Thursday, 9 May 2019

Few plan for long-term care though most will need it

As wait times to see a doctor for simple problems like sinusitis and urinary tract infection lengthen, more and more Americans are turning to retail health clinics—walk-in medical facilities located in pharmacies, grocery stores, and retailers such as Walmart and Target. The number of visits to such clinics quadrupled from 1.48 million in 2007 to 5.97 million in 2009, according to a study published in the journal Health Affairs, and topped 10 million last year.

What is driving this migration to retail health clinics? “For the majority of patients it is convenience,” says lead study author, Dr. Ateev Mehrotra, associate professor of medicine at the University of Pittsburgh and health policy researcher at the nonprofit RAND Corporation (he’ll be joining Harvard Medical School’s Department of Health Care Policy in June). You can walk into a retail health clinic without an appointment, and many clinics are open nights and weekends. In fact, nearly half of the visits in the study were on the weekends or other off-hours when doctors’ offices are typically closed.

The other attraction of retail health clinics is price, Dr. Mehrotra and his colleagues found. “Not the actual price, but the transparency of the cost,” he says. Clinics offer a menu of prices and services, which means there are fewer surprises when the bill arrives. And health insurance covers all—or a percentage of—the costs of services provided at these clinics, just as it does for care delivered at a doctor’s office.

As consumers increasingly turn to retail health clinics, the number of clinics has grown to meet demand—up to 1,423 this year and an estimated 3,200 by the end of 2014. And the types of services they offer has expanded beyond immunizations and common ailments such as strep throat and sinus infections. Last month, for example, Walgreens’ announced that its Take Care Clinics will now help manage chronic conditions such as high blood pressure, diabetes, high cholesterol, and asthma.
Quality comparison

Retail health clinics are often staffed by nurse practitioners instead of doctors. That’s not an issue for people who are visiting for routine vaccinations or an antibiotic prescription for an ear infection—but are these clinics equipped to manage chronic conditions?

The research comparing nurse practitioners with doctors on several measures of care has been reassuring, Dr. Mehrotra says. “People who went to the nurse practitioner did just as well as those who went to a doctor.”

In some aspects of care, retail health clinics may actually outperform physician’s offices. “Whatever they do is guided by evidence-based protocols,” says Regina Herzlinger, Nancy R. McPherson Professor of Business Administration at Harvard Business School, and author of Who Killed Health Care? Not only are nurse practitioners required to follow specific care guidelines, but they must also keep meticulous records on the care they’ve provided, she says. “They have a record of what they’ve done that’s very detailed.”

A key outstanding question is whether visiting retail health clinics might interrupt continuity of care between doctors and their patients. Dr. Mehrotra found that individuals who received care at a retail clinic were less likely to follow up within the year with their primary care doctor, although that lack of follow-up didn’t seem to affect the quality of care they received overall.

In the retail health clinic setting, the burden of continuity in record keeping often falls on the patient. Although clinics can send health records to a patient’s primary care doctor, there’s a good chance the two offices use incompatible electronic medical record systems, rendering the clinic’s records unusable to the physician. “It’s really up to the patient to make sure that the excellent records these retail medical clinics keep is embedded in their personal health record with their primary health care provider,” Professor Herzlinger says. Getting a printed copy of your record from the retail health clinic and bringing it to your doctor can help prevent any discontinuity of care.
Retail health clinics in the future

Today, retail health clinics are most appropriate for people with simple, acute health conditions such as a respiratory or urinary tract infection. “It’s generally people who don’t have a primary care doctor and who overall are healthier,” Dr. Mehrotra says.

That target group might change as more retail clinics expand their services to offer chronic disease care, and as the number of primary care doctors shrinks. “There is a tremendous shortage of primary care doctors,” says Professor Herzlinger. “Many of the people who use these clinics don’t have physicians, and can’t get physicians.”

What will happen to retail health clinics as the Affordable Care Act rolls out and the number of insured Americans rises? “We can only speculate,” Dr. Mehrotra says. “My own instinct is that as more people get insurance, they will increase the demand for primary care physicians. Given our fixed supply of doctors, wait times are likely to go up. This may drive demand to retail clinics.” Most reputable companies that provide services tell you what you’ll get for your money. Hospitals are an exception. They haven’t traditionally made public the cost of operations and other procedures. This secrecy has let hospitals set widely different prices for the same procedure. It’s also made it impossible to do any comparison shopping.

Yesterday’s release to the public of a once very private database shows just how big the differences can be from hospital to hospital.

On the South Side of Chicago, where I grew up, one hospital’s charge for implanting a pacemaker to keep the heart beating at a steady rhythm was $49,601, while another hospital charged $63,979 to do it. In Boston, a hospital not far from where I work charged $76,121 to implant a pacemaker while another hospital less than three miles away charged $55,687.

According to The New York Times, the Keck Hospital of the University of Southern California charged an average of $123,885 for a major artificial joint replacement (six times the average amount that Medicare reimbursed for the procedure) while Centinela Hospital Medical Center, also in Los Angeles, charged $220,881 for the same type of joint replacement surgery.

The database, released by the Centers for Medicare and Medicaid Services, details what 3,300 hospitals charged for the 100 most common treatments and procedures in 2011.

The data reinforce the big differences in charges from one part of the U.S. to another. What’s new and surprising are the huge differences sometimes seen between hospitals in the same city, or even the same neighborhood.

Keep in mind that these “charges” aren’t hard and fast. Medicare doesn’t pay the full charge. Insurers don’t either, as many of them negotiate lower charges. As NPR’s Robert Siegel said about the database, “it sounds like what you’ve got is a survey of the sticker prices in car lots all around America, but every deal is a special deal.”

At least for now, the database isn’t especially easy to use. It’s just an Excel spreadsheet listing the hospitals by state along their charges for the 100 procedures. The Washington Post created a nifty interactive tool that you can use to look at charges in your state for 10 conditions. Choose your state and the tool shows how its hospitals stack up against the national average, as well as the highest and lowest charges for these ten procedures. Expect other creative apps incorporating this information to be coming along soon.

If you decide to dive into the data, be aware—especially if you have private insurance (not Medicare)—that appearances can be deceiving. It may look like Hospital A charges more than Hospital B, but that may not be so. Your insurer and Hospital may have actually agreed on a lower payment. So the data don’t necessarily say what your insurance company is actually going to pay.
Reverberations

A few weeks ago, I finally finished reading “Bitter Pill,” Steven Brill’s extraordinary Time magazine article on the crazy cost of healthcare in America. I say “crazy” because, according to Brill, how hospitals set their prices has little rhyme or reason. The database from the Centers for Medicare and Medicaid Services reinforces that notion.

Publishing this information is one small step toward making the cost of healthcare more transparent. While it will be a long time before most of us will be able to figure out how much an operation or a hospital stay costs, the database could nudge hospitals with exorbitant charges to bring them in line. Most reputable companies that provide services tell you what you’ll get for your money. Hospitals are an exception. They haven’t traditionally made public the cost of operations and other procedures. This secrecy has let hospitals set widely different prices for the same procedure. It’s also made it impossible to do any comparison shopping.

Yesterday’s release to the public of a once very private database shows just how big the differences can be from hospital to hospital.

On the South Side of Chicago, where I grew up, one hospital’s charge for implanting a pacemaker to keep the heart beating at a steady rhythm was $49,601, while another hospital charged $63,979 to do it. In Boston, a hospital not far from where I work charged $76,121 to implant a pacemaker while another hospital less than three miles away charged $55,687.

According to The New York Times, the Keck Hospital of the University of Southern California charged an average of $123,885 for a major artificial joint replacement (six times the average amount that Medicare reimbursed for the procedure) while Centinela Hospital Medical Center, also in Los Angeles, charged $220,881 for the same type of joint replacement surgery.

The database, released by the Centers for Medicare and Medicaid Services, details what 3,300 hospitals charged for the 100 most common treatments and procedures in 2011.

The data reinforce the big differences in charges from one part of the U.S. to another. What’s new and surprising are the huge differences sometimes seen between hospitals in the same city, or even the same neighborhood.

Keep in mind that these “charges” aren’t hard and fast. Medicare doesn’t pay the full charge. Insurers don’t either, as many of them negotiate lower charges. As NPR’s Robert Siegel said about the database, “it sounds like what you’ve got is a survey of the sticker prices in car lots all around America, but every deal is a special deal.”

At least for now, the database isn’t especially easy to use. It’s just an Excel spreadsheet listing the hospitals by state along their charges for the 100 procedures. The Washington Post created a nifty interactive tool that you can use to look at charges in your state for 10 conditions. Choose your state and the tool shows how its hospitals stack up against the national average, as well as the highest and lowest charges for these ten procedures. Expect other creative apps incorporating this information to be coming along soon.

If you decide to dive into the data, be aware—especially if you have private insurance (not Medicare)—that appearances can be deceiving. It may look like Hospital A charges more than Hospital B, but that may not be so. Your insurer and Hospital may have actually agreed on a lower payment. So the data don’t necessarily say what your insurance company is actually going to pay.
Reverberations

A few weeks ago, I finally finished reading “Bitter Pill,” Steven Brill’s extraordinary Time magazine article on the crazy cost of healthcare in America. I say “crazy” because, according to Brill, how hospitals set their prices has little rhyme or reason. The database from the Centers for Medicare and Medicaid Services reinforces that notion.

Publishing this information is one small step toward making the cost of healthcare more transparent. While it will be a long time before most of us will be able to figure out how much an operation or a hospital stay costs, the database could nudge hospitals with exorbitant charges to bring them in line.New Jersey Governor Chris Christie’s revelation yesterday that he had secretly undergone weight-loss surgery back in February shouldn’t come as a big surprise. He has been publicly (and privately) struggling with his weight for years and fits the profile of a good candidate for this kind of operation.

Although weight-loss surgery, also known as bariatric surgery, should be considered a last resort when diet and exercise don’t work, it can do some amazing things. Among people who are severely overweight, it can yield a 25% to 35% weight loss within two years. In many people who undergo the surgery, type 2 diabetes, high blood pressure, high cholesterol, and the disruptive and potentially harmful snoring pattern known as sleep apnea disappear. It can also improve a number of other health problems, ranging from arthritis and heartburn to infertility and incontinence.
Good candidates

In general, weight-loss surgery is appropriate for people with a body mass index (BMI) of 40 or higher, as well as for those with a BMI of 35 to 39.9 and a severe, treatment-resistant medical condition such as diabetes, heart disease, and sleep apnea.

Much of the speculation about Christie’s surgery was whether he did it for political reasons or concerns about his future health. But there shouldn’t be any speculation about whether he was a good candidate for it. While the Governor never made public his exact weight, the estimate is over 300 pounds. At just under 6 feet tall, that gives him a body mass index of at least 41. Christie also acknowledged trying to lose weight many times, using different weight loss programs. He had some initial success. But like most obese people, he regained all the lost pounds and more.

Even if Christie’s claims of otherwise being in good health are correct, he was at high risk of developing problems directly related to his weight. I believe his choice was a good one for his health.
Types of weight-loss surgery

Gastric banding2Christie underwent laparoscopic gastric banding, also known as lap banding. There are also two other types of weight-loss surgery.

Gastric banding is done laparoscopically, meaning through small holes made in the abdomen. The surgeon wraps an adjustable silicone band about two inches in diameter around the upper part of the stomach. This creates a small pouch with a narrow opening that empties into the rest of the stomach. The small size of the upper stomach make a person feel full much sooner than before. Depending on the person’s rate of desired weight loss and how he or she feels, the band can be easily tightened or loosened as needed by injecting or withdrawing sterile salt water saline through a port implanted just under the skin. Compared with gastric bypass, the surgery is simpler and has a lower risk of complications immediately following the operation.

Gastric_bypass2Gastric bypass, also known as the Roux-en-Y procedure, shrinks the size of the stomach by more than 90%. This makes a person feel full after eating very small amounts of food. In addition, the body absorbs fewer calories because food bypasses most of the stomach and upper small intestine. The operation is done through an incision made in the abdomen or laparoscopically. The surgeon converts the upper part of the stomach into a small pouch about the size of an egg. The small intestine is then cut. One end is connected to the stomach pouch and the other is reattached to the small intestine, creating a Y shape. This allows food to bypass most of the stomach and the upper part of the small intestine, although both continue to produce the gastric juices, enzymes, and other secretions needed for digestion. These drain into the intestine and mix with food at the crook of the Y. Gastric bypass surgery is not reversible.

Gastric sleeve2The gastric sleeve technique transforms the stomach into a small, narrow tube by removing the curved side of the organ creates a small pouch using the side of the stomach rather than the bottom. One advantage is that no rearrangement of the intestines is needed. The vertical pouch the sleeve procedure creates is less prone to stretching compared to the pouch left by a gastric bypass. Like gastric bypass, the gastric sleeve technique is not reversible.
After surgery

For the first few months after surgery, appetite is usually turned down. Eating too quickly or too much overfills the stomach pouch. That can cause vomiting or pain in the chest and upper abdomen. After a high-carbohydrate meal, a person who has had gastric bypass surgery may suffer from “dumping syndrome,” a reaction that causes flushing, sweating, severe fatigue, nausea, vomiting, diarrhea, and intestinal gas. To prevent nutritional deficits, it’s also a good idea to take vitamins (especially vitamins B12 and D) and minerals (especially calcium and iron).

If you are considering weight loss surgery, realize that you must commit to a life-long change in the way you eat. Surgery without lifestyle change will either make you miserable or not result in successful weight reduction. Likely both. When pain strikes, it’s human nature to avoid doing things that aggravate it. That’s certainly the case for people with arthritis, many of whom tend to avoid exercise when a hip, knee, ankle or other joint hurts. Although that strategy seems to make sense, it may harm more than help.

Taking a walk on most days of the week can actually ease arthritis pain and improve other symptoms. It’s also good for the heart, brain, and every other part of the body.

A national survey conducted by the federal Centers for Disease Control and Prevention showed that more than half of people with arthritis (53%) didn’t walk at all for exercise, and 66% stepped out for less than 90 minutes a week. Only 23% meet the current recommendation for activity—walking for at least 150 minutes a week. Delaware had the highest percentage of regular walkers (31%) while Louisiana had the lowest (16%). When the CDC tallied walking for less than 90 minutes a week, Tennessee led the list, with 76% not walking that much per week, compared to 59% in the  District of Columbia.
This map shows the percentage of adults with arthritis in each state who walked less than 90 minutes per week during 2011.

This map shows the percentage of adults with arthritis in each state who walked less than 90 minutes per week during 2011.

The findings were published in the journal Morbidity and Mortality Weekly Report, one of its contributions to Arthritis Awareness Month.
Beyond walking

Walking is good exercise for people with arthritis, but it isn’t the only one. A review of the benefits of exercise for people with osteoarthritis (the most common form of arthritis) found that strength training, water-based exercise, and balance therapy were the most helpful for reducing pain and improving function. “Swimming or bicycling tend to be better tolerated than other types of exercise among individuals with arthritis in the hips or knees,” says rheumatologist Dr. Robert H. Shmerling, associate professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center.

Exercise programs aim to help people with arthritis:

    increase the range of motion in the affected joint
    strengthen muscles
    build endurance
    improve balance

You can create an exercise program of your own, with help from a trusted doctor, nurse, or physical therapist. Or you can try one that’s been developed by arthritis experts. Examples include the Fit and Strong! program from the University of Illinois at Chicago, or one of several programs developed by the Arthritis Foundation: its Exercise Program, Walk with Ease program, or Aquatics program.

The fatigue, pain, and stiffness caused by many types of arthritis present a barrier to exercise—but these are the same symptoms that tend to improve with regular exercise.

If you have arthritis and don’t currently exercise, start slow. Take a five-minute stroll around your block, swim, or workout on an exercise bicycle. Do it every day, and then gradually increase the time spent exercising or how hard you exercise, but not both at once. If you have heart disease or other health issues, check with your doctor before embarking on an exercise program.

“If exercise was a newly developed medicine, it would be a blockbuster,” says Dr. Shmerling. “It has an excellent safety profile, and enormous benefits for people with arthritis, heart disease, and a long and growing list of other health problems.” Two of every three Americans who reach age 65 will at some point need long-term care for up to three years. Yet the majority of those age 40 and older have done “little or no planning” for how they might pay for long-term care when they get older.

That’s a key finding from a new survey of 1,019 Americans over age 40 on the topic of long-term care. The survey was done by the Associated Press and NORC at the University of Chicago. Other interesting results:

    Most people underestimate the cost of nursing home care (it averages $6,700 a month) and overestimate what Medicare will cover.
    Few people are setting aside money for long-term care even as most worry about key issues of aging such as memory loss or being a burden to family members.
    Many people support public policy options for financing long-term care, either through tax incentives to encourage saving for long-term care or a government-administered plan.

Mismatch between perception and reality

As a primary care doctor, I see my patients struggle with how the cost of age-related care affects their lives and their financial realities. Long-term care costs are huge. We can’t afford not to think about them.

The U.S. Census Bureau estimates that $217 billion will be spent in 2015 on nursing home and residential care. This includes assisted living facilities and board and care homes. Currently, about 25% of these costs are paid out-of-pocket by older adults and their families. Almost two-thirds of the cost is paid by Medicaid and Medicare combined.

Medicare only pays for short-term care—20 days in a nursing home—when illness causes disability. After that, patients or their families must meet these costs out-of-pocket. Most older adults with chronic needs then “spend down” their funds to pay for long-term care until the money runs out. At that point, at poverty level, Medicaid support may be available.
Start early

Without a crystal ball, it’s tricky to plan for the future. It’s easy to convince yourself that you or a partner won’t need long-term care. But the statistics suggest you should start planning now, even if your plan isn’t perfect.

1. Talk with your family. Nearly 60% of older people who need long-term nursing or personal care rely fully on unpaid caregivers, usually their children or spouses. Sometimes this is an obvious arrangement. But your family must be flexible and committed. If a caregiver must stay at home, some family income will be lost. This is rarely a comfortable situation if everyone did not agree ahead of time.

2. Consider long-term-care insurance. Fewer than 3% of American adults have purchased a long-term care insurance policy. The average cost is high. A typical plan might cost $3,300 a year for a healthy 60-year-old couple. And it might pay only a $150 a day for up to 3 years. For a person who buys this insurance at age 65, there is a 45% chance of making a claim. If you never need long-term care, the payments you made to the plan are lost.

3. An “age in place” retirement arrangement might be right for you. Some campus-like retirement communities are designed to permit an older adult to “age in place.” This means you can go from a relatively independent life to a more dependent life while staying in the same community. Services often include recreation for the active elderly and 24-hour skilled nursing or rehabilitation services for the frail elderly. These organizations are called continuing care retirement communities. They are always expensive. Usually, they charge an up-front fee of $25,000 to $500,000. Then you pay a membership fee or rent each month.

4. Build up your savings. Making ends meet is a challenge. But in your working years, don’t underestimate how much you need to save. Many of us think, “After we no longer have our mortgage, we should be able to live on our savings.” It’s a good idea to factor long-term care into your savings plan. If disability strikes, you will need it.

5. Write an advance directive (“living will”). Some people receive intensive medical care after they become profoundly disabled. By then, some people who are in this situation are no longer able to communicate their wishes to family members and doctors. If you know that you would not want life-sustaining treatments in this condition, it is wise to record your wishes in a legal “advance directive.” It isn’t every day that an effective new treatment for some Parkinson’s disease symptoms comes along. Especially one that is safe, causes no adverse side effects, and may also benefit the rest of the body and the mind. That’s why I read with excitement and interest a report in the New England Journal of Medicine showing that tai chi may improve balance and prevent falls among people with Parkinson’s disease.

This degenerative condition can cause many vexing problems. These range from tremors and stiffness to a slowing or freezing of movement, sleep problems, anxiety, and more. Parkinson’s disease may also disrupt balance, which can lead to frightening and damaging falls.

A team from the Oregon Research Institute recruited 195 men and women with mild to moderate Parkinson’s disease. They were randomly assigned to twice-weekly sessions of either tai chi, strength-building exercises, or stretching. After six months, those who did tai chi were stronger and had much better balance than those in the other two groups. In fact, their balance was about two times better than those in the resistance-training group and four times better than those in the stretching group. The tai chi group also had significantly fewer falls, and slower rates of decline in overall motor control. In addition, tai chi was safe, with little risk of Parkinson’s disease patients coming to harm.

Other smaller studies have reported that tai chi can improve quality of life for both people with Parkinson’s disease and their support partners.

These studies are significant because they suggest that tai chi can be used as an add-on to current physical therapies and medications to ease some of the key problems faced by people with Parkinson’s disease.
Into the clinic

Parkinson’s disease affects more than one million Americans. This brain disorder interferes with muscle control, leading to trembling; stiffness and inflexibility of the arms, legs, neck, and trunk; loss of facial expression; trouble swallowing; and a variety of other symptoms, include changes in memory and thinking skills. These changes can greatly reduce the ability to carry out everyday activities and reduce quality of life. Medications can help, but they sometimes have unwanted side effects.

Since the appearance of the New England Journal of Medicine study, tai chi classes specifically for Parkinson’s disease patients have sprung up across the country, and the benefits of tai chi for Parkinson’s disease have been endorsed by the National Parkinson’s Foundation. (You can see a video of a tai chi class at Brigham and Women’s Hospital for people with Parkinson’s disease at the bottom of this post.)

Several colleagues and I have developed a tai chi program for people with Parkinson’s disease. It brings together Harvard Medical School doctors and other clinicians with tai chi experts. The 12-week program uses the traditional tai chi principles that I describe in my newly released book, The Harvard Medical School Guide to Tai Chi: 12 Weeks to a Healthy Body, Strong Heart & Sharp Mind. This program is jointly sponsored by the Parkinson’s Disease and Movement Disorders Center at Beth Israel Deaconess Medical Center and the Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School. So far, about 50 people have completed the program.

We have also begun a small, preliminary study across multiple Harvard Medical School hospitals focused on understanding the interactions between cognitive function, mobility, and motor function in early stage Parkinson’s disease. The idea is to examine how the mind-body connection of tai chi slows the loss of mobility and cognitive function in individuals recently diagnosed with Parkinson’s disease. The results of this pilot study will be used to guide randomized trials to further test the impact of tai chi.

I foresee a growing number of hospitals in the country developing similar tai chi programs for individuals with Parkinson’s disease. In addition to easing balance problems, and possibly other symptoms, tai chi can help ease stress and anxiety and strengthen all parts of the body, with few if any harmful side effects. I look forward to the day when evidence-based tai chi programs become widely available and used by individuals with Parkinson’s disease world-wide.

Peter Wayne, PhD, is an Assistant Professor of Medicine at Harvard Medical School and the Director of Research for the Osher Center for Integrative Medicine, jointly based at Harvard Medical School and Brigham and Women’s Hospital. He is also the author of The Harvard Medical School Guide to Tai Chi: 12 Weeks to a Healthy Body, Strong Heart & Sharp Mind.

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