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February 15, 2009

ChangingAging.org Redesign -- Please Bookmark!

Attention Readers! We are launching a new design for the blog that will be hosted directly at the URL www.changingaging.org. Please navigate to www.changingaging.org and reset your bookmarks and sign up for our new RSS Feed. In the coming days we will set up an automatic redirect to the new hosting site. See you there!

Web Master

Posted by Kavan Peterson on February 15, 2009 8:00 PM |Permalink |Comments (0)

February 13, 2009

Power Up Friday

As the studies of drug therapy for behavioral expressions in dementia continue to appear, a groundswell of critics has also followed. As I continue to speak out, so do these allies.

Sister Imelda Maurer from San Francisco wrote me last week, dismayed about the recent "aripiprazole for agitation" study in JAMDA. Next, Carter Williams wrote me about a new study in Annals of Long Term Care on "nursing home violence", with the comment: "They need your book!"

(For the record, all of these drug studies make a distressed symptom slightly quieter than placebo, and call it a "positive" outcome. The problem is that this doesn't rule out sedation and it doesn't show increased contentment, engagement or growth. Worse still, it views these expressions purely as a "problem" to be "managed", without asking what basic needs are not being met. Plus they double your mortality.)

Let me tell you what scares me even more:

I'm scared about the way these drugs are being marketed to younger people for depression and other illnesses. "Is your antidepressant not quite doing the job? Take Abilify!"
The practice of using anti-psychotics for life-threatening depression has been expanded to using them to "amplify" therapy less severe cases.

I have a friend whose daughter was diagnosed with "oppositional disorder" and given Abilify. She has had a lot of trauma -- about a dozen operations, due to a congenital cranio-facial problem. She is only 10 years old.

We have no idea what the long range effect of these drugs will be.

Posted by Dr. Bill Thomas on February 13, 2009 8:36 AM |Permalink |Comments (0)

February 8, 2009

Getting Closer!

Please let it be so...

President Obama looking at Sebelius to head HHS Posted: 05:00 AM ET
From CNN Senior White House Correspondent Ed Henry

WASHINGTON (CNN) – In a sign that she is getting a close look for Secretary of Health and Human Services, Kansas Gov. Kathleen Sebelius recently met with senior White House adviser Valerie Jarrett, according to two Obama administration officials.

Sebelius has a good personal relationship with the President and remained in the running for the vice presidential slot until near the end of the process, the officials also told CNN.

But the officials cautioned that President Obama is considering others for HHS as well. Those getting a look include Oregon Democrat Sen. Ron Wyden and Tennessee’s Democratic Gov. Phil Bredesen, according to the officials.

White House spokesman Reid Cherlin stressed to CNN that "no decision has been made." But Cherlin added the President "is moving quickly in filling this critical role."

Full story here

Posted by Dr. Bill Thomas on February 8, 2009 4:23 PM |Permalink |Comments (0)

February 4, 2009

My Pick for Health and Human Services

If I was the President of the United States and it was my job to pick the best possible candidate to run the sprawling Department of Health and Human Services, I would choose...

I have watched Kansas Governor Kathleen Sebelius work diligently and effectively to improve the quality of the services provided to seniors in her state. She has also opened the door to innovation. She is a powerful communicator and an extremely effective administrator. Also, she has done all of this as a Democratic Governor in one of the few remaining "red" states.

Posted by Dr. Bill Thomas on February 4, 2009 1:04 PM |Permalink |Comments (0)

February 3, 2009

Understanding Health Care Reform

When reading writers who either support or oppose major changes in our health care system it is easy to assume that we are faced with a single mighty question...

How will we reform our health care system?

Will we wind up like Canada, or Britain or France or Zimbabwe?

The issue actually consists of two densely intertwined problems.

First, there is the money problem. Who, we are asked, will pay? How much will they pay? How much will people receive in return for what they pay?

The health care financing geeks (you gotta love 'em) have their own set of buzzwords and catch phrases...

access--- A person's ability to obtain affordable medical care on a timely basis.

beneficence--- An ethical principle which, when applied to [health] care, states that each [patient] should be treated in a manner that respects his or her own goals and values.

no balance billing provision--- A provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amounts (except for co-payments, coinsurance, and deductibles).

The morbidly obsessed can go here for thousands more examples of this kind of language.

The second major question concerns quality. These reformers are primarily concerned with the care that is actually being delivered. They want to know if that care is any good. Does it create outcomes that are better, or worse, for the people receiving that care. America spends, per capita, more for its health care than any other nation on earth and yet the outcomes created by this (very expensive) system are middling at best. America does not have, as is so often claimed, "the best health care on Earth." Instead, we have the most expensive health care system on earth.

Real health care reform requires tackling the financing and the quality questions simultaneously.

So, as we hear more about the issue of health care reform, take note if the politician or expert you are listening too seems most concerned about quality or finance -- a few of the best will be concerned about both issues.

One last note for now. We will also be hearing people claim that we will "be like" some other country. This is not true. Whatever kind of health care reform we wind up with (and I am hoping for the best) it will be distinctly American because it will evolve out of the current system.

This is the concept of "path dependence."

Posted by Dr. Bill Thomas on February 3, 2009 9:11 AM |Permalink |Comments (2)

February 2, 2009

Monkhouse Monday

Looting the state pension fund (AHV) in Switzerland

The Swiss AHV (pension for old age) was founded 60 years ago. Every salary has a percentage deducted which goes into the funds. With the ever aging population this fund needs to be secured by other means as an ever decreasing workforce supports an ever increasing old generation, this is nothing new. However, in 1998 a study was conducted on how to achieve this (Wechsler/Savioz 1998). One of the striking points was that different organizations such as the Red Cross, publicly funded home care organizations (Spitex), Pro-Senectute (an organization to provide information and consultancy in old age) and a few senior-run-organizations received 65 million Swiss Francs in 1986, 205 millions in 1996 and over 300 millions in 2008. This is an exponential growth with no justification, so the authors.

This needs to be stopped, so the study, these organizations provide a wide variety of services, but they do not have to prove their impact and efficiency. It is not the job of an old age pension fund to subsidize them. Or as a politically engaged 83-year old person puts it: „Stop looting our pension funds“.

Posted by Dr. Bill Thomas on February 2, 2009 8:08 AM |Permalink |Comments (0)

January 30, 2009

Krugman Can't Wait...

New York Times columnist (and Nobel Laureate in Economics) Paul Krugman writes...

The whole world is in recession. But the United States is the only wealthy country in which the economic catastrophe will also be a health care catastrophe — in which millions of people will lose their health insurance along with their jobs, and therefore lose access to essential care.

and he concludes...

I agree with administration officials who argue that these financial bailouts are necessary (though I have problems with the specifics). But I also agree with Barney Frank, the chairman of the House Financial Services Committee, who argues that — as a matter of political necessity as well as social justice — aid to bankers has to be linked to a strengthening of the social safety net, so that Americans can see that the government is ready to help everyone, not just the rich and powerful.

The entire essay is here.

Posted by Dr. Bill Thomas on January 30, 2009 9:47 AM |Permalink |Comments (0)

January 27, 2009

Better Care for Seniors

Beth Baker has published a terrific article that highlights a really fun project I have been working on for the past year. This is an attempt to craft an emergency services center that is designed to meet the needs of older patients.

See what you think.

Washington Post

Kavan Peterson has also put together a nice video on the same subject.

Posted by Dr. Bill Thomas on January 27, 2009 4:57 PM |Permalink |Comments (1)

Dignity Champions

I have been very impressed the concept of "Dignity Champions" as a strategy for creating cultures with zero tolerance for elder abuse and neglect. I think that American care providers would benefit if they made explicit use of this concept.

Sir Michael Parkinson has learnt how Anchor Homes has boosted a Government campaign to improve the lives of people living in care homes across the UK.

Care Services Minister Phil Hope (far right) and Sir Michael Parkinson meet Anchor Homes’ Managing Director Jane Ashcroft and Help the Aged’s Policy Director Paul Cann for a working lunch at Sir Michael’s restaurant, The Royal Oak, in Maidenhead.

Accompanied by Care Services Minister Phil Hope, Sir Michael learnt how Anchor Homes’ commitment to quality dementia training for its staff has helped the Department of Health pass its goal of 3,000 Dignity Champions nation-wide.

The DoH Dignity in Care Campaign aims to drive up care standards and encourages people to become Dignity Champions, spreading best practice and giving advice. Anchor Homes’ Managing Director Jane Ashcroft said the not-for-profit organisation now had more than 300 Dignity Champions.

Since becoming a Dignity Ambassador in May, Sir Michael has helped raise the profile of the campaign and the work of Dignity Champions. Mr Hope wanted Sir Michael to hear about the success of Anchor Homes.

Mrs Ashcroft, who is also the Vice-Chair of the English Community Care Association (ECCA), said: “Maintaining the dignity of residents must be at the heart of every residential care service. We at Anchor are aware of how important it is to care for people with dementia with the dignity and respect they deserve.

“The number of people with dementia in the UK will soar from 700,000 today to more than a million by 2025. Anchor has addressed this issue head-on, giving dementia care training to more than 5,000 care staff in Anchor’s 102 residential and nursing homes.

“We also have 309 Dignity Champions who have received advanced dementia training. Anchor now has more Dignity Champions than any other care provider outside of the NHS.”

Sir Michael Parkinson added he had been inspired by the Dignity Champions he had met. He said: "I have had have the great honour of meeting some of our nation’s real unsung heroes, hearing their stories and bringing attention to what they are doing to hopefully inspire many others to follow suit.”

Care Services Minister Phil Hope said: “Dignity is about quality of life and enabling people to live their own lives as they wish, confident that the care and support they receive is of high quality.

“Government alone cannot make this happen. I look forward to continuing to work with the wide range of organisations that provide care services and represent the interests of those using them.”

Posted by Dr. Bill Thomas on January 27, 2009 11:34 AM |Permalink |Comments (0)

January 26, 2009

January 16, 2009

Power Up Friday

I know what you're thinking out there - you are expecting me to
blog about the new Clive Ballard dementia study on
anti-psychotic safety. Well, okay, but that seems too easy.
Let's see if we can get more creative with it...

First, the study. Just published in Lancet Neurology is Dr.
Ballard's three-year, placebo controlled study of anti-psychotic
use in people with dementia. The results show a doubled
mortality of those on the drugs. After three years, two thirds
of those taking the placebo were still alive, versus fewer than
one third on the drugs.

UK officials stressed the need to use these drugs sparingly, and
recommended further education and research into alternate
approaches. Regular readers know that we've been blogging about
these concerns for some time. So where else can we go with this?

Let's look at an unrelated (?) Associated Press item from
January 8th: A group of federal scientists has filed a complaint
with the Obama Administration about gross misconduct within the
FDA. Ricardo Alonso-Zalvidar writes that the group alleges that
"agency managers use intimidation to squelch scientific debate,
leading to the approval of medical devices whose effectiveness
is questionable and which may not be entirely safe... Managers
have ordered, intimidated and coerced FDA experts to modify
scientific evaluations, conclusions and recommendations in
violation of the laws...and to accept clinical and technical
data that is not scientifically valid." Similar FDA complaints
arose a few years ago during the firestorm surrounding the drug
Vioxx.

So let's take a bit of a leap and put these two news items
together:

To me, this is another indictment of a system where careful
science is overshadowed by politics and pharmaceutical profit
motives. Superimpose this on a society that increasingly "looks
to the pill" to create health and well-being, and it's no
surprise that we have bought into such a wrong-headed approach
to behavioral symptoms of dementia.

There's a way out, but it's not easy. It requires that we
continue working to change our view of aging, and to see people
with dementia not as broken people to be "managed", but as whole
people whose needs are unmet by our current approach to care. It
takes creativity, artistry and compassion to truly get "out of
the box" and accomplish this.

Next week, I'll summarize the new paradigm that can take us out
of this vicious circle.

Posted by Dr. Bill Thomas on January 16, 2009 7:46 AM |Permalink |Comments (0)

January 1, 2009

Woooptee Deee Do

Ruth at Cab Drollery catches this article from the NYT...

Starting Jan. 1, the pharmaceutical industry has agreed to a voluntary moratorium on the kind of branded goodies — Viagra pens, Zoloft soap dispensers, Lipitor mugs — that were meant to foster good will and, some would say, encourage doctors to prescribe more of the drugs.
No longer will Merck furnish doctors with purplish adhesive bandages advertising Gardasil, a vaccine against the human papillomavirus. Banished, too, are black T-shirts from Allergan adorned with rhinestones that spell out B-O-T-O-X. So are pens advertising the Sepracor sleep drug Lunesta, in whose barrel floats the brand’s mascot, a somnolent moth.

The new voluntary industry guidelines try to counter the impression that gifts to doctors are intended to unduly influence medicine. The code, drawn up by Pharmaceutical Research and Manufacturers of America, an industry group in Washington, bars drug companies from giving doctors branded pens, staplers, flash drives, paperweights, calculators and the like.

She adds (and I agree)...

Well, whooptee-damn-doo. That ought to clear up any claims of impropriety, eh?

Posted by Dr. Bill Thomas on January 1, 2009 1:25 PM |Permalink |Comments (0)

December 29, 2008

Waste Not Want Not

Matt Yglesias has a very insightful post on waste in health care.

BTW he is a great blogger, very much worth keeping an eye on his blog.

He writes...

There’s a real lack of understanding in this country of the extent of the problem of medical waste and what I guess you’d have to call doctors’ incompetence. Uwe Reinhardt has a great post laying much of this out including the striking fact that “on average, American patients receive the recommended treatment for their condition only slightly more than 50 percent of the time.”

The structure of Medicare allows us to do pretty solid apples-to-apples comparisons of what different hospitals are spending on treatment, and the evidence is clear that the hospital-to-hospital variance is costs is large, and in quality is also pretty big, but the differences seem uncorrelated:

According to the Dartmouth researchers, if physicians with relatively higher cost preferred practice styles could be induced to embrace the preferred practice styles of their equally effective but lower-cost colleagues, overall per-capita Medicare spending probably could be reduced by at least 30 percent without harming patients, and similarly for commercially insured younger Americans. How can a nation that routinely wails over its high cost of health care ignore such important research?

I’ve been watching a lot of House re-runs lately, and they’re a striking encapsulation of part of what’s wrong with the way Americans think about medicine. Dr House is unfailingly portrayed as a bad person but a fantastic doctor and the medical ideal is seen to be that of the brilliant explorer-hero who does what it takes to solve the most difficult cases. An alternative model would see the doctor as a kind of custodian of public health. A general practitioner who develops an effective method of nudging people toward quitting smoking or exercising more during his brief post-checkup chats would save many more lives at dramatically lower cost than would all of Dr House’s heroics.

And of course most doctors in the real world aren’t like genius television characters — unleash them from concerns about cost-efficacy and imbue them with a heroic self-conception and they don’t even give you costly-but-effective medicine. Almost half the time they don’t even do the right treatment.

Posted by Dr. Bill Thomas on December 29, 2008 1:37 PM |Permalink |Comments (0)

November 21, 2008

Power Up Friday

President-elect Obama is facing some challenges that are
unprecedented in recent decades. As he prepares his transition
and selects his advisers, he will need two things to help the US
through the very tough days ahead.

The first thing he will need is leadership - the kind that calls
everyone to work together toward a higher goal, even if the
personal rewards are not evident. The kind of leadership that
Roosevelt had, the kind that Churchill had.

The second thing he needs is elder counsel. No one under 75 has
any real memory of the Great Depression, and few people under 70
have any recollection of World War II. As we look forward toward
a time when the world needs shared sacrifice to survive and
thrive, we would do well to hear the voices of those who have
lived through such times before. What worked and what didn't?
What got people through from day to day? It's not all in the
history books.

Elders don't need to run the country, but they need a formal
advisory voice. Their wisdom and perspective has been sadly
lacking in our government, and many others as well. They need to
be volunteers, not those seeking political office or lobbying
for contracts.

Leadership and elder counsel. Obama has one. He needs the other.

Posted by Dr. Bill Thomas on November 21, 2008 10:06 AM |Permalink |Comments (0)

November 14, 2008

Power-Up Friday: A Staggering Question of Health Care Ethics

In the latest issue of Health Affairs, medical technology is highlighted and many questions are raised. A study from Stanford reports that even though the use and cost of MRI and CT scans have increased dramatically since 1995, there is little evidence to suggest that there has been an impact on overall health care or mortality outcomes.

The explosion of medical imaging technology since my medical school days is absolutely staggering. Nevertheless, our infatuation with the latest and greatest machines sometimes keeps us from critically examining just how useful they are in the larger scheme of things. With increasingly tough economic questions being asked, these types of studies will put our health care practices under greater scrutiny in the days to come.

Nowhere is this more important than in the care of older adults. Changing medical conditions and life expectancy put even further constraints on the usefulness of diagnostic testing, as comfort and quality of life concerns begin to overshadow the ability to cure disease. A recent task force on colon cancer screening, for example, has recommended it not be done routinely in people over 75, and similar guidelines for prostate cancer suggest that people with a life expectancy of fewer than ten years not be screened.

The point is that we need to look at each individual in terms of their own situation, their prognosis and life goals, before blindly walking through the available diagnosis and treatment options. This requires practitioners to know their patients well and to initiate values-based discussions with each person before deciding how to proceed. These conversations alone may serve to cut the cost of health care dramatically.

Here's a great quote from A. L. Caplan (speaking about nursing homes), which is even more true 18 years after it was written:

"...ethics concerns not only questions of life and death but how one ought to live with and interact with others on a daily basis. The ethics of the ordinary is just as much a part of health care ethics as the ethics of the extraordinary. For the resident, the small decisions of daily life set the boundaries of his or her moral universe."

-- Al Power

Posted by Kavan Peterson on November 14, 2008 7:03 AM |Permalink |Comments (1)

October 6, 2008

Privatizing Social Security

Strictly from a political point of view, these are dark days for any candidate with a history of supporting George W. Bush's plan to privatize Social Security.

Posted by Dr. Bill Thomas on October 6, 2008 12:47 PM |Permalink |Comments (0)

September 12, 2008

Power-Up Friday: Taking Stock

As the presidential debates begin and we start hashing over such issues as national security, terrorism, the economy, the environment, etc., I'd like to pause and ask what is it that truly makes a country strong. I have my own opinion (of course). I place a nation's strength and solvency squarely on three fundamentals, which I will refer to with the old moniker of "Health, Education and Welfare".

Health - in order for a nation to be solid and productive, its citizens must have access to good preventive health, and must be secure in having access to effective treatment, should they become ill. A sick population cannot produce, cannot innovate, cannot protect itself from any kind of challenge. Unfortunately, this is not our situation.

With a third of our population either uninsured or under-insured, and an industry that favors expensive intervention over prevention and human services, we are in a precarious position. We already spend far more than any other nation on health care, and many of our outcomes are much worse than many other nations. This situation does not show signs of improving in the near future.

Education - An educated citizenry is the best resource for progress in our rapidly changing world. We are clearly lagging behind many other countries in this measure. A friend of mine recently related that she was asked to help a college student with his calculus homework. She was a bit nervous until she discovered that the problems were similar to what she had learned in middle school in her native Japan!

Unfortunately, we seem to have become a nation that does not value education as highly as we should. We seem to be more concerned with whether our next President can be the kind of person who can "share a beer with the guys". Any candidate's attempt to speak intelligently is often dismissed as "elitism". For the record, elitism, (favoring one group of people over others), better describes those whose policies favor the wealthy, or those who give multibillion dollar no-bid contracts to their former companies.

I don't know about you, but I would want the person who inherits the most powerful job on the planet Earth to be very, very intelligent.

Welfare - a dirty word for many. We have become, more and more, a nation that finds fault with those in need, and the gap between the haves and have-nots widens every year. We seem to have forgotten that charity -- giving without expectation of return -- is a cornerstone of all of the major religions, from the Five Pillars of Islam to the Diamond Sutra to the Sermon on the Mount.

I subscribe to the belief of Dr. Samuel Johnson, who in the 18th century declared, "a decent provision for the poor is a true test of civilization". (BTW, he's also the guy who said "Patriotism is the last refuge of scoundrels".)

In summary, I believe that in our zeal to maintain our position on prominence in the world, the US is forgetting its fundamentals; hence the crumbling infrastructure which, in turn, impacts our economy, energy policy, competitiveness, and overall security. History has shown that most empires and dominant nations do not last longer than 200 years. We need REAL change if we are to avoid being the latest casualty.

-- Al Power

Posted by Kavan Peterson on September 12, 2008 3:19 PM |Permalink |Comments (0)

July 25, 2008

Power-Up Friday: Prognosis -- Negative

[Editor's Note: Al Power guest blogs weekly for Power-Up Fridays.]

According to the BBC News, the US health report card is out, and the results aren’t good. The American Human Development Report was funded by the Rockefeller Foundation, Oxfam America and the Conrad Hilton Foundation.

This study found that the world’s richest nation has slipped almost to the bottom of the industrialized countries – 42nd – in overall life expectancy. In the overall “human development” score, which takes into account factors of health, education and income, we slipped to 12th.

Further analysis reveals great disparities in outcomes in different geographic or socio-economic groups. We all know this, but the numbers are startling. The Development Index of people in Mississippi is 30 years behind those in Connecticut. In life expectancy, African-American male life spans were 14 years shorter than Asian-American males. African-American life expectancy today trails what it was for the average American in the 1970s.

We have the highest percentage of children living in poverty, the highest percentage of people in prison and our infant mortality rate continues to rank near the bottom. It was estimated that if our infant mortality rate were equal to #1 Sweden’s, an additional 20,000 babies a year would survive!

So how can the world’s richest nation with the highest health care expenditures do so poorly? I would offer the following contributing factors: (1) Poor access to health care, with 47 million uninsured and an equal number with inadequate coverage, (2) inadequate social capital in the realms of maternity and childcare assistance, nutrition programs, etc., (3) money spent promoting high cost pharmaceuticals and filling the coffers of private insurers, rather than giving good preventive care and treatment to all, and (4) concentrated poverty and worsening recession without any sound economic or social policy.

I know some people are going to decry any suggestion of “socialized” health care. I would just point out that the people in those countries that have it are living longer and better than we Americans, and saving money in the process. Maybe it’s time to stop regarding these systems so dismissively and find out why they are so much better than what we have.

-- Al Power

Posted by Kavan Peterson on July 25, 2008 9:15 AM |Permalink |Comments (1)

July 2, 2008

Arkansas Green House

Some good news in Arkansas...

"One size doesn't fit all," Congressman John Boozman, a strong advocate for improvements to senior care, told a group gathered to celebrate the first shovels of dirt turned for the Green House Assisted Living project in November. "These are the kinds of projects that really do change people's lives."
Now that the finishing touches are being put on the exteriors of the first four Green Houses, a stateof-the-art assisted living environment at Legacy Village, the calls are rolling in. For the past several months, visual progress on the Green Houses has prompted a growing list of seniors and their loved ones to inquire about what will be the first project of its kind in Arkansas.

The Green House model was developed by Dr. Bill Thomas, a nationally recognized geriatrician dedicated to eliminating institutionalstyle nursing homes in America. The Green House success story began with the opening of Thomas' pilot project in Tupelo, Miss., in 2002. There are now 10 such projects across the country.

Posted by Dr. Bill Thomas on July 2, 2008 6:22 AM |Permalink |Comments (0)

June 17, 2008

Will McCain Privatize Social Security?

You be the judge...

Posted by Dr. Bill Thomas on June 17, 2008 6:54 AM |Permalink |Comments (0)

June 5, 2008

Let's Not Forget

Let's not forget that John McCain was an enthusiastic supporter of George Bush's plan to privatize Social Security.

Posted by Dr. Bill Thomas on June 5, 2008 6:54 AM |Permalink |Comments (0)

May 30, 2008

Power-Up Friday: Is Grandma Drugged Up?

Check out the news article on CNN.com, "Is Grandma drugged up?". This is important information, especially for older health care consumers.

The article states that 38 million older Americans suffer from drug complications every year, 180,000 of which are life-threatening.

It adds that people over 65 have a "risk for drug errors" that is seven times greater than those under 65. I'm not sure if their wording is correct here. This ratio might actually reflect the risk of drug complications, not errors. Either way, it is an important caution for older people on multiple medications, (see my post from April 25).

New drugs are rarely tested on older people before FDA approval. The study populations are carefully selected to minimize risk. That's not necessarily a bad thing; but after approval, the companies will often take drugs tested in healthy 40 and 50 year-olds, and promote them for people in their 70s and 80s. It is NOT a valid assumption that these pills will have the same efficacy and safety in older people.

I'm not a big fan of CNN-TV, which seems to use a lot of fearmongering and histrionics to peddle its news. However, this article is a good read. It has lists of potentially harmful drugs and drug interactions, instructions for doing a "brown bag review" of your pills, and suggestions for discussing these concerns with your doctor. Check it out!

--Al Power

Posted by Kavan Peterson on May 30, 2008 9:54 AM |Permalink |Comments (0)

May 29, 2008

Culture Change

The main nursing home trade association shines a light on culture change.

Interesting.

It’s no secret that adopting culture change principles in a nursing home is the right thing to do. But a new report from the Commonwealth Fund finds that it may be better for business too.
Take staff retention. Researchers found that 59% of nursing homes who implemented seven or more culture change intiatives, like letting residents determine their daily schedule or asking nursing assistants to participate in care planning, had improved their staff retention rate since they implemented these initiatives.

That’s not all. Occupancy rates went up and operating costs fell as nursing homes adopted more programs that empowered direct care staff and focused on residents’ needs and preferences.

That’s not to say these programs aren’t costly. 31% of nursing homes surveyed reported that cost was the biggest barrier to implmenting more culture change programs in their facility. This survey, however, begs the question: does embracing culture change give nursing homes a better “bang for their buck?”

Posted by Dr. Bill Thomas on May 29, 2008 10:04 AM |Permalink |Comments (0)

May 16, 2008

Power-Up Friday: Enough Mickey Mouse Health Care

Reporting from Disney World, where I'm speaking at a conference:

Associated Press reporter Linda Johnson reported Wednesday in the Washington Post that 51 percent of all insured Americans are on at least one prescription drug for a chronic medical condition. The breakdown includes: two-thirds of women 20 and over, one quarter of children and teens, 52 percent of men and three-quarters of people age 65 and over.

In the final group, 28 percent of women and 22 percent of men are on 5 or more prescription drugs!

In spite of spending more money per capita than any other nation, the US continues to lag many other countries in life expectancy and other important health indicators.

Experts interviewed attributed this trend to poorer public health and more aggressive early treatment of conditions like hypertension and high cholesterol. Average body weight in US adults and children is higher than ever.

Yes, BUT...

- How many of these early treatments truly improve quality and quantity of life, and how many are fueled by relentless advertising by the pharmaceutical companies, and ready reimbursement through Medicare D and other plans? People in other industrialized nations don't treat so aggressively, yet they live longer. We need more evidence-based studies that are not sponsored by the people selling the drugs!
- How much of the pile of health care dollars do we spend for prevention, education and public health improvements? Have we decided that it's just easier to prescribe (or take) one more pill?
- Everyone runs away from the idea of universal coverage because of the fear that it will place too much of a financial burden on companies and taxpayers. Has anyone considered what it costs us all to have such poor public health and 50 million uninsured people?

-- Al Power

Posted by Kavan Peterson on May 16, 2008 6:23 AM |Permalink |Comments (0)

May 14, 2008

Pinnacle of Adaptation

[Editor's Note: Below is a teaser to Dr. Thomas' new health column to be published bimonthly on www.timegoesby.net. Thanks to Ronni Bennett for inviting Bill to become the TGB Geriatrician.]

I am excited about guest blogging here with Ronni Bennett. TGB is a terrific blog and if I can add something of value to this community, I will be happy.

I am a physician and my background is in Family Medicine and Geriatrics.

My approach to medical issues tends to focus more on the big questions of emphasis and interpretation and less on specific remedies. (Although I do get into that from time to time.) In medical school we used to joke that certain professors seemed to have favorite molecules that they studied exhaustively. That's never really been my thing.

What do I mean by big ideas? Well, how about this: I believe that older people are the healthiest people on the planet.

Huh?

Aren't old people sick most of the time? What about all of the billions of dollars we spend on Medicare? What about the statistics that show older people using the most health care resources per capita of any age group?

Those objections are valid, but they miss the deeper reality.

Click here to continue reading the TGB Geriatrician...

Posted by Kavan Peterson on May 14, 2008 9:38 AM |Permalink |Comments (1)

May 6, 2008

Dr. Bill Blogs as The TGB Geriatrician

Ronni Bennett at www.timegoesby.net has an exciting announcement that will interest ChangingAging.org readers:

I am pleased and excited that Dr. Thomas has agreed to become The TGB Geriatrician. Because there are already too few geriatricians in the U.S. and the number of elders will increase dramatically over the coming decades, I'm convinced that we ourselves must take more personal responsibility for our health by educating ourselves and working in collaboration with our physicians who may not have a lot of experience with elder medicine. Dr. Thomas is going to help us do that.
Beginning later this month, his column will appear twice monthly at Time Goes By covering such topics as the myths of aging, exercise, medications, supplements, adaptation to changes, how our bodies age, and our minds, and much more. And as long as you keep it to general topics and not your personal health problems, you will have an opportunity to suggest health issues Dr. Thomas might tackle for us.

This is an extraordinary opportunity for us to learn from one of the most knowledgeable, experienced and visionary aging experts in the world - and, a guy who really likes old people.

We'll keep you posted as Bill's column is published, and feel free to email your suggestions for general health topics you'd like Bill to discuss to changingaging@gmail.com.

---
Kavan, Blog Meister

Posted by Kavan Peterson on May 6, 2008 11:34 AM |Permalink |Comments (0)

May 5, 2008

Power-Up Tuesday: Antipsychotic Restraints Part II

[Editor's Note: Continued from Al Power's April 25 post Antipsychotic Restraints]

My good friend (and restraint reduction pioneer) Dr. Bernie Shore once said to me, “You know, Al, we have a lot of people with dementia who are calm and engaged when you sit and interact with them, but they get agitated again after you leave, and you can’t do one-to-one care all day.” We have all had this experience. Here’s my explanation:

“That person is sitting on a ledge, 50 stories up. And you can crawl out on the ledge and put your arm around him, tell him he’s okay, and calm him for a moment. But when you leave, he’s still on the ledge.”

This is why simple algorithms like a weekly hand massage and daily washcloth folding don’t quite do the job. Until the environment feels safe and comfortable, not toxic and foreign, one can never make great inroads into serious medication reduction.

But it’s happening out there, as we speak. Some people have moved below 5 - 10% prevalence of antipsychotics, and a few homes keep the number near zero.
Three steps to transforming the care environment: (1) create meaningful, continuing relationships. These allow everyone to be well-known, and provide care partners with vital clues to the experiences of the elder. (2) create an environment filled with positive, affirming interactions that provide the elder with choice, engagement and meaning, and respect her basic personhood. (3) Move our frame of reference to enter the elder’s world, rather than to drag her into our reality.

This last step bothers many people, who feel that it means “giving up” on the person, or allowing her to slip further. Some of us have found, however, that much of the psychic distress people experience is caused by trying to force them back into a pattern of “normalcy” that they can no longer process. In fact, when you go to the elder’s point of view and relate on their terms, providing a safe, validating approach and reducing their medications, people usually improve their cognition and engagement to a greater extent than we see when we try to force the improvement.

Ironic, isn’t it?

Is it easy? No! Is it critically important? Yes!!

I’m collecting success stories of people working in this realm. Feel free to share them or pass on any questions; here, or to apower@stjohnshome.com.

Posted by Kavan Peterson on May 5, 2008 3:29 PM |Permalink |Comments (0)

April 25, 2008

Power-Up Friday: Antipsychotic Restraints

The latest issue of the Journal of the American Geriatrics Society adds another nail to the coffin of antipsychotic drugs in older adults. In a Dutch study of nearly 23,000 people on these drugs, there was a 60% increase in pneumonia, compared with those not taking the medications.

Add this to the growing list of concerning reports about this class of drugs in recent years - they make Vioxx look good.

In nursing homes around the industrialized world, about 40% of people with dementia are taking antipsychotic drugs for behavioral symptoms of dementia. Looking at all of the published studies of drug effectiveness, even if you take the results at face value, fewer than one in five people show a clinical benefit.

If these were heart medications or antibiotics, we would have abandoned them long ago. We cling to them because of our narrow view of what elders with dementia need.

Antipsychotic use for dementia is dead – we just don’t know it yet! These drugs are the “physical restraints” of the 21st century. Thirty years ago, we couldn’t conceive of a safe way to untie people without causing greater harm, until some intrepid pioneers showed us the way. We were locked in the wrong paradigm.

And so it is with dementia. The problem lies in our approach to care. We create an institutional environment that favors tasks and interventions over relationships. We remove all aspects of autonomy and control. We try to force people with dementia to try and reorient their minds and bodies to the patterns of “normal” adults. Then we medicate the predictable result. (This happens in the community as well as the nursing home.)

Can we un-medicate people with dementia and have them live fuller, healthier lives? Absolutely! People are doing it as we speak, though their voices are still mostly out at “the fringe”. I’ll tell you how next Friday…

-- Al Power

Posted by Kavan Peterson on April 25, 2008 7:11 AM |Permalink |Comments (0)

How to Live Longer

The New York Times and Dr. Robert Kane explain how it is done.

Posted by Dr. Bill Thomas on April 25, 2008 5:29 AM |Permalink |Comments (1)

April 23, 2008

Not So Old Ladies

Your health care system is run for profit, results--- not so much. Seriously, this is not a story about how we are worse off than Britain or France or Canada or Cuba, this is a story about an absolute decline in lifespan for women in 1,000 American counties.

Something is going terribly wrong.

Longevity for women is falling in the USA.

For the first time since the Spanish influenza of 1918, life expectancy is falling for a significant number of American women.

In nearly 1,000 counties that together are home to about 12 percent of the nation's women, life expectancy is now shorter than it was in the early 1980s, according to a study published today.

The downward trend is evident in places in the Deep South, Appalachia, the lower Midwest and in one county in Maine. It is not limited to one race or ethnicity but it is more common in rural and low-income areas. The most dramatic change occurred in two areas in southwestern Virginia (Radford City and Pulaski County), where women's life expectancy has decreased by more than five years since 1983.

The trend appears to be driven by increases in death from diabetes, lung cancer, emphysema and kidney failure. It reflects the long-term consequences of smoking, a habit that women took up in large numbers decades after men did, and the slowing of the historic decline in heart disease deaths.

The WaPo has the rest here

Posted by Dr. Bill Thomas on April 23, 2008 6:48 AM |Permalink |Comments (0)

April 21, 2008

Closing the Barn Door

After the Horse Needs Health Care...

Diane from Cab Drollerly takes a hard look at "post-claim underwriting."

This reality provides a nearly perfect illustration of why our health needs to rescued from the "profits before people" mania that is damaging the lives of millions of people.

Be sure to click through for the whole exceptional post.

For the past several weeks I've been whining about the mess the governor and state legislature have made of the California budget and the resultant mess they've made of the state due to their recalcitrance and ineptness. Today, however, I've got some good news. The state stepped forward in the battle against health insurers who rescinded policies when the policy holders naively filed claims under the policy.

The Money graf...

"Post-claims underwriting" is the perfect term for this outrageous practice. Let me provide a brief reminder of how the insurance companies operated this scam. Prospective customers filled out an application for health insurance and submitted the first premium payment. They continued to pay the premiums and the insurance companies cashed their checks. Then, when the policyholder filed a claim for benefits under the policy, the insurance company went back and reviewed the applications looking for even the slightest error, and finding one, rescinded the policy without paying a nickle on the claim. One consumer advocate gave an example: a woman with breast cancer had her policy rescinded during treatment because she failed to note that she had taken an antidepressant drug in the distant past. Nice, eh?

Cab Drollery Bustin' Chops

Posted by Dr. Bill Thomas on April 21, 2008 6:40 AM |Permalink |Comments (0)

April 18, 2008

Top Comment

DeanOR gets it right with reference to the workforce issue. This is why addressing the meaning, worth and value of ELDERHOOD is key to solving these other problems...

I think those who serve the elderly, like those who serve the poor, have low status (which also determines their income and the attractiveness of the professions to potential recruits) because the group they serve has low status. That in turn seems to stem from our society viewing the worth of every person in terms of their economic value. Even those who serve children, despite the children having economic value in the future, have lower status because economic value is judged more in terms of immediate profit-making than in terms of potential contributions. Those of us who are younger or wealthier keep this system going through psychological denial, imagining that we will never be old and needy, or that if we are we will have all our needs met through our money, and by keeping groups such as the elderly and the poor out of sight and out of mind. We also tend to turn lower status professions over to women, who in turn have lower status. Lower economic status also means less influence over the politicians who could help solve the problems.
I don't usually rely this much on the concepts of sociology or political theory in analyzing problems, but this is how it looks to me. That does not mean that problems are insurmountable. Raising awareness, through activities such as this blog is one way to promote change. Raising hell helps too.

Posted by Dr. Bill Thomas on April 18, 2008 10:20 PM |Permalink |Comments (0)

April 17, 2008

Geriatric Care Is Facing Crisis

This is conventional wisdom inside the field of aging but it is nice to see that it is getting attention from the Wall Street Journal. See article below with my comments bold...

Surge in Training
Called for to Meet
Exploding Demand
By THEO FRANCIS and VANESSA FUHRMANS

Health-care institutions must rapidly increase training in geriatric care to ward off an "impending crisis" as 78 million baby boomers head toward old age, according to a report by the federal Institute of Medicine.

Calling the U.S. health-care work force "too small and woefully unprepared" for the growing elderly population, the 242-page report lays out a stark picture of increased demand for health-care workers -- unmet by a stagnant or even dwindling supply of those trained to treat the elderly.

This is a case of market failure. There is a large lead time in recruiting and training people who can work in this field. The need is great but current market incentives are pulling people into fields other than aging. Without action, the age boom will really hit and it will be impossible to meet the needs.

"This could be seen as evidence that our society places little value on the expertise needed to care for vulnerable, frail older Americans," said John W. Rowe, chairman of the committee that wrote the report and former chairman and chief executive of health-insurance giant Aetna Inc.
In addition to training specialists, the report recommends weaving more geriatrics training into general medical education for doctors, nurses and others. "We're not saying every [old] person needs a geriatrician any more than every person who has a heart needs a cardiologist, but we need to enhance the care they do receive," Dr. Rowe said.

I agree with Dr. Rowe's view on this...

Some nursing homes and other institutions are already pairing with medical, dental and nursing schools to provide hands-on geriatric training. Hebrew SeniorLife, a nonprofit nursing-home and senior-housing group in Boston, helps train about 750 medical, dental, nursing and other students from more than a half-dozen local schools; second-year Harvard Medical School students spend two weeks treating its elderly residents. Next month, Brandeis University plans to announce a program with Hebrew SeniorLife to train health-care administrators interested in focusing on the elderly.
But such efforts are rare, due to the time and expense of implementing them. Another Hebrew SeniorLife program -- giving nurse aides a day off a week to work toward becoming a licensed practical nurse -- costs some $450,000 a year, funded by a state grant and donations.

"The first thing you need are patients, and the second thing you need are health-care professionals who have a spare moment to be providing high-quality teaching," said Len Fishman, the nonprofit group's chief executive and a former New Jersey Commissioner of Health and Senior Services. "Most long-term-care facilities are small; they don't have medical staffs."

The other big problem is that pushing "new recruits" into training programs which are nursing home-centric winds up giving people a false impression of the field. It is like scooping water with a sieve.

Monday's report also recommends training for those taking care of elderly people, noting that 90% of those receiving care at home get help from family and friends, and 80% rely solely on them.

This is what Eden at Home is all about...

By 2030, one American in five will be over 65, and in coming years more than half of all medical care in the U.S. will go to that group, the report notes. Those over 65 currently make up about 12% of the population and account for a quarter of doctors' office visits and at least a third of hospital stays, prescriptions and ambulance trips. Patients over 75 average three chronic conditions and may take four or more medications.
Currently, just one doctor specializes in geriatrics for every 2,500 Americans over age 65, and similar shortfalls exist among other geriatric specialists, including psychiatrists and social workers, the report said. Between 2000 and 2006, the number of certified geriatricians actually fell, by 22% -- and to maintain existing ratios of medical professionals, the U.S. would need to increase its health-care work force by 35%, or 3.5 million people, the report said.

The report blamed misplaced financial incentives for much of the shortfall. Doctors specializing in geriatrics averaged income of $163,000 a year in 2005, compared with internists who earned $175,000 with no specialty training. Other specialists, from surgeons to radiologists and dermatologists, can earn more than twice as much.

Not mentioned is the relatively low professional status NOT enjoyed by the field of geriatrics. This needs to change as well.

Meanwhile, half of those workers caring directly for the elderly -- helping them dress, bathe and eat, for example -- are paid less than $9.56 an hour, the report notes.

Posted by Dr. Bill Thomas on April 17, 2008 5:41 AM |Permalink |Comments (2)

April 13, 2008

Eden and CMS

At the recent Pioneer/CMS Summit on Design and Long-Term Care, Eden Alternative Executive Director concluded her remarks with these stirring words...

The Eden Alternative is happy to have a voice in this discussion of the physical environment as it relates to home. But we also know through our work with hundreds and hundreds of organizations around the globe, who are struggling to create real home, that true home is not found in the physical environment. It is not about walls and carpet and chandeliers, any more than it is about fur and feathers. The physical environment is merely the container in which the human spirit can either grow or wither. The current physical environments are sorely pressed to support growth. They are like frozen tundra, devoid of warmth and growth. So we certainly need to address the issue. But the most important part of a true human habitat is the soil. Every gardener knows that a rich and nourishing soil is vital to the garden. The soil is the social environment that exists in out long-term care facilities.
We know through our work that there are providers who are currently creating authentic home despite the shortcomings of the physical environments they have inherited. These highly creative people are transforming what they have been given, and in the smallest of ways creating home in their physical environments, while concentrating mostly on creating a warm, caring ethos, where every person has the opportunity to give and receive care. It is in these types of environments that Elders will truly find home and a sense of belonging. We also know through our work with Eden At Home™ that even an Elder’s own personal home can become like an institution when she needs care and all the focus is on the care of the human body while her human spirit is neglected, and her rights to autonomy and choice are removed.

Some of you may be thinking, “We can’t go that far. These ideas are just too bold. We need to take our time and go slowly. The Eden Alternative would remind you that over a million and a half people live in institutional nursing homes in this country. These people are at this very moment in harm’s way. There is widespread immediate jeopardy and actual harm being caused by this pursuit of the inauthentic. There are people suffering and dying from the plagues of the human spirit. That kind of pain is far greater and much deeper than any pain of the body. We do not have the luxury of taking this slowly. We must act swiftly and we must act boldly.

This is the hour. And we are the ones our Elders have been waiting for. The Eden family is honored to be on this journey with you.

Posted by Dr. Bill Thomas on April 13, 2008 5:58 AM |Permalink |Comments (2)

April 12, 2008

Unwise Use

Millions of people continue to take medications even after sophisticated published medical studies have shown that the medicines do not work as intended.

Among these millions is, apparently, John McCain, Republican candidate for President.

The New York Times reports...

Mr. McCain has undergone each year since 2000, stress tests show no evidence of heart disease, and “his doctors consider him in very good health,” his campaign staff said in a recent statement.
The campaign also said Mr. McCain regularly took Vytorin to lower his cholesterol, a baby aspirin to help prevent heart attacks, a multivitamin and, occasionally, Claritin or Flonase for allergies.

So how effective is Vytorin?

After an almost two-year delay, Merck and Schering-Plough finally released partial data from their own two-year study of Vytorin called “Enhance. This study tested their drug on 720 patients with high cholesterol. The “surprise” results revealed that Vytorin was no more effective than a high dose of one of its components, Zocor, which is available in the generic form at one-third of the cost! Vytorin’s annual sales of about $5 billion likely justified the “delay” in releasing the results of the “Enhance” study, in the minds of its makers.

Despite the companies claim of acting with “integrity and good faith” law suits are piling up in several states over allegations they misled consumers into thinking the drugs were more effective than generics.

Article here.

It really is enough to make me wonder about the wisdom of placing the future of the American health care system into the hands of a man whose own personal physicians remain unaware of current research regarding the medicines used by their most famous patient.

The wise use of medications is not more medicine and it is not less medicine, it is the use of medicine based on evidence rather the business strategies of multi-national pharmaceutical companies.

Posted by Dr. Bill Thomas on April 12, 2008 6:17 AM |Permalink |Comments (0)

March 31, 2008

Health Care Design

Andrew Sullivan highlights an important issue--- the role good design should play in health care.

This quote is from Virgina Postrel's article in the Atlantic Monthly...

Mounting clinical evidence suggests that better design can improve patients’ health—not to mention their morale. But the one-sixth of the American economy devoted to health care hasn’t kept up with the rest of the economy’s aesthetic imperative, leaving patients to wonder, as a diabetes blogger puts it, “why hospital clinic interiors have to feel so much like a Motel 6 from the ’70s.”

A Hyatt from the early ’80s might be more accurate. The United States is in the midst of a hospital-building boom, with some $200 billion expected to be spent on new facilities between 2004 and 2014. Although more spacious and sunlit than the 50-year-old boxes they often replace, even new medical centers tend to concentrate their amenities in public areas, the way hotels used to feature lavish atriums but furnish guest rooms with dirt-hiding floral bedspreads and fake-wood desks. Hospital lobbies may now have gardens, waterfalls, and piano music, but that doesn’t mean their patient rooms, emergency departments, or imaging suites are also well designed. “Except for the computers you see, it’s like a 1980s hospital,” says Jain Malkin, a San Diego–based interior designer and the author of several reference books on health-care design. “The place where patients spend their time 24/7 is treated as if it’s back-of-the-house.”

Can we do better?

We sure can...

Posted by Dr. Bill Thomas on March 31, 2008 5:53 AM |Permalink |Comments (1)

March 25, 2008

Gallstones and Magnesium

An interesting study, just out shows that men who increase their dietary intake of Magnesium (a mineral) cut their risk of developing symptoms related to gallstones.

Consumption of a diet rich in magnesium appears to reduce the risk of symptomatic gallstone disease, according to findings from a US study of over 42,000 men.
Dietary consumption of magnesium has been declining over the years, lead author Dr. Chung-Jyi Tsai and colleagues note, due in part to the overprocessing of foods.

Magnesium deficiency is known to cause elevated triglyceride levels and decreased HDL cholesterol levels, both of which may raise the risk of gallstones. Still, the long-term effect of magnesium consumption level on the risk of gallstones in humans was not known.

Honestly, I think that this is the payoff paragraph.

"From many studies by this group and others, it appears that a generally healthy dietary pattern, with more plant-based foods, fiber, and increasing complex carbohydrates, and now increasing magnesium intake will decrease the risk of symptomatic gallstones and cholecystectomy," Dr. Cynthia W. Ko, from the University of Washington in Seattle, writes in an accompanying editorial. "This 'healthy' dietary pattern will also help in prevention of other chronic diseases in addition to gallstones."

This is the kind of research that I like and respect. Too many people are taking too many supplements that have never been adequately studied. I agree with the dictum...

There is no such thing as "alternative medicine."

There is medicine that works and medicine that does not work.

As for me, I prefer medicine that works.

The citation for this article is...

Am J Gastroenterol. 2008;103:375-382.

Posted by Dr. Bill Thomas on March 25, 2008 6:23 AM |Permalink |Comments (0)

March 21, 2008

Cost and Value

Nice conversation going on about the fundamental goals of health care reform...

This post from Ezra Klein's blog draw an important and often overlooked distinction. If you like thinking about our health care system and how it can be improved, his blog is a great place to start. He is reacting to a post written by Kevin Drum...

How Kevin was able to get an early glance at my next tattoo is anyone' guess (I had the whole thing translated into kanji, too!), but that's a pretty perfect description of how I understand the role of the progressive health reformer. It's also why I joke at panels that my plan for health reform is invading France and taking their system. I'm down with no blood for oil, but I'd give some blood for universal coverage.

Meanwhile, a quick thought on cost control: When talking about costs, folks need to distinguish whether they're talking about getting more value for each dollar or reducing total spending. The two might not be the same. Prevention, for instance, gets far more value out of each dollar. But if it keeps people alive a whole lot longer, that's more time for them to contract various illnesses, and when they grow old, to die from something expensive. So though prevention may mean our health dollars are doing a whole lot more good, it may not mean we're spending less as a total percentage of GDP. Conversely, we could outlaw coverage of statins, which would save some money, but kill a lot of folks. Now, I'm not saying the two ends are opposed. Indeed, getting good value is probably a complementary goal to spending less. But it's not the same thing.

Getting more is not always necessarily better than getting less of something. We want better health care (and better measures of health) rather than just getting more care- regardless of its ultimate impact on public health.

Posted by Dr. Bill Thomas on March 21, 2008 6:16 AM |Permalink |Comments (0)

March 12, 2008

Good Old Brain Surgery

Healing is an ancient art...

Greek archaeologists said Tuesday they have unearthed evidence of what they believe was brain surgery performed nearly 1,800 years ago on a young woman — who died during or shortly after the operation.

The rest of the article is here.

Posted by Dr. Bill Thomas on March 12, 2008 10:43 AM |Permalink |Comments (0)

March 7, 2008

Power Up Friday: Be Cool Edition

Dr. Al Power writes...

Here's my take on Bill's March 5th post, "Doctor, Doctor, Give Me the News":

The advancement of the nurse practitioner profession has caused a great deal of controversy in the medical community. From where I sit, it appears that the majority of doctors are happy with NPs in a subservient role, but get nervous when they "strike out on their own", or expand their realm of practice.
There is no doubt that MDs have a great deal of specialized training and skills. However, most of them are using this training to go into specialized fields, and there are few who are willing to provide general care for the population at large, especially for older adults in nursing homes or other communities.
There are many things that doctors do that can be done as well by nurse practitioners. To me, there is something amiss with doctors being so territorial about this. Are they really concerned about quality of care? Or is it more of a "turf war", or a fear of loss of income to someone that a patient might prefer seeing?
A basic premise of the advancement of knowledge should be that it is shared freely with all who wish to attain it. To jealously guard a realm of practice from others who wish to make a contribution will only hurt the community as a whole, and reduce access to care. There is a parallel here with doctors of past decades, who objected to their patients having access to medical information that made them want to be more active partners in their care.
Wake up, folks! There are many excellent NPs out there, providing excellent care. As an internist and geriatrician, if I have a patient that is complex, I often engage the help of a specialist. There's no reason why an NP cannot do the same. If MDs were more pro-active in working with NPs in this manner, we would have a much better, more efficient system of health care.
I work with two geriatric NPs at my nursing home. I think they understand geriatric medicine better than many, if not most docs in town.
Finally, let's stop guarding our titles so fiercely. A "doctor" may be one of various kinds of healers, or one who has obtained advanced knowledge in a variety of fields. No one complains about saying "Dr. Martin Luther King", or addressing their dentist, veterinarian or school superintendent that way. So why get so bent out of shape if an NP was referred to as "doctor"? What are we afraid of?

Al Power, MD

Posted by Dr. Bill Thomas on March 7, 2008 5:59 AM |Permalink |Comments (2)

March 5, 2008

Doctor, Doctor-- Give Me the News

Here is a sample comment posted on a mostly doctors-only discussion thread. The term "midlevels" refers to nurse practitioners and physician assistants.

"Is it my imagination or is the line between midlevels and physicians in office-based practice becoming nonexistent? FNPs can practice without a doctor on site, as long as one is available to back them up and sign their charts. They can bill using their own UPIN numbers, and Medicare reimburses them at 85% of the physician rate. In my community, some list themselves with physicians in the Yellow Pages under Family Medicine. Some are busier than the FPs. And a few don't correct their patients when they refer to them as 'Doctor.'"

Posted by Dr. Bill Thomas on March 5, 2008 6:53 AM |Permalink |Comments (2)

March 3, 2008

More Slow Medicine

Here is a review of a book advocating "slow medicine."

My Mother, Your Mother Embracing "Slow Medicine," the Compassionate Approach to Caring for Your Aging Loved Ones. By Dennis McCullough, M.D. HarperCollins. 263 pages. $25.95

It was two decades ago that a group of culinary mavericks took a giant step backward down the evolutionary trail with the "slow food" movement. Instead of fast food produced by the assembly lines of giant consortiums, they championed products of small-scale agriculture — time-consuming to prepare, beautiful to behold, very good for you.

Now (and, some might add, at last) doctors are following suit, rejecting the assembly line of modern medical care for older, gentler options. The substituted menu is not for all patients — at least not yet. For the very elderly, however, most agree the usual tough love of modern medicine in all its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps.

In its place, doctors like Dr. Dennis McCullough, a family physician and geriatrician at Dartmouth Medical School, suggest "slow medicine" — as he puts it, "a family-centered, less expensive way."

This medicine is specifically not intended to save lives or to restore youthful vigor, but to ease the inevitable irreversible decline of the very old.

His bottom line is this: It is up to friends and relatives to rescue the elderly from standard medical care. And slow medicine, like slow food, involves a lot of hard work. Readers who sign on will acquire a staggering list of tasks to perform, some of which may be just as tiring and tear-producing as chopping onions.

All the while, medical care for the parent should favor the tried and true over the high tech. For instance, McCullough points out that instead of a yearly mammogram, a manual breast exam may suffice for the very old, and home tests for blood in the stool may replace the draining routine of a colonoscopy.

The parent's doctors should be nudged to justify flashy but exhausting diagnostic tests, and to constantly re-evaluate medication regimens. The high-blood-pressure pills that are life-saving at 75 may cause problems at 95, and paid companionship or a roster of visitors may prove to be antidepressants at least as effective as any drug.

The pace of care should be slowed to a crawl. For doctors, that means starting medications at low doses and increasing them gradually. For children, that means learning not to panic and yell for an ambulance on every bad day. And for a good overall picture of a parent's condition, a child is well advised to ignore the usual medical and nursing jargon and to focus instead on the sound of the parent's own voice. "No one," McCullough says, "can be a bigger expert on a parent's voice than a former teenager trained in the same household."

Posted by Dr. Bill Thomas on March 3, 2008 7:58 PM |Permalink |Comments (0)

February 28, 2008

Just the Facts Ma'am

This just in regarding the lobbying tab for America's (the world's?) largest for profit nursing home trade association...

From the Houston Chronicle

NEW YORK — The American Health Care Association spent about $1.7 million lobbying the government last year on a variety of bills affecting health care.

The AHCA, which represents nursing homes and assisted-living facilities, spent $860,000 in the first half of 2007 and $881,000 in the second half, according to a disclosure form posted Feb. 14 by the Senate's public records office.

The organization also paid Patton Boggs LLP $160,000 in the second half to lobby the government.

The AHCA lobbied on a range of legislation including laws affecting Medicare and Medicaid.

Lobbyists are required to disclose activities that could influence members of the executive and legislative branches, under a federal law enacted in 1995.

Posted by Dr. Bill Thomas on February 28, 2008 3:50 PM |Permalink |Comments (0)

Oh No Aibo!

The blogosphere takes this wacky idea down...

Thirty-eight residents were divided into three groups -- one saw Sparky once a week for 30 minutes, another group had similar visits with Aibo, and a control group saw neither.

"The most surprising thing is they worked almost equally well in terms of alleviating loneliness and causing residents to form attachments," says William A. Banks, M.D., professor of geriatric medicine at St. Louis University. "For those people who can't have a living pet but who would like to have a pet, robotics could address the issue of companionship."

Sorry. But I’m not buying it – either a robot dog, or the research. Either the researchers weren’t real perceptive in watching the interactions, or they chose residents who couldn’t tell the difference.

No way can a mechanical dog – tidy and sterile and convenient as it might be – lead to the same joyful bonding, produce the same therapeutic effects, make an institution feel more homelike, and give its owner the same sense of purpose that a real one does.

And furthermore, to suggest that, possibly, among the elderly, they can is insulting to the elderly – a group I don’t plan to join unless I can bring my dog.

Posted by Dr. Bill Thomas on February 28, 2008 5:38 AM |Permalink |Comments (1)

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.

Posted by Dr. Bill Thomas on February 26, 2008 6:11 AM |Permalink |Comments (0)

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 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 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 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 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)

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)

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 21, 2008

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)

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)

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)

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 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 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)

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)

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 5, 2007

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)

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)

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)

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 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 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)

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)

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 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 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 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 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 8, 2007

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)

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 (1)

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 (2)

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)

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.

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February 15, 2009

ChangingAging.org Redesign -- Please Bookmark!

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February 13, 2009

Power Up Friday

Posted by Dr. Bill Thomas on February 13, 2009 8:36 AM |Permalink |Comments (0)

February 8, 2009

Getting Closer!

Posted by Dr. Bill Thomas on February 8, 2009 4:23 PM |Permalink |Comments (0)

February 4, 2009

My Pick for Health and Human Services

Posted by Dr. Bill Thomas on February 4, 2009 1:04 PM |Permalink |Comments (0)

February 3, 2009

Understanding Health Care Reform

Posted by Dr. Bill Thomas on February 3, 2009 9:11 AM |Permalink |Comments (2)

February 2, 2009

Monkhouse Monday

Posted by Dr. Bill Thomas on February 2, 2009 8:08 AM |Permalink |Comments (0)

January 30, 2009

Krugman Can't Wait...

Posted by Dr. Bill Thomas on January 30, 2009 9:47 AM |Permalink |Comments (0)

January 27, 2009

Better Care for Seniors

Posted by Dr. Bill Thomas on January 27, 2009 4:57 PM |Permalink |Comments (1)

Dignity Champions

Posted by Dr. Bill Thomas on January 27, 2009 11:34 AM |Permalink |Comments (0)

January 26, 2009

More on Medicare for Everyone

Posted by Dr. Bill Thomas on January 26, 2009 11:26 AM |Permalink |Comments (0)

January 16, 2009

Power Up Friday

Posted by Dr. Bill Thomas on January 16, 2009 7:46 AM |Permalink |Comments (0)

January 1, 2009

Woooptee Deee Do

Posted by Dr. Bill Thomas on January 1, 2009 1:25 PM |Permalink |Comments (0)

December 29, 2008

Waste Not Want Not

Posted by Dr. Bill Thomas on December 29, 2008 1:37 PM |Permalink |Comments (0)

November 21, 2008

Power Up Friday

Posted by Dr. Bill Thomas on November 21, 2008 10:06 AM |Permalink |Comments (0)

November 14, 2008

Power-Up Friday: A Staggering Question of Health Care Ethics

Posted by Kavan Peterson on November 14, 2008 7:03 AM |Permalink |Comments (1)

October 6, 2008

Privatizing Social Security

Posted by Dr. Bill Thomas on October 6, 2008 12:47 PM |Permalink |Comments (0)

September 12, 2008

Power-Up Friday: Taking Stock

Posted by Kavan Peterson on September 12, 2008 3:19 PM |Permalink |Comments (0)

July 25, 2008

Power-Up Friday: Prognosis -- Negative

Posted by Kavan Peterson on July 25, 2008 9:15 AM |Permalink |Comments (1)

July 2, 2008

Arkansas Green House

Posted by Dr. Bill Thomas on July 2, 2008 6:22 AM |Permalink |Comments (0)

June 17, 2008

Will McCain Privatize Social Security?

Posted by Dr. Bill Thomas on June 17, 2008 6:54 AM |Permalink |Comments (0)

June 5, 2008

Let's Not Forget

Posted by Dr. Bill Thomas on June 5, 2008 6:54 AM |Permalink |Comments (0)

May 30, 2008

Power-Up Friday: Is Grandma Drugged Up?

Posted by Kavan Peterson on May 30, 2008 9:54 AM |Permalink |Comments (0)

May 29, 2008