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News Roundup: January 29, 2016

As Population Ages, Where Are the Geriatricians?

Published by The New York Times
By KATIE HAFNER
January 29, 2016

PORTLAND, Ore. — Ruth Miles, 83, sat in a wheelchair in a small exam room, clutching a water bottle, looking frightened and uncomfortable.

She was submitting to the tender scrutiny of Dr. Elizabeth Eckstrom, who scooted her stool so close that she was knee to knee with her patient.

Ms. Miles had broken her pelvis after tripping on an electric cord in her apartment. The weeks since then had been hellish, she told her doctor. At the rehab center, incapacitated and humiliated, she had cried for help from the bathroom. Her hands were covered with bruises from the blood thinners she was on. She winced as Dr. Eckstrom tugged slightly at a bandage that adhered stubbornly to her left elbow. “We’ll have to get that changed,” Dr. Eckstrom said softly.

Dr. Eckstrom, 51, who spends her days focused on the complex medical needs of older patients, is, like the Central African okapi, a species that is revered, rare and endangered. She is a geriatrician.

Geriatrics is one of the few medical specialties in the United States that is contracting even as the need increases, ranking at the bottom of the list of specialties that internal medicine residents choose to pursue.

“One of the greatest stories of the 20th century was that we doubled the life expectancy of adults,” said Terry Fulmer, president of the John A. Hartford Foundation, which funds programs to improve the care of older adults. “Now we need to make sure we have all the supports in place to assure not just a long life but a high quality of that long life.”

Here in Oregon, there is approximately one geriatrician for every 3,000 people over 75. The shortage will grow more acute as the state’s population continues to age.

Oregon’s problem is mirrored across the United States. According to projections based on census data, by the year 2030, roughly 31 million Americans will be older than 75, the largest such population in American history. There are about 7,000 geriatricians in practice today in the United States. The American Geriatrics Society estimates that to meet the demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more a year than the current rate.

Yet, the field is becoming even less popular among physicians in training. Oregon Health and Science University, where Dr. Eckstrom practices, had five slots open for geriatrics fellows for 2016 and filled only three.

Last year, Dr. Elizabeth White-Chu, who directs the university’s geriatrics fellowship program, said she had resorted to cold-calling residency programs throughout the Pacific Northwest in search of candidates. This year, there were so many unfilled slots around the country that Dr. White-Chu did not even bother to call. “It would have been a total waste of time.”

A geriatrician is a physician already certified in internal or family medicine who has completed additional training in the care of older adults. In addition to providing clinical care, geriatricians are skilled in navigating the labyrinth of psychological and social problems that often arise in the aging population.

“Part of the reason aging has such a negative connotation is this sense that you can’t cure older people’s problems,” said Dr. Kenneth Brummel-Smith, a professor of geriatrics at Florida State University College of Medicine in Tallahassee, Fla., a state with a particularly severe geriatrician shortage. “And yet a good geriatrician can bring someone back to functional status.”

People avoid the field for understandable reasons. Geriatrics is among the lowest-paying specialties in medicine. According to the Medical Group Management Association, in 2014, the median yearly salary of a geriatrician in private practice was $220,000, less than half a cardiologist’s income. Although geriatrics requires an extra year or two of training beyond that of a general internist, the salary for geriatricians is nearly $20,000 less.

Since the health care of older patients is covered mostly by Medicare, the federal insurance program’s low reimbursement rates make sustaining a geriatric practice difficult, many in the field say.

“Medicare disadvantages geriatricians at every turn, paying whatever is asked for medications and procedures, but a pittance for tough care-planning,” said Dr. Joanne Lynn, a geriatrician and the director of the Center for Elder Care and Advanced Illness at Altarum Institute, a nonprofit health systems research organization based in Ann Arbor, Mich.

Dr. Eckstrom said she knew of several board-certified geriatricians in Oregon who, in order to avoid attracting too many older patients, went into practice as general internists, making certain not to mention their geriatrics training. “With too many Medicare patients in their practice, they wouldn’t be able to make ends meet,” she said.

Marie Hall, 84, who lives in Portland, knows all too well the difficulty of finding a geriatrician. A little over a year ago, several months after Ms. Hall underwent back surgery that left her with nerve damage, her longtime geriatrician retired, and the hospital did not replace her.

Eventually Ms. Hall got in touch with Marcy Cottrell Houle, a Portland author who had just written a book with Dr. Eckstrom. To Ms. Hall’s relief, Ms. Houle helped get her in to see a new colleague of Dr. Eckstrom.

“I knew I needed that kind of specialized care,” Ms. Hall said, “that I needed to think ahead for when the downhill slide really comes.”

A Debate on Necessity

Some primary care physicians argue that geriatricians are unnecessary, that most ailments among older adults are the same as those that hit the middle-aged population, such as diabetes, hypertension and heart disease. The difference, they say, is that older patients just have more of them.

“This is simply untrue,” Dr. Eckstrom said. “Just think about dementia, or delirium caused by a medication. Those are just two conditions you seldom see in middle-aged adults.”

Dr. Eckstrom embodies both the frustration and gratification that characterize a geriatrician’s day. She spent most of her 40 minutes with Ms. Miles sweeping up after the caregivers who had preceded her: pressure ulcers, a wound dressed poorly, dehydration, depression.

She gave her patient a pep talk, urging her to be up and walking as much as possible, and to take in more fluids. She commented on her patient’s brightly colored shoes. Throughout the morning, in fact, she made a point of admiring something each patient was wearing: a bright piece of jewelry, a colorful scarf, an all-purple outfit.

Then, as if Ms. Miles were doing her doctor a personal favor, Dr. Eckstrom added, “I very much appreciate that you’re not taking too much of the oxycodone.”

At the end of the appointment, Dr. Eckstrom took Ms. Miles’s hand and said, “You can always call me.”

“You’re too busy,” Ms. Miles said.

“I’ll squeeze you in. I’ll make it work.”

Ms. Miles had arrived at her appointment defeated and anxious. By the end, she was relaxed, even animated.

That afternoon, Dr. Eckstrom worked with three residents who were on a rotation that included geriatrics. When the residents went in to see patients, they were engaged enough, but decidedly ho-hum about the specialty, voicing a preference for more vibrant fields like oncology, with its experimental new drugs, and cardiology, which combines good pay with the excitement of new technologies.

Young physicians in training find it difficult to muster interest in the slow grind of caring for older patients, and days filled with discussions about medication management, insomnia, memory loss and Meals on Wheels deliveries.

An old family member is often the inspiration for medical students who choose geriatrics. “My grandmother was one of my best friends when I was growing up,” said Dr. Emily Morgan, 37, who recently joined Dr. Eckstrom in her practice. Dr. Morgan said that watching her grandmother’s decline after a car accident, followed by a terribly painful death, instilled in her a deep belief “in the inherent dignity and worth of a life, especially towards the end.”

Chase West, a second-year medical student at Florida State, was present for much of his own grandmother’s decline. “Just seeing how the specialists worked with her in the last two months triggered that light-bulb moment,” he said.

Dr. Eckstrom was a general internist who practiced in primary care for nine years before returning to Oregon Health and Science University to complete a geriatrics fellowship. “I thought I was doing a good job caring for my patients,” she said. “But I wanted to do more geriatrics teaching and research.” The fellowship opened her eyes. “I had no idea what I didn’t know,” she said.

Phyllis Wolfe, 76, has been seeing Dr. Eckstrom for more than 12 years. Two years ago, she had a series of mini-strokes that affected her memory. Then she developed two small-bowel obstructions, and each surgery was followed by significant cognitive decline and delirium. Her gait was unsteady, and she was in danger of falling.

Ms. Wolfe’s health gradually improved not by virtue of drastic interventions, but from careful attention to every possible detail. Dr. Eckstrom stopped Ms. Wolfe’s prescription for Ambien, an insomnia drug that can cause confusion in older patients. Dr. Eckstrom also suggested an exercise program to prevent a fall, and put Ms. Wolfe on a nutrition plan.

In Dr. Eckstrom’s office that day, Ms. Wolfe was transformed — lively and clearheaded. “If you hadn’t seen her six months ago, you’d never know she had all those problems,” Dr. Eckstrom said.

Ms. Wolfe passed a standard memory test with ease, and the appointment turned into a session of helpful hints that seemed almost homespun but were backed by evidence.

“Elevate your legs for 30 minutes before going to sleep and you’ll need to go to the bathroom during the night less often,” Dr. Eckstrom said when Ms. Wolfe asked about needing to stay well hydrated, then having her sleep disrupted by frequent trips to the bathroom.

“Instead of iron pills, buy a cast-iron skillet, one of the best ways for the body to absorb iron,” Dr. Eckstrom advised in response to Ms. Wolfe’s concern about iron pills.

Ms. Wolfe said she had tried to get a few of her friends in with Dr. Eckstrom, with little luck. Her practice is full.

Dr. Eckstrom began taking care of Ms. Wolfe when she was 64. Dr. Eckstrom said she prefers to start with patients when they are still relatively young, so she can follow them into old age.

“The majority of my patients are in their 80s and 90s, but I’ve been seeing many of them for 20 years,” she said, adding that care for these patients is less complex, as they have entered old age in better shape.

‘Sick of the Whining’

While many in geriatrics have resigned themselves to their predicament, some believe the field will soon receive the recognition it deserves. New payment models that hold doctors and health systems accountable for keeping people healthy are on the rise, and geriatricians foresee a day when they are better valued and compensated.

“A lot of us are sick of the whining,” said Dr. Rosanne M. Leipzig, a geriatrician and professor at the Icahn School of Medicine at Mount Sinai, which is experimenting with a two-year program that combines geriatrics and palliative care.

And there is an emerging emphasis on training many different health care professionals — nurses, pharmacists, internal and family medicine physicians, physician assistants, and physical and occupational therapists — to see older patients through a geriatrics lens rather than focusing solely on creating more geriatricians. Mini-fellowships at teaching hospitals to train practicing physicians in geriatrics have sprung up around the country. Cardiology, urology, emergency medicine and other specialties are promoting geriatrics training and research within those disciplines.

Acknowledging an older person’s need for dignity is an important part of Dr. Eckstrom’s practice. When talking with a patient about giving up driving, she refers to it as “retiring from driving,” casting it as an act of liberation, as if driving were a job to be freed of.

It is that kind of perspective that drew the attention of trainees already attracted to the human side of medicine. Dr. Kathleen Drago grew to love geriatrics while training under Dr. Eckstrom. “I got caught in Elizabeth’s web,” she said. “You meet people who have walked these incredible paths, and are starting to reflect on their lives and focus in on what’s important in the time they have left.”

Dr. Drago, 31, left medical school with a debt of around $270,000. “I made a decision that was distinctly against my own financial interests,” she said. “But I come to work every day, and I get to deliver the patient-centered care that I dreamed of as a med student.”

She now works as a geriatrician at Oregon Health and Science University, seeing only hospitalized patients. Recent evidence about care provided by geriatrics teams shows that with the care of such teams, the hospitalization of older adults runs shorter, costs less and results in fewer complications, including falls, pressure ulcers and urinary tract infections.

While making her rounds in the hospital one recent afternoon, Dr. Drago introduced herself to a 79-year-old woman in the intensive care unit. The patient, who has dementia, had been found lying on the ground the previous night a quarter-mile from her home, bruised and bloodied, with three cracked ribs and bleeding in her brain. She had left the house with a Bible in one hand and an American flag in the other.

Dr. Drago sat down and began a frank yet gentle conversation with the patient and her daughter about the next steps. The doctor stayed for two hours.

CMS Finishes Face-To-Face Rules For Home Health, Medical Equipment

Published by Inside Health Policy
By Michelle M. Stein
January 29, 2016

CMS released a final Medicaid rule Wednesday (Jan. 27) that lays out face-to-face requirements for medical equipment and home health services. The rule aligns timelines for home health face-to-face requirements with similar requirements for Medicare, and one home health lobbyist says industry is pleased that the Medicaid home health face-to-face requirements only mirror the basic elements of Medicare's difficult standards.
“This rule will promote program integrity and provide clear guidance on the parameters of the home health benefit in Medicaid which will enable beneficiaries to receive high quality care in the community, rather than rely on care in the more expensive institutional settings,” CMS says in a fact sheet. The agency also says the rule aligns with Medicare to where possible to help streamline beneficiaries' access to needed items and maximize consistency between the programs.
The Affordable Care Act required home health face-to-face requirements for both Medicare and Medicaid, and providers see the Medicare requirements as flawed and unclear. William Dombi, vice president for law at the National Association for Home Care and Hospice, says CMS delayed the Medicaid rule so agency officials could first monitor the effects of the Medicare version.
For home health, the final rule requires providers to document face-to-face meetings with patients no more than 90 days before or 30 days after patients begin receiving home health services. For initial medical supply orders, physicians or authorized non-physician providers must document face-to-face encounters no more than six months before services start. This process can be done through telehealth.
The rule also provides a new definition of medical supplies, equipment and appliances, which CMS says expands coverage.
“Based on this new definition, the rule will expand coverage of medical supplies, equipment, and appliances under the home health benefit; certain items that had previously only been offered under sections 1915(c) and 1915(i) waivers will now meet the definition of medical supplies, equipment, and appliances and thus be covered under the state plan home health benefit,” CMS says. The agency says this definition is better aligned with Medicare's definition of durable medical equipment.
The rule also clarifies that medical supplies, equipment and appliances can't be restricted to the home setting, and that home health services cannot be restricted to care furnished in the home itself. It also says states cannot require a beneficiary to be homebound in order to receive home health services.
“We are also very pleased that CMS finalized the rule changes to include a specific prohibition on [a] state using a 'homebound' requirement and the extension of services outside the home consistent with certain federal court rulings,” Dombi says.
The rule also codifies CMS guidance from 1998 that said that while states may have a list of pre-approved medical supplies, equipment and appliances, that list could not be a limit on coverage. The rule also codifies that states must provide beneficiaries with a reasonable and meaningful way to request medical supplies, equipment or appliances that aren't on the list based on medical necessity. If beneficiaries are denied access, they must be informed of their right to a fair hearing to appeal, the rule says.
Dombi says although he is still reviewing the rule, initially it seems that CMS fairly considered comments to encourage state flexibility in implementation, provide time for compliance and reduce paperwork and unnecessary documentation. -- Michelle M. Stein (mstein@iwpnews.com)

Case study: House call program reduces monthly spending, provides meaningful care

Published by Beckers Hospital CFO
By Tamara Rosin
January 29, 2016

House calls have come back in style. Under the Affordable Care Act, healthcare providers are incentivized to develop new value-based programs to address the needs of high-risk populations by improving outcomes, preempting the need for emergency care and ultimately lowering costs.

In an examination of one such initiative in Southern California, Health Affairs found house calls effectively reduced operating costs per patient, as well as hospital utilization.

HealthCare Partners Affiliates Medical Group, based in Torrance, Calif., launched the House Calls program in 2009. The in-home program provides, coordinates and manages care for recently discharged high-risk, frail and psychosocially compromised patients, according to the report. Its main goal is to reduce preventable emergency room visits and hospital readmissions.

House Calls, which is available to HealthCare Partners' Medicare Advantage and commercially insured HMO population, provides home-based medical and behavioral healthcare, palliative care management and support for high-risk frail and homebound patients, as well as those whose physical, mental or social limitations make access to regular sources of care challenging.

Here are six key findings on the House Calls program, according to Health Affairs.

1. House Calls care teams, called pods, are led by a physician and include nurse practitioners, social workers and medical assistants. Psychologists, psychiatrists, podiatrists and ophthalmologists are often called for consultations. Nurse practitioners develop a care plan for the patient and monitor him or her and stay in contact with his or her primary care physician. They also arrange referrals to specialists and community resources, such as volunteer-based support groups and senior transportation services.

2. Social workers conduct assessments of the patient and his or her home environment, noting and addressing potential issues such as fall risks, needed home modifications, medication organization, food and nutrition counseling, financial concerns, transportation needs, social isolation and support networks.

3. Between 2009 and 2013, House Calls served 11,184 patients, including 7,925 unique patients. The program is not representative of the overall Medicare population, but is highly skewed to those ages 85 and older.

4. Most House Calls patients have multiple comorbidities, with an average of 7.5. The top comorbidities include hypertension (81 percent), peripheral vascular disorders (60 percent), renal failure (59 percent), cardiac arrhythmias (47 percent), uncomplicated diabetes (43 percent), chronic obstructive pulmonary disease (42 percent), congestive heart failure (41 percent) and depression (40 percent).

5. On average, patients are enrolled in the program for 223 days (179 days for patients whose death ends their participation and 267 days for patients who are discharged alive).

6. In the three and six months prior to enrolling in House Calls, patients had high hospital inpatient and emergency department use and spending. After three months in the program, per month utilization and inpatient total spending by Healthcare Partners on behalf of House Calls enrollees decreased. Per month utilization and spending decreased further in the first three months and six months after disenrolling from the program.

Senior Living Provider Launches ‘Virtual’ In-Home Program

Published by Home Health Care News
By Kourtney Liepelt
January 29, 2016

Aging in place has never been easier, thanks to one senior living provider’s new continuing care program likened to “virtual senior living.”

Life Enriching Communities, which operates two nonprofit continuing care retirement communities (CCRCs) in the Cincinnati area, had been wanting to reach a subset of the retirement aged population who are in good health but not necessarily considering moving to a senior housing community. That’s where Confident Living comes into play, as a program that takes services similar to those offered in senior living communities to people in their homes and helps them plan ahead for unforeseen events.

“We thought, why not bring the same quality of living to them?” Connie Kingsbury, vice president of marketing for Life Enriching Communities, tells Home Health Care News. “Why limit it just to the people in our senior living communities? The goal really is to keep people living in their homes.”

Confident Living centers on care coordination for people between the ages of 50 and 80. Memberships are highly personalized based on a person’s age and health, as well as what types of services he or she wants as part of a package. Fees can range anywhere from $800 to several thousand dollars.

Once a year, a care coordinator will meet with each member to discuss lifestyle goals and how to achieve them, and explain how to navigate the health care system. A care coordinator is also tasked with helping members arrange home care services and outline options for assisted living or nursing care, if the need arises.

“It’s helping people who are at the younger end of that age range consider the importance of having a plan,” Kingsbury says.

Life Enriching Communities has planned several seminars in the Cincinnati area through the end of February to begin promoting the Confident Living program, and Kingsbury says the provider hopes to have its first members enrolled by mid-March.

“We’ve got a lot of educating to do,” Life Enriching Communities CEO Scott McQuinn told the Cincinnati Business Courier. “We’re expecting a slow ramp-up because it’s such a new approach. It’s a new category, so we have to sell the category before we sell the program.”

Opening the Front Door to Better Care

Published by Huffington Post
Steve Landers MD,MPH
January 29, 2016

This article is co-authored with Dr. Bruce Leff, Professor of Medicine and Director of the Center for Transformative Geriatric Research at Johns Hopkins @HopkinsMedicine.

America is experiencing a dramatic population shift -- one that will turn the country on its head. As Baby Boomers age, more people will live with chronic conditions, like heart disease or dementia, and many will have difficulty with basic abilities like walking and managing their household.

These shifts will create enormous challenges for our country. We must do everything possible to ensure that older Americans remain independent and healthy at home, without experiencing the suffering, indignity, and costs associated with unnecessary hospitalizations and institutionalization.

Our success in answering this call will dictate quality of life vs. suffering for millions of people. The country's economic health is also at stake as the growing costs of Medicare and Medicaid threaten to squeeze out funding for other priorities. A key to solving this vexing problem is improving access to quality care at home.

In the wake of the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015, we are seeing a shift toward more care coordination and "value-based" care. These trends have led to more interest by doctors and hospitals in helping people succeed in home and community-based settings.

This new attention is a good start, but it's not enough.

The focus of current reform efforts has centered on insurers, hospitals, physicians, and employers. Home-based care has been left out of high profile national policy conversations, despite the fact that most older Americans prefer to stay at home and "age in place."

Our policymakers aren't putting enough time and resources into strengthening home health care and developing new home-based care strategies. Further, some home care policy proposals actually risk hurting the positive programs that already exist.

Out of this leadership void, the Future of Home Health (FOHH) Project was born. Developed by the Alliance for Home Health Quality and Innovation , the FOHH Project has taken on the challenge of starting a national conversation on these issues and the project really picked up steam when the Institute of Medicine (IOM) and National Research Council (NRC) hosted 'The Future of Home Health Care' workshop. The summary book and videos from the workshop are available online.

A few overarching themes recurred throughout the workshop, these themes could provide a head start for leaders interested in improving care:

1. There's no place like home. Stakeholders from many backgrounds called for a shift towards community based care--making the home the center of care whenever possible. Family caregivers at the workshop were especially passionate about the importance of home care.

2. Better care at lower costs. Home health care of the future must be a solution to high costs and quality of care concerns. One example is Medicare's Independence at Home Demonstration, which is showing that medical teams that make house calls to Medicare's sickest and most costly patients at home can support these individuals and save lots of money.

3. Payment policy and regulations need improvement. To build and grow new approaches to home care there will need to be policy and payment changes that support innovation. Many current policies and programs are fragmented and outdated. There should be more coordination, integration, and alignment around addressing both medical and social issues. Several historical policies and programs have created an unnatural separation between medical and social concerns even though high quality care for an aging population requires both to work in concert.

4. Don't forget about the workforce! We must improve training, especially in geriatrics and palliative care, for all types of health professionals. Developing people to work in team-based care will be key.

5. Technology, technology, technology. Smart use of mobile health, health information, remote monitoring, telemedicine, independent living, and point of care technologies are essential for the shift towards home and community based care.

6. Accurate report cards. Quality and outcomes will need to be measured in order to reflect the value of community and home-based care. We must take care to ensure appropriate quality measures that fit the needs and goals of older people with multiple medical problems, rather than current measures that often focus on single diseases.

The ultimate goal of the FOHH Project is to develop a framework for home health delivery in the future and to take advantage of the many promising innovations that have not been scaled widely due to gaps in policy and for lack of attention.

These efforts serve as a foundation for beginning a discussion, but more national dialogue is required, with input from a wide range of leaders. To truly have a person-centered, compassionate, and responsible healthcare system we must work on building a bright future and prominent role for home health care.