad. You can't expect any other chipmunks to give a damn about you.

"It's every chipmunk for himself and the devil take the hindmost."
---- Richard Dawkins

Interestingly, the story told above collides with everything we know about morality, ethics, theology and, especially, human nature. We are not chipmunks, and never have been.

It is said, by those who know, that before the invention of the freezer, the best place to store surplus meat was in a neighbor's stomach. In other words, sharing the surplus in good times with the expectation that we will be helped by others in hard times is woven into the fabric of our species. Social insurance programs (like Social Security) take this principle one step further and create a situation where members of a nation make a promise to each other and then work to keep that promise, generation after generation.

Efforts to lead us away from the promises that, we, as a people, have made are, when you get down to it --- inhuman.

We are not chipmunks, never have been, never will be.

Posted by Dr. Bill Thomas on October 22, 2007 5:27 AM |Permalink |Comments (0)

October 24, 2007

Main Street versus Wall Street

What Is...

Merrill Lynch & Co. on Wednesday took a $7.9 billion write down because of the summer's credit crisis, a bigger-than-expected amount that raised the specter of more trouble ahead from risky home loans.

The world's largest brokerage was caught off guard by its bad bets, leading to its first loss in six years. Merrill Lynch's quarterly performance was the worst by far of the Wall Street firms.

The shortfall calls into question how one of the biggest names in finance could be so off the mark, just three weeks after telling Wall Street its losses would be significantly less.

"I'm not going to talk around the fact that there were some mistakes that were made," Chairman and Chief Executive Stan O'Neal told analysts during a conference call.

AND

What Will Never Be...

The Social Security Administration on Wednesday took a $7.9 billion write down because of the summer's credit crisis, a bigger-than-expected amount that raised the specter of more trouble ahead from risky home loans.

America's legendary safety net for older people was caught off guard by its bad bets, leading to its first loss in six years. Social Security's quarterly performance was just as bad as that of the Wall Street firms.

The shortfall calls into question how one of the Social Security could be so off the mark, just three weeks after telling Wall Street its losses would be significantly less.

"I'm not going to talk around the fact that there were some mistakes that were made," Social Security Chief Executive Stan Shunpike told analysts during a conference call. " I mean come on, it's not like we are playing around with people's financial security or anything like that." Shunpike added.

Posted by Dr. Bill Thomas on October 24, 2007 12:42 PM |Permalink |Comments (1)

October 26, 2007

Endless Tales of Woe

nursing%20home.jpg
Those who know me and my work know I'm an insufferable optimist and am whole-heartedly dedicated to reversing the most intractably pessimistic aspect of our culture -- how we feel about AGING.

But, even my cheerful demeanor blanches every morning when I open my Google-New-Alerts for the two most unfortunate words in the LTC lexicon -- "Nursing Home."

Here is a sample of today's news:

Man Dies Trying To Escape Nursing Home CHICAGO -- A 66-year-old man died after falling from a second-story window at a Northwest Side nursing home Wednesday morning.
Kiril Kirilov, who may have suffered from mental disabilities, attempted to exit Harmony Nursing and Rehabilitation Center from a second floor window via bedsheets he tied together, according to an Albany Park District police officer.

ARE YOU KIDDING ME?

But wait -- it gets worse:

Seniors Fear Losing Independence, Moving Into Nursing Home More Than DEATH
Senior citizens fear moving into a nursing home and losing their independence more than death, according to a new research study, “Aging in Place in America,” commissioned by Clarity and The EAR Foundation.

Tragic, and painfully true. I will write more about this terrible reality soon. Click here to read the full study posted at MyHearingHealth.com.

However, there was one gem out of more than a dozen articles today on abuse, neglect and fraud:

'Home Again' will aid seniors who wish to move out of nursing home
TERRE HAUTE — A new program called “Home Again” will provide rental assistance to seniors on Medicaid who desire to move from a nursing home back into a more independent and affordable community setting.

If you're looking for another ray of hope, go to www.edenalt.org

Posted by Dr. Bill Thomas on October 26, 2007 10:24 AM |Permalink |Comments (6)

November 14, 2007

Speak Up Speak Out

John has a point, this is important and living in a democracy requires us to pay attention.

The House is expected to attempt to override the President’s veto of the Labor/HHS/Education appropriations bill (H.R. 3043) possibly as early as this week. Two-thirds of each chamber must approve the bill in order for it to pass into law without the President’s support. For this to happen, Republicans would need to break ranks with the President.

Take Action
Ø Call your Representative(s) today and tomorrow. You can reach any DC legislative office through the Capitol Switchboard at 202-224-3121. It is particularly important that you reach out to Republicans — they hold the cards in this vote.
Ø Identify yourself, your agency if applicable, and where you are calling from in the state/district. Ask to leave a message for the Representative.
Ø Sample message: “Please vote in support of H.R. 3043, the Labor/HHS appropriations bill that provides our community with critical dollars to support older adults living independently at home, supports their family caregivers, and, in doing so, helps save the federal government Medicaid dollars which would otherwise go to nursing homes. There are modest increases for these home and community-based services for seniors in the bill and we ask the Congressman/woman to ensure that older adults in our community are able to continue living independently by overriding the President’s veto.”

Background & Talking Points
The Labor/HHS bill would provide $150.7 billion in discretionary spending, which is $6.2 billion above the fiscal 2007 level and $9.8 billion more than Bush proposed. President Bush vetoed the bill over his objection to this $9.8 billion difference.
The bill contains $63 million more for Older Americans Act programs and services under the Administration on Aging, roughly a 4.6 percent increase over last year.
It would also fund a wide range of social service, education and other critical federal support programs in addition to OAA, such as the Community Service Block Grant, the Low Income Home Energy Assistance Program, the Social Services Block Grant, and many others.
If Congress cannot override the veto, they will have to either cut the bill to meet the President’s demands or another series of continuing resolutions (CRs) may continue to fund federal programs at last year’s levels.
To see how OAA is funded under the bill, n4a members can go here.

Posted by Dr. Bill Thomas on November 14, 2007 4:15 PM |Permalink |Comments (4)

November 17, 2007

It Takes A Team: To Fight Generics

Generic medications are safe, cost-effective substitutes for expensive brand-name drugs.

Switching to generics saves money for individuals and for the health care system as a whole.

Naturally, the big drug companies see generics as a threat to their profits.

So...

RESEARCH TRIANGLE PARK, NC -- 10/25/07 -- Branded pharmaceutical companies plan for generic competition years in advance. A solid head start isn't enough, though -- to build the best counter-generics plans, companies need contributions from personnel in different departments.
Involving multiple people is key to prolonging brand life, according to a new study by Cutting Edge Information (http://www.PharmaGenerics.com). While marketing teams almost always contribute to counter-generics planning, stakeholders from other groups ensure that strategies include as many viable options as possible. They also help to establish contingency plans.

Those with strong stomachs can read the whole pile of rubbish here.

Posted by Dr. Bill Thomas on November 17, 2007 5:08 AM |Permalink |Comments (1)

November 29, 2007

Perverse Incentives

I continue to believe that health care is a right, not a business.

Diane over at Cab Drollery: "A place for a tired old woman to try to figure things out so that the world makes a bit of sense." We find a bit more evidence of what happens when profits come before people.

At the end of September, I posted on how some private contractors for a Medicare audit had turned into bounty hunters eagerly savaging the bills of rehab hospitals providing services to Medicare beneficiaries. The audit was a trial run ordered by Congress and involved three states: California, Florida, and New York. In California, records show that the auditors routinely rejected bills (up to 90%) from those rehabilitation hospitals providing services to those who'd had total knee or total hip replacements. As a result, several of those hospitals have closed or are about to.

There is a rat here somewhere. Either these hospitals have been dragooning elders into un-needed and un-necessary rehabilitation on a massive and unprecedented scale, turning entire hospitals into giant engines of fraud...

Or the auditing company is being too aggressive and retroactively denying huge number of legitimate claims.

Which could it be?

Among the biggest concerns is that the congressionally created program relies on "recovery auditing" – auditors who are paid a percentage of the money they recoup from hospitals through claims denials.

"This contingency fee or bounty mechanism sets some incentives for these auditors to be overly aggressive and to make questionable decisions in their favor by denying claims," May said.

Posted by Dr. Bill Thomas on November 29, 2007 6:55 AM |Permalink |Comments (2)

November 30, 2007

Arkansas Celebrates First Green House

From Jeff Mores of the Benton Daily Record in Arkansas:

BENTONVILLE — There was a day when senior care meant moving into a hospital-style nursing home.
Things have changed. And in Arkansas, Bentonville’s Legacy Village is leading the way.

Click here to learn how.

Posted by Kavan Peterson on November 30, 2007 10:56 AM |Permalink |Comments (0)

December 5, 2007

List of Shame

A guest post from UMBC's Kavan Peterson:

In an unprecedented move, The Centers for Medicare & Medicaid Services is shining the public spotlight on America's Worst Nursing Homes by publicly releasing a list of 54 facilities with the most serious health and safety problems in the nation. Thanks to The Consumerist for alerting us to this development:

CMS has released the first-ever official list of America's Worst Nursing Homes— a move that leads us to suspect that the Department of Health & Human Services must be getting pretty fed up if they are resorting to public shaming. The list includes the 54 most egregious health and safety violators of the 128 SFF, or "Specialty Focus Facilities," in the U.S.
A Special Focus Facility is basically a nursing home that is on double-secret probation— subject to twice as many inspections as a non-SFFs, with the threat of funding cuts for non-compliance.

According to the CMS, the average facility isn't perfect (6-7 violations is the national average.) Those designated as SFFs are guilty of either more violations or more serious violations than usual, as well as a history of fixing problems just long enough to pass inspection, then going right back to business as usual. The CMS dubs this "yo-yo compliance," and the SFF program is designed to deal with it by combining more frequent inspections with more stringent enforcement until the nursing home falls back in line.

If the facility in question doesn't shape up, correct the underlying problems that lead to violations and "graduate" from the SFF program (in about 18-24 months) their funding is cut and they will likely close.

Of course, the first thing I looked for on this list was the names of any nursing homes that cared for loved ones in my family or employed members of my family. To my absolute dismay, I found that the only nursing home in Montana to make this infamous list was none other than Evergreen Missoula Health & Rehab. This facility not only cared for my wife's grandfather during the last months of his life, but it is located on the corner of the street I grew up on and where my parents still live today. I can only hope the public humiliation of making this list will work where government regulations and inspections have not.

Besides sharing this list with as many people as possible, CMS recommends families use its Nursing Home Compare tool to review the ratings of any nursing home they are considering.

For those looking for a ray of hope, go to www.edenalt.org

Posted by Kavan Peterson on December 5, 2007 9:55 AM |Permalink |Comments (0)

Update Shame on CMS

Guest Post by UMBC's Kavan Peterson:

Almost immediately after posting the below story I came across this update from the Des Moines Register:

Names of worst care centers witheld from public, but given to lobbyists

The federal agency that refuses to publicly identify three of the worst-performing nursing homes in Iowa has shared that same information with lobbyists for the nursing home industry.
"This is absolutely outrageous," said John Tapscott, a former member of the Iowa Legislature and an advocate for nursing home reform.

"I don't know when I've been so livid in all my life," he added. "This just speaks to a larger problem, which is that the lobbyists are now running the government."

The U.S. Centers for Medicare and Medicaid Services has compiled a list of 128 "special-focus facilities" that are among the worst-performing nursing homes in each state. Those care centers are alleged to have consistently provided poor quality care while repeatedly falling in and out of compliance with government health and safety regulations.

But the federal agency has publicly identified only 54 of those 128 nursing homes. Among the 54 is Blair House, a care center in Burlington.

Shame on me for giving CMS the benefit of the doubt below. Des Moines Register reporter Clark Kauffman sums up my amazement at this egregious action:

It's unusual for a government agency charged with protecting the public to give information to an industry it regulates while withholding that same information from the public.

I'll also give Hillary Clinton credit for being the first presidential candidate in Iowa to lash out at CMS over this.

Stay tuned.

Posted by Kavan Peterson on December 5, 2007 10:56 AM |Permalink |Comments (0)

December 21, 2007

Pills that Kill

Lucette Lagnado over at the WSJ

She takes a look at the damage being done by the overuse of prescription medications in nursing homes all over America.

It is sad.

And true.

The widespread use of antipsychotics among the elderly has begun to draw criticism from regulators, researchers, lawmakers and some in the nursing-home industry. Sen. Charles Grassley, the ranking Republican on the Senate Finance Committee, this month asked several drug manufacturers for records on how they may have marketed these drugs for use in geriatric patients. He also has asked the Inspector General of the Department of Health and Human Services to investigate use of the drugs in nursing homes.

The take home message is that the "system" is biased toward using powerful drugs in place of recommended levels of staffing and ongoing staff training and development.

It can be different.

Posted by Dr. Bill Thomas on December 21, 2007 11:42 AM |Permalink |Comments (1)

December 31, 2007

Ruh-Roh

Big business is ever eager to privatize the profits while at the same time socializing the risks...

Prediction: In 2007 we will see corporations dumping their obligations on public (tax-payer funded) safety net programs at a record pace.

Who knew that the big shots loved socialized medicine so much?

The Equal Employment Opportunity Commission said Wednesday that employers could reduce or eliminate health benefits for retirees when they turn 65 and become eligible for Medicare.
The policy, set forth in a new regulation, allows employers to establish two classes of retirees, with more comprehensive benefits for those under 65 and more limited benefits — or none at all — for those older.

More than 10 million retirees rely on employer-sponsored health plans as a primary source of coverage or as a supplement to Medicare, and Naomi C. Earp, the commission’s chairwoman, said, “This rule will help employers continue to voluntarily provide and maintain these critically important health benefits.”

Premiums for employer-sponsored health insurance rose an average of 6.1 percent this year and have increased 78 percent since 2001, according to surveys by the Kaiser Family Foundation. Because of the rising cost of health care and the increased life expectancy of workers, the commission said, many employers refuse to provide retiree health benefits or even to negotiate on the issue.

Posted by Dr. Bill Thomas on December 31, 2007 6:52 AM |Permalink |Comments (1)

January 8, 2008

Is It An Emergency?

I've been concerned about the kind of care that people of all ages but especially older people get in American Emergency rooms.

Turns out I'm not the only one...

Is There A Crisis in Emergency Medicine?

Q. Is there a crisis in the nation’s emergency departments?

A. Yes. Emergency department visits in 2003 rose to 114 million, up from 89.8 million in 1992. At the same time, the number of emergency departments decreased by 15 percent, resulting in dramatic increases in patient volumes and waiting times at the remaining facilities.
Q. What is the impact of overcrowding on patient care?

A. According to the U.S. General Accounting Office, overcrowding causes prolonged pain and suffering for patients, long emergency department waits, and increased transport times for ambulance patients.
Q. What is causing the crisis?

A. A lack of hospital inpatient beds; a shortage of on-call medical specialists; an increasing elderly population; and nationwide shortages of nurses, physicians, and support staff.
Q. Why do hospitals "board" inpatients in the emergency department?

A. Hospitals are not always able to meet the demand for inpatient beds for emergency patients because of financial pressures. This can lead to waits of hours or days for an available inpatient bed
Q. What are the solutions?

A. the United States must make a national commitment and recognize that emergency medicine is an essential community service that must be funded.
Q. Can the problem be solved by educating people not to use the emergency department for minor medical problems?

A. No. Most patients who seek hospital emergency care are very sick or would be by the time they could see a primary care doctor. Only 10 percent of emergency department visits in 2002 were classified as non-urgent.

I am interested in stories from and about older people who encounter the American Emergency Medical System...

Posted by Dr. Bill Thomas on January 8, 2008 10:05 AM |Permalink |Comments (1)

January 15, 2008

No Miracle Pill

Alzheimer's drugs may not delay dementia
Study finds little benefit from treatment for early memory problems

Giving Alzheimer's drugs to people with early memory problems does not seem to delay the onset of the disease, researchers said on Tuesday.

Three main drugs — Aricept, or donepezil; Exelon, or rivastigmine; and Reminyl, or galantamine — are currently approved for use in mild-to-moderate Alzheimer's disease.They are also often prescribed on a so-called "off-label" basis to people with pre-dementia.

But doctors are divided over their effectiveness, leading to differing rates of use and bitter arguments over patient access to treatment, notably in Britain where a dispute over their cost-effectiveness has led to legal clashes.

I have taken care of many people who were living with dementia. Their loved ones were uniformly in favor of and even desperate in their search for something that could change the course of the disease. I was always under pressure (all doctors are) to prescribe these drugs. The pressure comes from other doctors (peer pressure if you will) , family members, patients themselves and most especially from the drug companies that make these products.

The problem is that, outside of a small number of exceptional circumstances, the drugs listed above are largely ineffective and expose patients to substantial and sometimes dangerous side effects.

Having said that, I guess I can forget about Big Pharma sending me a nice fat check!

Posted by Dr. Bill Thomas on January 15, 2008 6:20 AM |Permalink |Comments (2)

January 16, 2008

Elders – Boon or Burden?

[Guest post by Kavan from UMBC]

In my years tracking state government news as a reporter for Stateline.org, I saw a lot of doom and gloom stories like this gem from the Cincinnati Enquirer:

Study: Aging Ohioans putting strain on economy
COLUMBUS -- Ohio's aging population is going to put a backbreaking strain on the state's economy, property-tax base, health-care and retirement systems starting in 2012, according to a study released last week.

“Backbreaking”? Sounds like Ohio has a pretty serious problem… OLD PEOPLE… here are the numbers:

Today, Ohio experiences a daily net increase of 14 people age 65 or older. By 2012, that number grows to 119 new retirees per day.

The publisher of the report goes on to call Ohio’s aging population a ”disaster for state and local budgets, with no obvious solution.”

Well, that’s one way to look at our elder-rich future. And I won’t argue with the numbers. For the first time ever in a handful of states, healthcare is supplanting education as the largest chunk of the budget. And we know most healthcare spending goes towards caring for people in the final years or months of their lives. Nationally, America's official debt is over $9 trillion, and our primary social safety nets for older adults -- Social Security and Medicare -- face unfunded liabilities upwards of $40.9 trillion. Locally, nationally and globally, we face some pretty significant public policy challenges in terms of adapting to our rapidly expanding population of elders. Duh. Nobody is arguing with that.

But that is no excuse for the hysterical tenor of most news coverage about the "Silver Tsunamai" waiting to wipe out our economic future. I don't care how scary the demographic projections are, there is no excuse for painting the entire over-65-demographic as a bunch of freeloading leeches poised to suck our economy dry.

In fact, some folks are making a case that there is actual VALUE -- social, economic, spiritual, etc. -- to be gained by welcoming elders with open arms.

Take Colorado for instance -- Boomers blogger Brent Green explains here:

Our state is going to beat your state.
What I mean by this is simply a promise that Colorado will be doggedly persistent in transforming the aging of the Boomer generation into a strategic focus and an economic opportunity. Many states are talking about it; few are taking substantive action.
[snip]
After two years of planning and generous contributions of time, resources and energy, Colorado introduced last November its strategic vision called Silverprint Colorado. Our goal is straightforward:

Colorado will establish a culture for positive aging addressing the needs, contributions and opportunities for all its older residents.

Certainly this vision addresses our intentions to provide quality care and assistance to older Coloradoans late in life. But it’s also a revelation about economic opportunities.

As I discussed in my keynote address, Colorado has exceptional prospects to capitalize on aging in the areas of tourism, housing, spirituality, healthcare, biotechnology, the arts, the green movement, and education, to name a few.
[snip]
Colorado has a mile-high vision for aging; we have broad-based support; and we have an entrepreneurial drive that’s endemic of the new west.

If you live elsewhere and I’ve stimulated your competitive instincts to challenge Colorado's preeminence as the nation’s most hospitable state for Boomers and pre-Boomers, then, frankly, we all win.

I say let the competition begin. Click the logo to learn more.

Posted by Kavan Peterson on January 16, 2008 7:09 PM |Permalink |Comments (3)

January 21, 2008

Marketing Over Science

Out here in the real world, researchers understand that so-called negative results can be just as helpful as positive results.

For example, a positive result can look like this:

Drug X is more effective than a sugar pill when it comes to treating the symptoms of major depression.

A negative result, in contrast, might read like this:

Drug Y is no more effective than a sugar pill when it comes to treating the symptoms of depression.

For a scientist, both results are important and useful.

Because marketing and science are two very different things, companies which are interested in maximizing sales are likely to emphasize positive results while attempting to bury negative results.

It turns out that is exactly what is happening.

The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs’ true effectiveness, a new analysis has found.
In published trials, about 60 percent of people taking the drugs report significant relief from depression, compared with roughly 40 percent of those on placebo pills. But when the less positive, unpublished trials are included, the advantage shrinks: the drugs outperform placebos, but by a modest margin, concludes the new report, which appears Thursday in The New England Journal of Medicine.

Previous research had found a similar bias toward reporting positive results for a variety of medications; and many researchers have questioned the reported effectiveness of antidepressants. But the new analysis, reviewing data from 74 trials involving 12 drugs, is the most thorough to date. And it documents a large difference: while 94 percent of the positive studies found their way into print, just 14 percent of those with disappointing or uncertain results did.

Some people believe that the market and market mechanisms are the key to solving our shared health care crisis.

I disagree.

A market system has powerful built in incentives which value sales over science. If we have learned one thing over the past century it is that the careful, skillful and unbiased application of science to the problem of human disease and suffering is powerfully effective.

This powerful historic insight is undermined whenever and wherever marketing is given dominion over the unbiased application of clinical research.

Posted by Dr. Bill Thomas on January 21, 2008 6:22 AM |Permalink |Comments (1)

More on Marketing Over Medicine

Saw this article this morning and thought it might compliment the post below...

When a Duluth-based operator of hospitals and clinics purged the pens, notepads, coffee mugs and other promotional trinkets drug companies had given its doctors over

The operator, SMDC Health System, intends to ship the 18,718 items to the west African nation of Cameroon.

The purge underscored SMDC's decision to join the growing movement to ban gifts to doctors from drug companies.

SMDC scoured its four hospitals and 17 clinics across northeastern Minnesota and northwestern Wisconsin for clipboards, clocks, mouse pads, stuffed animals and other items decorated with logos for such drugs as Nexium, Vytorin and Lipitor.

Trinkets, free samples, free food and drinks, free trips and other gifts have pervaded the medical profession, but observers say that's starting to change.

"We just decided for a lot of reasons we didn't want to do that any longer," Dr. Kenneth Irons, chief of community clinics for SMDC, said Friday.

By the way, the image above comes from John Mack's Pharma Marketing Blog.

John offers readers an incredible insider's view of the drug industry's unquenchable thirst for sales. I highly recommend it. Plus he's got great images.

Posted by Dr. Bill Thomas on January 21, 2008 10:42 AM |Permalink |Comments (0)

Comment of the Week

If it takes two to tango, it takes a few more to get a real community dialog flowing. Below is the Changing Aging post-of-the-week from Dorothea in response to Cheney-Care. Dorothea didn't just comment, she told us how it is. Folks, this topic is worth a few more comments.

Personally, I am very pessimistic that we will ever create a national health care system in this country. I don't understand this paradox - Americans are extremely charitable and giving people. This is evident by the number of volunteer organizations, numerous charitable causes, and the daily stories of heroic efforts by individual people who would give the shirt off their back to help others in need.
Yet, when it comes to the notion of getting together as a nation to formulate a plan that provides a basic human right to health care for all, we are at each others' throats in conflict. Do we really think that we are that invincible? That our pitiful middle class wages are sufficient to help us in a health crisis? Do we really think that by moving into the suburbs, placing our kids in a private school, and holding two jobs to pay for it, that we can "protect" ourselves from the rest of the nation's problems?

There is something inherently wrong with our collective consciousness and sensibility when we fail to see that this is not just a moral issue but an economic one as well. And that it affects all of us, no matter how hard we try to hide and avoid it.

One of the morning shows on NPR ran a segment yesterday talking about the national fury that a leak to the German press caused last week. You see, the citizens there are angry about a recent disclosure of the salaries of car maker Porsche's Management Board. The German nation was outraged to learn that the average take home pay for a CEO of their top 30 publicly traded companies is $6 million.

The average director in Germany makes about 8 times the salary of a skilled worker. In our country, this ratio is 200. Germans think of this as a moral outrage where as we consider it to be a positive value of the entrepreneurial spirit.

Similarly, our strong sense of individualism and self-reliance (certainly values with a lot of merit) has blinded us to the fact that, at the very core, we are completely dependent on each other for survival. Whether we see this or not, it's true.
--Dorothea Johnson

Posted by Kavan Peterson on January 21, 2008 1:16 PM |Permalink |Comments (1)

January 29, 2008

Hey Doc, tell us how you REALLY feel...

From the Telegraph, London, British doctors in a survey tell us how they really feel about the National Health Service, Britain's publicly-funded healthcare system:

Don't treat the old and unhealthy, say doctors By Laura Donnelly, Health Correspondent
Doctors are calling for NHS treatment to be withheld from patients who are too old or who lead unhealthy lives.

Smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.

NHS.htm

So much for the Hippocratic oath. But seriously, this kind of tawdry tabloid news coverage distracts from the real debate raging in Britain -- how does a country, with finite resources and a mandate to provide universal coverage, decide how to allocate those resources? There are no easy answers. What do you think of this decision by the British government (also from the above Telegraph story):

The Government announced plans last week to offer fat people cash incentives to diet and exercise as part of a desperate strategy to steer Britain off a course that will otherwise see half the population dangerously overweight by 2050.
Obesity costs the British taxpayer £7 billion a year. Overweight people are more likely to contract diabetes, cancer and heart disease, and to require replacement joints or stomach-stapling operations.

Continue reading here.

[Picture courtesy of NHS agency auxiliary nurse Tim Burness]

Posted by Dr. Bill Thomas on January 29, 2008 9:57 AM |Permalink |Comments (3)

January 30, 2008

Bob Ball, Dead at 93

Josh Marshall at Talking Points Memo recognizes the death of a great man:

You probably don't know his name. And you probably won't see any news of his passing outside of the obit section. But Bob Ball, who died last night at the age of 93, probably played a greater role in expanding and defending Social Security than anyone in the second half of the 20th century.

There's more about Ball's life and career here at the SSA website.
(Photo courtesy of SSA.)

Posted by Dr. Bill Thomas on January 30, 2008 1:28 PM |Permalink |Comments (0)

February 8, 2008

Power Up Friday: Honoring Our Elders

The latest edition of the Administration on Aging's "Profile of Older Americans" has been released. Here are a few highlights:

We are becoming more elder-rich. Older Americans, (those 65 and over), now account for 1 in 8 Americans. Elders have increased 10% over the past ten years, and currently number over 37 million. There are nearly 74,000 centenarians.

Our elder population will "boom" soon. The number of people aged 45 - 64, (tomorrow's elders), increased by 39% in the same period, as our "Baby Boomers" move toward becoming "Elder Boomers".

Elders continue to raise children. Nearly a half million elders have primary responsibility for grandchildren who live with them.

Many elders have little or no "nest egg". Nearly 10% live below the poverty level. A third of all elders derive 90% of their income from Social Security.

Elders are overall better educated. From 1970 - 2006, the number of elders with a high school diploma rose from 28% to 77.5%. About 20% of our current elders hold bachelor's degrees.

Elders' health expenses are high. Out-of-pocket costs averaged $4331 last year, over 12% of their total expenses. About 20% of that ($887) was for medications.

If you went to college, you are doing okay.... Elders with a degree had an increase in median household income from $80,000 to $87,000 over the past 20 years.

But if you didn't finish high school, you probably are doing poorly. Median household income dropped from nearly $30,000 in 1984 to only $28,403 in 2004.

Racial disparities persist. Median incomes are 30% lower in people of color and poverty rates are disproportionately high, especially among older African-American and Hispanic women who live alone (about 40% living in poverty).

"Social capital" remains critical. From Laura Beck, Program Director of Eden At Home: About 80% of home care services are provided by family care partners. This represents about 257 billion dollars in unpaid labor yearly.

Commentary: Other than grandparenting and workforce figures, the report makes no mention of the many gifts we have received, and continue to receive, from this amazing group of people. Debates about rising costs of elder care should be framed within a much larger discussion: How should our society honor its elders?

-- Al Power

Posted by Dr. Bill Thomas on February 8, 2008 9:15 AM |Permalink |Comments (0)

February 12, 2008

More Than Just Pills

Emily writes to let me know that there is a new study that looks at an integrated approach to depression among elders.

Published in the February issue of the American Journal of Managed Care, the results examine the long-term effects of the IMPACT (Improving Mood - Promoting Access to Collaborative Treatment for Late Life Depression) care model on the health care costs of 551 study participants at Kaiser Permanente of South California and Group Health Cooperative of Puget Sound, enrolled in cooperation with the University of Washington.

The IMPACT treatment model features a depression-care manager (a nurse,
social worker or psychologist) who works with the primary care physician
and a consulting psychiatrist to care for depressed patients in their
primary care clinic. An earlier study, in the Dec. 11, 2003, Journal of
American Medical Association, shows that the model provides powerful
overall health benefits.

Why this study is important:

· Clinical depression affects about 3 million older adults in the
United States and is associated with 50 to 70 percent higher health care
expenses, mostly due to an increased use of medical, not mental health,
services.

· Over a four-year period, patients enrolled in the IMPACT study
had over $3,000 lower total health care costs than those in usual care,
including the roughly $500 cost of the IMPACT depression care program.

· Costs in every category (inpatient and outpatient medical and
mental health services, and total pharmacy costs) were lower in the
patients who were assigned to IMPACT.

Posted by Dr. Bill Thomas on February 12, 2008 9:25 AM |Permalink |Comments (0)

February 14, 2008

We Are Too Poor To Afford Childhood and Old Age

I get tired of people saying that we are so poor a nation that we can not afford to care for the young, the old, the sick, the injured and the frail.

Then I ask, "Why are we so poor?"

Posted by Dr. Bill Thomas on February 14, 2008 11:50 AM |Permalink |Comments (0)

February 15, 2008

Power Up Friday: Thinkin' 'bout home edition

Dr. Al Power writes...

A new study has been published in the Journal of the American Geriatrics Society, and like many studies, it raises some important issues, but does not address some larger concerns. A group of people living in nursing homes (or their proxies) were interviewed regarding whether they could transition back to community living. Fewer than 1 in 4 elders or their proxies felt this was feasible, although nearly half stated a preference to do so. After discussing possibilities for community support, the number who thought they could make such a move increased to 1 in 3. The study concluded that transitioning back to the community is a complex decision and that a systematic approach was needed to help people address this issue. Some questions raised in my mind:
More residents felt they could move back home than their proxies. How much of this is due to the resident being unrealistic, and how much due to families not understanding their elders' wishes?
How many of the elders felt they could not go back home because the institutional system has convinced them that they are helpless and unable to do more for themselves, or make more choices?
The MDS (a quarterly survey which is used to assess people in nursing homes) did not identify all of the people who wanted to move back home. How much more information is missed by our standardized assessments?

The larger question which was not addressed was: What if there were another option: a small non-institutional home for 8-10 elders, with skilled care provided by constant, enlightened universal workers, and visiting doctors and nurses? How many would want to leave then?

The citation is Nishita CM et al., JAGS 2008;56(1):1-7.

Posted by Dr. Bill Thomas on February 15, 2008 6:33 AM |Permalink |Comments (2)

February 18, 2008

GAO Head David Walker is Out

Here is the news...

David M. Walker, head of the Government Accountability Office, announced Friday that he would resign his position effective March 12 to head a new foundation.
Walker, who has served as comptroller general since late 1998, will be president and chief executive officer of the Peter G. Peterson foundation, which GAO said will be dedicated to "seeking and supporting sensible policy solutions to a range of sustainability and transformation challenges."

Walker said Peterson, senior chairman of the Blackstone Group, a financial services firm headquartered in New York, and former Commerce secretary and Council on Foreign Relations chairman, asked him to head the new foundation within the last few months, and he was undecided until very recently.

Why should you care?

The nation's top accountant has watched with growing alarm as the amount of money the country owes has skyrocketed.
"We're underwater to the tune of $50 trillion, and that number is going up three to four trillion a year on autopilot. So we need to start getting serious soon in order to make sure that our future is better than our past," David Walker, the head of the Government Accountability Office, told CNN in a recent interview.

As of March 1, 2007, the federal debt was $8.78 trillion -- $5 trillion of which was treasury bills, bonds and other securities held by entities outside the government.

The figure Walker cites includes future payments that government entitlement programs would have to pay, including $32 trillion owed by Medicare.

Federal spending on Medicare, and also Social Security and Medicaid, will increase dramatically as the programs expand to accommodate the large baby boomer population, Walker said in testimony on January 2007 before the Senate Budget Committee. The baby boomers become eligible in 2008 for Social Security and in 2011 for Medicare.

The increase in federal spending on those programs, along with rising health care costs, and a burgeoning population with longer life expectancies, could make the debt unsustainable over the next 20 years, Walker said.

So, in an attempt to educate Americans about this "long-range problem," Walker has embarked on a national expedition of sorts over the last year, conducting town hall meetings in 19 states on the shape of the federal deficit. He calls it a "fiscal wakeup tour."

Hey we are proud that he brought that tour right to the UMBC campus. Those interested in getting a Fiscal Wakeup can watch the whole show right here:

But the question is -- what's next?

From DailyKos...

The head of the GAO is resigning. That means Bush may get the chance to appoint his successor for a fifteen-year term as the federal government's chief watch dog.

Ouch...

Posted by Dr. Bill Thomas on February 18, 2008 5:52 AM |Permalink |Comments (4)

February 26, 2008

Density is Good

The always reliable Alex M passes this link on to ChangingAging readers.

A report by the Ontario College of Family Physicians on public health as it relates to development patterns suggests that the greater the density, the fewer the fatalities per 1,000 people, as calculated over 83 United States regions covering two-thirds of the total population.

Contrary to popular belief, the pace and proximity of urban living can actually contribute to more healthful lifestyles, while lower-density communities tend to have a higher incidence of cardiovascular and lung diseases, including asthma in children, as well as cancer, diabetes, obesity, traffic injuries and deaths; these are exacerbated by an increase in air pollution, gridlock and traffic accidents, and by a lack of physical activity. The study recommended that people seek out cities and towns with reliable public transportation systems, bicycle lanes and pedestrian paths, ones that have schools, businesses and stores within walking distance.