09 August 2013

The Over 65 Project

The Over 65 Blog was an interesting find for me. It speaks to many ideas that I can relate to at age 71 and I am not afraid to admit it. Yes, there are some ideas that are difficult to agree to and this is as it should be. We all need to be aware of some of the thorny issues facing us as seniors and be prepared to agree or disagree.

First, I would name the individuals behind the over 65 project. They include:

  • James Sabin, M.D.
    Clinical Professor of Psychiatry
    Harvard Medical School
  • Sherwin Nuland, M.D.
    Professor of Surgery Emeritus
    The Yale School of Medicine
  • Daniel Callahan
    President Emeritus
    The Hastings Center
  • Susan Gilbert
    Public Affairs & Communications Manager
    The Hastings Center

The most challenging point for me is in their introduction. When they are talking about the current technology hungry model that feeds that system and consumes a large share of resources this is quite a challenge. They continue, “That model has put an unbridled pursuit of cure, not care, in the saddle, a balance that must now shift to a better balance in the direction of care. It has made end-of-life decisions more difficult, blurring the line between living and dying and offering seductive hope that death can be indefinitely overcome. The latter is both damagingly expensive and often an affront to human dignity and a peaceful death. The present over 65 generation, as well as the aging baby boomers, will be caught in the throes of the necessary revolution. They need a strong voice. Their own welfare is at stake, and their wisdom and insight are necessary for the good of all. ”

Since I am older than the baby boom generation, it will be on many of us to prepare people in the baby boomer generation to know how to be heard and to be able to speak to the problems we are facing. Presently, there are approximately 40 million Americans over the age of 65. By 2030 the predicted number is 72 million.

The Over 65 Project has five goals. No one said they would be simple goals, but they are goals that we can embrace and generally support. I have quoted them because of their importance.

#1. A stronger role for seniors:A much livelier, wider, more articulated, and stronger role for the elderly must be initiated to address the future of Medicare and related health and economic problems of old age. That aim will require a dialog among themselves, with their physicians, and with legislators. All three will be important.”

#2. Self determination:The importance of self-determination in seniors’ lives needs to be strengthened and clarified, not only for end-of-life care but also for the managing of their health and illness in general. Yet that self-determination will only become meaningful if they have had many occasions early in their elder years to talk with other elders about how to discover and shape their personal values about illness and their inevitable mortality. Many seniors come into old age without a well-defined set of values about how they might best think of their aging and making medical decisions, particularly in the face of complicated, life-threatening, chronic illness. Even when they do have some well-formed values, they can encounter complexities that were unforeseen or resistance from doctors or family members in following their wishes. Understanding oneself, and one’s aging, takes work, experience, and some help.”

#3. More care, less technology:The balance between cure and care is now too heavily weighted to an unbridled pursuit of cure, even when the potential for cure is vanishingly small. The health care system needs more care and less technology. The present system is beset with excessive and costly diagnostic tests, the use of treatments with poor evidence to support them, and doctors too inclined to respond to illness with technological fixes and desperate “last ditch” interventions at the expense of compassion and a good doctor-patient relationship. Seniors need to support comparative- and cost-effective research, which is a powerful way to determine the value of various technologies. Armed with that information, they can learn when to say no to tests and treatments that are not beneficial and to embrace those that fit with their needs and values.”

#4. Confronting the cost problem:At the heart of the present Medicare debate is the high and increasing cost of that program. Those costs must be attacked by adherence to evidence-based, efficient care, some reduction in prices, as well as some combination of reducing benefits and raising taxes. There will be no painless way to avoid making these changes. Seniors should be part of that debate, not simply resisting the painful reforms. A central, but neglected, issue for discussion should be that of intergenerational responsibility. What do the young owe the old and what do the old owe the young? Medicare is a pay-as-you go system. That means that the cost of the present Medicare beneficiaries is borne by the younger generation of workers today and future generations tomorrow. How heavy a burden can be asked of them by those who are old? What is a reasonable obligation of the young to the old? What are the reasonable obligations of the old to the young?”

#5. The economic and family needs of the over 65 generation:A large proportion of the baby boom generation will go into their late 60s and 70s with inadequate financial resources, estimated on average to be only 40% of their retirement income. Those pressures will in too many cases be exacerbated by the need to be family caretakers for their spouses or partners. Even now, most people over 65 are responsible for at least one spouse, parent, or other relative of an advanced age. That burden can all too often be financially and emotional overwhelming (notably in the case of Alzheimer’s). The burden they in turn will place on their baby boom children will be no easier—and many more will have to bear it in the future. That certainty not only touches directly on intergenerational obligation but no less on what family members owe to each other—and to what extent they can ask for government help to lighten the pressure on them.”

I will have more in future blogs and add some of my thoughts to these from the patient's perspective of type 2 diabetes as we age.

08 August 2013

Health Care Rationing, Why Should the Elderly Support It?

This is a catch 22 situation if I ever heard of one. Dr. James Sabin, writing blogs for “Over 65” makes some excellent points. I think he admits if what he is proposing is done wrong, it will not be a good thing. In reading and rereading his blog here, I am inclined to agree with many of his ideas. Yet in the back of my brain, I keep going back to a discussion I had with a now deceased doctor who said there is too much rationing for the sake of rationing. He said he hated to give up on a patient unless the patient asked him to. As a doctor of oncology, he would not give up easily. He was not afraid of trying different treatments and did discover a lot of drug combinations that were successful for cancer. He never sought credit for his work and all he cared for was the well-being of his patients.

A point that Dr. Sabin makes, but does not emphasize hard enough (although this is done in the introduction for the over 65 project), is all the money wasted on cures for the diseases of the elderly when some of this could better be used to care for the elderly. Not only care for the elderly, but also to develop preventive medicine which could alleviate the pain and suffering many of the elderly experience.

Dr. Sabin does make four excellent points which need consideration. While I have some reservations, I would urge everyone to read his blog. His first point as to why we should support health care rationing is improved health. While moving money to infrastructure investments such as housing, social services, and transportation could help many people, I am afraid that putting more people into care facilities too early is not an answer. Yet, I see this all around me and many people do not last long when confined in care facilities.

First, social services is not made part of this care, more often excluded if possible, and transportation is often limited for lack of funds and normally this is reserved for trips to the doctor or the hospital. I do not know what assisted living facilities are like in other parts of the country, but here they seem more like confining facilities that restrict the residents like cattle and only allow them freedom within the facility.

Then we can discuss retirement homes which are purchased and the residents can come and go just like it was their residence, medical facilities exist on the site of up to 25 plus retirement homes and is available to the residents during certain hours and available to others of elderly public for certain hours. Medical personnel are on call to the retirement home residents 24/7 and they may be transferred to hospitals when needed.

The second point in the blog is improved access. This means doing this for the poor elderly populations. This would include access to primary care and geriatric care. If a patient is hospitalized, then these two cares would ensure proper care and/or oversee care when discharged to ensure there is minimal readmission to the hospital. This will prevent the hospitals from gaming the system to apply more and more tests not needed on the elderly.

The third point is improved medical care. This is a powerful point as it could prevent health care rationing. By preventing hospital after hospital readmission, much of the wasteful interventions would not happen and therefore costs could be contained rather than continue to rise. When it comes to the elderly, often less treatment is better and less harm is inflicted on the elderly because of the over treatment which hospitals and many physicians are wont to do.

The fourth and last point Dr. Sabin presents is the need for improved intergenerational equity. This is probably the weakest of the points. I say this because until the over treatment waste is removed from the equation, care is taken to not always use the latest and most costly treatments, the coming expansion of the over 65 population will continue to put a severe drain on the resources for elderly care; and rationing will become a necessity whether we like it or not.

To make Dr. Sabin's points workable, those of us over 65 now need to help point the way and work to see that rationing does not become a reality. I am often accused of being too harsh in my expression of hospital greed, but this is a large part of what will drive rationing for those needing more care at times. What I am unable to justify is the millions of dollars taken out of hospitals by hospital administrators and some administrator staffs for their salaries and bonuses. This is a large part of the drivers behind all the tests conducted by hospitals that are not necessary and considered wasteful and harmful for elderly patients.

To keep salaries and bonuses increasing, staff reductions are common among the nurses and overtime is forbidden among the overworked staff. Unnecessary tests are ordered and hospitalists are directed to see that tests are done. Several investigations around the country are being done in hospital emergency departments where doctors have been ordered to find ways to admit patients to the hospital so that more tests could be done, which in turn could stretch the hospital stay of the patients.

This blog is applicable to what hospitals are doing to cause readmissions. This is a large area for concern if we are to prevent health care rationing.

07 August 2013

VA, HHS Team Up On Telehealth

This is a very informative article and I am disappointed that I was so late in finding it. In talking to my VA Clinic, they are aware of the program, but not yet involved in anything like it. They are noticing that veterans are being forced back to the VA by local hospitals (I am one of them) and hospital doctors when they don't wish to deal with them.

The Health and Human Services Department and the Veteran Affairs Department announced in early September 2012 a joint effort to expand the care delivery to veterans living in rural areas. Three states with the highest density of veteran residents, Virginia, Montana, and Alaska, will each receive approximately $300,000 to implement or upgrade telehealth capabilities for veterans who must otherwise travel long distances to access medical, mental, and behavioral health care. The grants will be used for telehealth equipment and to develop electronic health records that are compatible with the VA’s VistA EHR.

With this new initiative, the two agencies will promote collaboration between VA facilities, and private hospitals and clinics. This will seek to improve access and coordination of care through telehealth and health information exchanges in rural areas thereby preventing many veterans from having to travel 75 or more miles one way to receive medical health care.

The Department of Veterans Affairs Telehealth Expansion Initiative, launched in May 2011, is growing VA’s telehealth workforce across the country. When fully implemented, it will provide a potential capacity of 1.2 million telehealth consultations annually. Working with partners like HHS, VA will continue to increase the reach of our services beyond our 152 major medical centers to ensure veterans receive the care they have earned and deserve.

Administered by the Health Resources and Services Administration, the grants are part of a pilot program to spur collaborative telehealth networks and virtual linkages among rural health providers and the VA to help meet the needs of rural veterans. The Office of the National Coordinator for Health IT is working to implement health information exchange among VA hospitals and rural hospitals to make high quality, safe and affordable health care more available to returning veterans living in rural areas.

06 August 2013

ACA Without Meaningful Use = Failure

Healthcare be damned, full speed ahead for rationing. The author of this healthcare blog did not state it this way, but he should have. I have had the suspicion that patient engagement was not intended and Adrian Gropper, MD at least states this. Most physicians don't want patient engagement in the first place just like they do not want patients to have access to their electronic health records (EHRs) as I stated in my blog here.

Dr. Gropper had this to say about patient engagement, “Not surprisingly, patient engagement is an afterthought (talking about EHR).” Then he continues, “Patient engagement, from a health economics perspective, is incidental in care coordination but essential in avoiding the perception of rationing.” Ouch, the perception of rationing when rationing is planned. Many Medicare and Medicaid patients are already feeling the pinch of rationing as Accountable Care Organizations (ACO) and hospitals are attempting to make their funds stretch and grow their profits.

This statement is also worth quoting, “By paying ACO institutions instead of individual service providers, health insurance companies and Medicare provide direct economic incentives to reduce waste, lower costs and, if we’re not careful, withhold needed care. An ACO is by definition an organization or institutional construct.” Bold is my emphasis. “The book on patient engagement is yet to be written. EHRs still treat patient engagement as a liability and state health information exchanges (HIEs) are still being designed without any patient engagement at all. (Opt-in and opt-out is still as far as they go.) Both EHRs and HIEs still perceive strong privacy principles and fair information practices as obstructionist.”

At least Dr. Gropper recognizes the changing landscape and the need for stronger doctor/patient relationships. He acknowledges that patients and doctors need our Internet-age tools in a form for privacy and communications. Patient engagement is a euphemism for communication and I personally don't like the obtuse way they express this. Patient engagement is also used to describe meaningful use.

Dr. Gropper concludes by saying, “Let’s start by making sure our data can be liberated from the various EHRs via Blue Button Plus (see explanation below) and that every federally certified HIE includes provisions for a patient-accessible EHR Record Locator Service. These are the foundation of patient engagement (meaningful use) and essential to the success of the Affordable Care Act.

Blue Button Plus is a blueprint for the structured and secure transmission of personal health data on behalf of an individual consumer. It meets and builds on the view, download, and transmit requirements in Meaningful Use Stage 2 for certified EHR technology. Read more about this at this link.

05 August 2013

No, You Don't Want Shingles

If you have not had chickenpox, you have no worry about having shingles or herpes zoster. If you are one of the people that has had chickenpox, then please consider obtaining the vaccination for herpes zoster if your are age 60 or older. Anyone that has recovered from chickenpox may develop shingles; even children can get shingles. However, the risk of disease increases as a person gets older. About half of all cases occur among men and women 60 years old or older.

People who have medical conditions that keep their immune systems from working properly, such as certain cancers, including leukemia and lymphoma, and human immunodeficiency virus (HIV), and people who receive immunosuppressive drugs, such as steroids and drugs given after organ transplantation are at greater risk of getting shingles. People who develop shingles typically have only one episode in their lifetime. In rare cases, however, a person can have a second or even a third episode.

Shingles occurs when the virus that causes chickenpox starts up again in your body. After you get better from chickenpox, the virus is dormant in your nerve roots. In some people, it stays dormant forever. In others, the virus "wakes up" when disease, stress, or aging weakens the immune system. Some medicines may trigger the virus to wake up and cause a shingles rash. It is not clear why this happens, but after the virus becomes active again, it can only cause shingles, not chickenpox.

Shingles is only contagious during the time when the rash is in the blister-phase. A person is not infectious before blisters appear. Once the rash has developed crusts, the person is no longer contagious. You are unable to catch shingles from someone that has shingles. They can only spread the virus to another person who has never had chickenpox and who has not had the chickenpox vaccination.

Often the rash occurs in a single stripe around either the left or right side of the body. The rash can occur on one side of the face. Less often, the rash may be more widespread and look similar to a chickenpox rash (normally among people with a weakened immune system). The dangerous part of shingles is when it affects the eye and this can cause loss of vision.

Other symptoms of shingles can include fever, headache, chills, and upset stomach. If you have shingles, keep the rash covered, do not touch or scratch the rash, and wash your hands often to prevent the spread of the varicella zoster virus. Until your rash has developed crusts, avoid contact with pregnant women who have never had chickenpox or varicella zoster virus. Also, avoid contact with all children and anyone having a condition in the second paragraph above.

If shingles develops a complication, this is called postherpetic neuralgia (PHN). People with PHN have severe pain in the areas where they had the shingles rash, even after the rash clears up. This pain from PHN may be severe and debilitating, but it usually resolves in a few weeks or months in most patients. PHN can, however, persists for many years in some persons. The older you become the more likely you are to develop PHN. Occasionally shingles can lead to pneumonia, hearing problems, blindness, brain inflammation, or death.

This is a good reason to have the shingles vaccine (Zostavax®). This was recommended by the Advisory Committee on Immunization Practices (ACIP) in 2006 to reduce the risk of shingles and its associated pain in people age 60 years and older.
Your risk for developing shingles increases as you age. The vaccine is currently recommended for persons 60 years of age and older. Even people who have had shingles can receive the vaccine to help prevent future occurrences of the disease.

Shingles vaccine is available in pharmacies and doctor's offices. Talk with your healthcare provider if you have questions about shingles vaccine.