Vol. 18, No. 6
July 17, 2018

In This Issue: Chronic care delivery, ACA’s constitutionality, “skinny” health insurance, the future of HHS, Medicaid work roadblocks, a Medicaid “scorecard,”  family leave in Massachusetts, nursing home staff shortages and “boomerang hospitalizations,” Gawande takes the helm, an “age-friendly” health system, predicting dementia, alleviating dementia caregiver depression, the benefits of high-intensity hospital care, home health care delivery, “three wishes” at the end of life, mother knows best, living wills in the ER, face-to-face primary care and computers, membership-only primary care, social factors and value-based performance measurement, and three cheers for “Dolores”
In the healthcare arena, June and early July saw major developments affecting the health insurance marketplace, Medicaid services, federal budgetary and long-term care, not to mention the matter of a impending Supreme Court nomination.
Chronic Care Act Moves Forward
To begin, however, with a rare product of bipartisan legislation, the recently enacted Chronic Care Act is moving from concept to operational status by virtue of newly-issued HHS guidance. As reported by the New York Times’ Robert Pear, the coming changes “tackle a vexing and costly problem in American healthcare: how to deal with long-term diseases that can build on one another, and the social factors outside the reach of traditional medicine that can contribute to them, like nutrition, transportation and housing. To that end additional benefits can include social and medical services, home improvements like wheelchair ramps, transportation to doctors offices and home delivery of hot meals. Under Trump Administration policy, most of the benefits will be reserved for Medicare Advantage plans, which will be able to offer additional benefits tailored to the needs of people with conditions like diabetes, Alzheimer’s, Parkinson’s disease, heart failure, rheumatoid arthritis and some types of cancer. ‘An inexpensive railing in the bath can avoid a fall that can cause a hip fracture and potential complications,’ said David Sayen, who worked in the Medicare program for 37 years. One caveat was sounded by AARP’s legislative policy director David Certner, who, while applauding the expanded services afforded to Medicare Advantage plans, argued that ‘the benefits should also be made available to traditional fee-for-service Medicare beneficiaries.’” And health policy analysts Amber Willink and Eva H. DuGoff, writing in the New England Journal of Medicine, posited that “the changes have the potential to substantially affect risk selection in Medicare advantage plans, which may derail the potential for progress on integration of medical and non-medical care. The promise of better outcomes and significant cost savings as a result of reduced hospitalizations and emergency department visits should give the plans opportunities to better serve high need beneficiaries, yet these changes may also attract the sickest beneficiaries who require the costliest care to switch from traditional Medicare to Medicare Advantage. It will be critical,” the analysts write, “for CMS to oversee the design and marketing of supplemental benefits.”
DOJ Refusal to Defend the ACA
On June 12 HHS Secretary Alex Azar, appearing at a Senate committee hearing, listened as New Hampshire Democratic Senator Maggie Hansen told him that what the Trump Administration had just done was “like some kind of sick joke.” Hansen’s barb came in the wake of the startling announcement that the Justice Department will not defend the ACA’s constitutionality in a lawsuit alleging that Congress’ repeal of the Act’s individual mandate invalidated the entire law—including, most significantly, protections against pre-existing condition exclusions. As ACA expert Professor Timothy S. Jost observed , “What are the ramifications of the Trump Administration’s position? Nothing yet. Several Democratic attorneys general are aggressively defending the ACA, and the case probably won’t be decided until late summer or fall. If the judge, however, buys the Administration’s argument, and if his ruling is upheld on appeal, 52 million Americans with pre-existing conditions face denial of coverage or higher premiums. The Administration’s argument would also allow insurers to charge women, older people, and people in certain occupations higher premiums. This policy change would jeopardize coverage not just for consumers in the individual market, but also people with pre-existing conditions who have employer-sponsored coverage. If these people lost or left their jobs, they may not be able to get individual market coverage.”
Further ACA Sabotage: Association Health Plans
Other rapid fire Trump Administration announcements manifested additional antagonism to Obamacare elements. A final Labor Department regulation concerning the health insurance marketplace, issued in June, will, the New York Times’ Robert Pear reported , “make it easier for small businesses to join forces and set up health insurance plans that circumvent many requirements of the Affordable Care Act, cutting costs but also reducing benefits. The new health plans would be exempt from many ACA consumer-protection mandates. They may not have to provide certain ‘essential health benefits’ like mental health care, emergency services, maternity care, and prescription drugs. Labor Department officials said Association Health Plans (AHPs) will not be able to deny coverage or charge higher rates to individual employees with pre-existing medical conditions. Still, consumer groups and many state officials remain opposed to the push for AHPs.” Meanwhile, two state attorneys general, Modern Healthcare’s Harris Meyer reported , “have announced they plan to file a lawsuit to block implementation of the rule because, they argue, ‘it will invite fraud and mismanagement and deception.’ And, added a spokesman for the Coalition Against Insurance Fraud, which includes the Blue Cross and Blue Shield Association, National Association of Insurance Commissioners, and Families USA, ‘the relaxed federal standards for forming these Association Plans risk opening the doors wider to a surge of scam operators who will seek to exploit the looser environment.’ The spokesman noted approvingly that the rule does preserve the authority of state insurance regulators to oversee AHPs but, ‘the big question is how robust the state and federal enforcement resources will be.’” Delving deeply into the final regulation, Health Affairs blogger Katie Keith concluded that “the department acknowledges that the AHPs will insure healthier people at the expense of sicker people. The rule notes that they are likely to result in expanding coverage to those from low-risk demographics while those with higher health costs from high-risk demographics are more likely to be uninsured. Rather than addressing this concern and the potential impact on the ACA risk pool, the rule says only that ‘states may pursue steps to more generously subsidize high risk individuals.’”
OMB Proposal to Move SNAP and Reshuffle Social Welfare Programs
While events were unfolding on the regulatory front, the White House Office of Management and Budget greeted the summer with a proposed major overhaul of the government’s health and social services’ administrative structure. “Among the most consequential ideas,” the New York Times’ Glenn Thrush and Erica L Greene, reported , “is a proposal to shift the Supplemental Nutrition Assistance Program, a subsistence benefit that provides aid to 42 million poor and working Americans, from the Agriculture Department to a new mega-agency that would have ‘welfare’ in its title. Produced over the last year by President Trump’s budget director, Mike Mulvaney, the proposal would reshuffle social welfare programs in a way to make them easier to cut, scale back or restructure, according to several officials involved in the planning. The core of Mr. Trump’s safety net policy is an expansion of work requirements to foster self-sufficiency among recipients of food assistance, Medicaid and housing subsidies to reduce dependence on the government, according to the OMB’s Domestic Policy Council’s Director Andrew Bremberg. ‘Our goal is to get people on the path to self-sufficiency.’ Its real purpose, advocates for poor people claim, is to kick hundreds of thousands of the needy off the federal rolls, to cut taxes for the rich.”
Obamacare: Alive and Kicking
Trying to put a bottom line on all of the interlacing healthcare insurance marketplace developments is proving somewhat elusive. As the New York Times Reed Abelson observes , “Obamacare is proving hard to kill. While President Trump may insist that the Obamacare law has been essentially gutted, the ACA market appears to be more robust than ever, according to insurance executives and analysts. A few states are likely to see a steep spike in prices next year, but many are reporting much more modest increases. Insurers don’t appear to be abandoning markets altogether. In contrast to last year, regulators are not grappling with the prospect of so-called ‘bare counties,’ where no carrier is willing to sell ACA policies in the given area. At the same time,” Abelson continues, “steadily higher prices are driving away more people who cannot afford those rising costs. Those whose income levels are low enough to qualify for federal tax credits are largely insulated from price hikes because the credits they receive increase to cover the higher premiums. Individuals can use the credits to help pay for monthly premiums and, in some cases, are able to cover the entire cost of the plan. But the number of people buying ACA plans at full price dropped by roughly 20% from 2016 to 2017, according to federal data. While some people may qualify for subsidies for the first time because of the higher prices, about 1 million people appear to have stopped buying coverage.”
Kentucky Medicaid Work Requirement Denied
For one US District Court, adding a work requirement to Medicaid coverage proved to be a nonstarter. Ruling in a suit challenging CMA’s approval of Kentucky’s imposition of such a requirement, federal judge James Boasberg concluded that “the Secretary never adequately considered whether the work requirement would in fact help the state furnish medical assistance to citizens, a central objective of Medicaid. This signal omission renders his determination arbitrary and capricious.” Judge Boasberg also noted that “the Secretary never provided a bottom-line estimate of how many people will lose Medicaid with Kentucky Health in place. This oversight is glaring especially given that the risk of loss coverage was factually substantiated in the record.” The ruling’s immediate effect was an announcement by Kentucky’s governor that the state would eliminate vision and dental benefits to nearly 500,000 Medicaid enrollees. The broader impact, however, is less clear. Other states are pressing ahead in pursuit of the addition of a Medicaid work requirement, and the entire issue of whether they are allowable under Medicaid law could ultimately come before a reconstituted Supreme Court.
Minnesota Defeats Medicaid Work Requirement Bill; Michigan’s Medicaid Expansion at Risk
The twists and turns of Medicaid expansion can be seen in two states, Michigan and Minnesota respectively. In the latter, a broad coalition of 154 nonprofits, medical providers, and faith based groups mounted a grassroots effort to defeat a bill that would have instituted a Medicaid coverage work requirement. In an editorial welcoming the outcome, the Minnesota Star Tribune observed that “at first glance the bill sounded reasonable. It would have required ‘able bodied’ people enrolled in Medicaid to work or seek work. But dig deeper and the reality is that the cost of this reform would outstrip savings while creating new hurdles for care. Bigger counties reported that they would have had to spend millions to handle the new reports enrollees would have had to file to prove they were employed or looking for work—making another unfunded mandate from the state. In addition, the additional red tape and the inevitable paperwork mix ups could lead to people eligible for coverage getting cut off. Exemptions from this requirement also weren’t broad enough to adequately protect people who have a mental illness. The bottom line: It would have cost more to cover fewer people had the measure passed. No one should be in favor of that.”

Not too far away, as reported by the Detroit Press’s Kathleen Gray, “tucked in the bill that requires able-bodied Medicaid recipients to work at least 80 hours a month is a provision that could kill the Healthy Michigan plan altogether. The poison pill would end the Medicaid expansion that was approved by the legislature in 2013, which covers 680,000 Michiganders with healthcare, if the federal government fails to approve the waiver within 12 months. Moreover, if the state’s Medicaid expansion plan deviates from previous practices, it has to apply for a waiver from the federal government to implement those changes. In Michigan’s case, it will have to apply for a waiver regarding a provision that would limit benefits for recipients to 48 months and if they exceed that time, require them to start paying 5% of their income into their healthcare and prove they are practicing healthy behaviors, such as quitting smoking or losing weight. If the Trump Administration,” Gray observes, “which has wanted to repeal Obamacare since taking office in 2017, wants to end Medicaid expansion in Michigan, the 12-month trigger could give it the excuse to do that.”
Health Insurance Landscape Returning to Pre-ACA Days
Taken together, the Washington Post’s Amy Goldstein observes , the effect of the patchwork of state efforts to either erect barriers against the Trump Administration’s anti-ACA moves or condition expansion of Medicaid coverage on highly controversial work and other requirements is that “the nation is starting to revert to the insurance landscape of a decade ago—a hodgepodge that created the political pressures that culminated in the sweeping 2010 ACA law. At the time, Americans’ ability to find and afford decent health plans, especially if they could not get one through a job, depended on where they lived and whether they were healthy or sick. ‘The ACA was about standardizing and now we’re going back to more divergence,’ said Heather Howard, a lecturer at Princeton University’s Woodrow Wilson School of Public and International affairs.’”
New Paid Family Leave Law in Massachusetts
The news from state capitals has not been all about Medicaid. Massachusetts has a new law that, among other provisions, contains a Paid Family and Medical Leave Program for Massachusetts employers and employees. The program will provide employees who contribute to the program the ability to take paid leave for up to 12 weeks a year to care for a family member or bond with a new child, 20 weeks a year to deal with a personal medical issue, and up to 26 weeks to deal with an emergency related to deployment of a family member for military service. Weekly benefit amounts will be calculated as a percentage of the employees average weekly wage, with a maximum weekly benefit of $850. Self-employed persons may opt into the program.
CMS Initiative to Assess States’ Medicaid Populations
Amid the policy debates over the future of Medicaid, CMS Administrator Seema Verma has unveiled a major federal initiative: creation of a “scorecard” to assess how states are impacting the health and well-being of their Medicaid populations. The initial such report, the Washington Post’s Amy Goldstein reported , is meant as a “conversation starter. With the Trump Administration’s giving states greater leeway in managing their Medicaid programs, Verma said, ‘such flexibility must be accompanied by heightened federal efforts to keep tabs on how well each state’s Medicaid program is functioning. With all the flexibility must come accountability.’ The scorecard’s initial information is based on states that voluntarily report a series of measures about the health of their Medicaid and CHIP enrollees. It shows, for instance, that the percentage of adults on Medicaid with high blood pressure under control as of 2016 varied from 26% in Louisiana to 72% in Rhode Island. The percentage of children ages 3 to 6 on Medicaid and CHIP who were getting adequate doctor’s care varied from 48% Alaska and Idaho to 86% in Massachusetts.”
Recent Spotlight on Nursing Home Deficiencies
“It’s almost like a ghost town. Most nursing homes overstated staffing for years.” So read the headline in Jordan Rau’s distressing New York Times article discussing Kaiser Health News’ analysis of new federal data emanating from daily payroll records Medicare only recently began gathering and publishing from 14,000 nursing homes. The records, Rau writes, for the first time reveal frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. The payroll records provide the strongest evidence yet that over the last decade, the government’s five-star rating system for nursing homes often exaggerated staffing levels and rarely identified the periods of thin staffing that were common. Medicare is now relying on the new data to evaluate staffing, but the revamped star ratings still mask the erratic levels of people working from day-to-day. When nursing homes are short of staff,” Rau observes, “nurses and aides scramble to deliver meals, ferry bed-bound residents to the bathroom and answer calls for pain medication. Essential medical tasks such as repositioning a patient to avert bedsores can be overlooked when workers are overburdened, sometimes leading to avoidable hospitalizations.”

In a second article , this one published by Kaiser Health News, Rau takes aim at the phenomenon—no doubt related to nursing home staff shortages—of “boomerang hospitalizations.” With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes skeletal medical staffing, often fail to handle post-hospital complications—or create problems by not heeding or receiving accurate hospital and physician instructions. Patients, caught in the middle, may suffer. One in five Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors. Such hospitalizations occur 27% more frequently than for the Medicare population at large. Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which give both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients care. While in recent years, the government has begun to tackle the problem with penalties for high readmission rates in an attempt to curtail premature discharges, some patient advocates,” Rau reports, “fear that the campaign against hospitalizing nursing patients may backfire, especially when Medicare begins linking nursing readmission rates to its payments. We’re worried that they bad nursing homes are going to get the message, ‘Don’t send anyone to the hospital,’” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform—even when the patient’s condition clearly calls for it.’”
Atul Gawande to Head J.P. Morgan Chase / Amazon / Berkshire Hathaway Healthcare Initiative
A surprise announcement was greeted enthusiastically across wide swaths of health policy experts, provider organizations, and patient advocates: Atul Gawande, gifted surgeon, teacher, New Yorker Magazine correspondent, and business executive will take the helm of a new venture, launched by J.P. Morgan Chase, Amazon, and Berkshire Hathaway, aimed according to StatNews, “at developing ways of reducing healthcare costs for the companies’ employees, as well as solutions that could be applied across the entire country.” Not exactly a small-bore project, but, as Fortune Magazine Editor-in-Chief Clifton Leaf reported J.P. Morgan Chase CEO Jamie Dimon’s discussion of the appointment, “We interviewed quite a few people. If you know Atul, you know he’s got a big brain and a big heart. He has a huge work ethic. He’s trustworthy. Gawande’s knowledge about the flaws in, and potential fixes for, the healthcare system runs deep. And all of it, importantly, derives from real-world experience, not a textbook.”
‘Age Friendly’ Health Systems: Testing of AHA Model
The American Hospital Association has embarked on a journey towards the creation of an “age friendly” health system. AHA plans to employ a “4M model” comprising 1) what matters: know and act on each older adult’s specific health outcomes and care preferences across settings; 2) medications: if medications are necessary, use age friendly medications that do not interfere with what matters, mentation or mobility; 3) mentation: identify and manage depression, dementia and delirium, across care settings; and 4) mobility: ensure that older adults at home and in every setting of care move safely every day in order to maintain function and do what matters. Five US health systems, AHA reports in its policy paper, are testing a prototype of the age friendly care model in hospitals, long-term care, ambulatory, and postacute care settings. The systems include Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence St. Joseph Health, and Trinity Health.
Addressing Social Determinants of Health With Demonstration Programs in Utah
Utah’s Intermountain Healthcare will provide funding to support the Utah Alliance for the Determinants of Health’s initial demonstration programs in Ogden and St. George. The Alliance is designed within the accountable health communities model by CMS and includes screening Select Health Medicaid members for social needs and assisting with coordination of those needs. It will also include working with community partners to ensure that services are aligned with the needs of community members.
Addition of Visual Association Test (VAT) Improves Accuracy Predicting Dementia
Dutch researchers have reported improved accuracy in predicting dementia by adding the Visual Association Test (VAT) to the Mini-Mental State examination (MMSE). The latter is widely used in clinical practice and research in spite of its limitations, including limited sensitivity for early stages of cognitive impairment. The visual association test (VAT) is a very brief (three-minute) and easy to administer test of associative memory that is highly sensitive for detecting impaired and anterograde memory, without bias based on language skills. It has particularly good test characteristics for the detection of early signs of Alzheimer’s disease, and it has a higher specificity and positive value for the recognition of dementia than any other cued recall instrument. “Our findings,” the researchers report, “showed that the VAT score has incremental value in discriminating between older adults with and without increased risk of dementia, especially among those with a minor decline in the MMSE score. In our analyses, an imperfect VAT in patients with a decline of only one or two points in MMSE score was associated with a significant and clinically meaningful increased risk of dementia.”
Analysis of Interventions for Depression in Caregivers of Family Members With Dementia
Geriatric psychiatrists in Singapore have published an analysis of the efficacy and acceptability of several interventions for curing depression arising out of caring for dementia-stricken loved ones. “With the expected rise in the number of persons with dementia and in the global cost of dementia care, there is a considerable need, and some urgency, to implement effective and acceptable interventions to support the well-being of family caregivers who commonly provide most of the informal care to these persons. In implementing interventions for caregiver depression and dementia, it may be reasonable for policymakers to consider initiating interventions that address caregiving competency first, and to introduce interventions that address the care needs of persons with dementia in a graded manner as tolerated and needed by the caregivers. Interventions to provide emotional support for loss and grief may not need to be introduced routinely and may be more appropriately reserved to a subgroup of family caregivers who have ongoing difficulty coping with the loss and grief related to caregiving.”
Research on Benefits of Care: Academic Medical Center Care and ‘Hospital at Home’ Model
Researchers in Boston and New York have published data analysis that they believe demonstrates that patients deemed relatively low-risk do, nonetheless, benefit from receiving care in academic medical centers. “Policymakers have increasingly emphasized high-value care and scrutinized high cost providers,” the researchers observe. “Because academic medical centers (AMCs) are widely seen as having higher costs than nonteaching hospitals, some insurers have begun to exclude them from narrow networks. Additionally, some policymakers have argued for limiting care in AMCs to patients with the most complex conditions or those who require additional resources, while preferentially caring for healthier patients at less expensive community settings. In a study of Medicare fee-for-service hospitalizations, however, we “found lower likelihood of 30-day mortality at academic medical centers for patients who were very ill and for patients who, despite being sick enough to require hospitalization, were relatively healthier. For patients with common medical conditions in aggregate, the benefits of being at an AMC were present across all patient groups examined. For surgical patients, outcomes were better at AMCs than in nonteaching hospitals for both medium and high severity patients, but we found no difference in outcomes for low severity patients. Our findings suggest that stratifying by risk is unlikely to be a fruitful enterprise. To the extent policymakers or clinical leaders want to steer patients away from teaching hospitals, they will need a different approach to identify which patients don’t benefit from that care.”

The AMC findings to the contrary notwithstanding, home-based care is increasingly in the spotlight and receiving accolades. In a strong endorsement of the “hospital at home” (HaH) model, studied by the Icahn School of Medicine at Mount Sinai, researchers report that “patients receiving HaH care had shorter acute lengths of stay, lower odds of hospital and emergency department readmissions and skilled nursing facility admissions, and higher ratings of care than in-hospital patients. Both HaH and in-hospital patients experienced few adverse events. The episode of HaH care was initiated when an HaH physician or nurse practitioner wrote the admission note and orders, and the patient was transferred home by ambulance or taxi service. Once the patient was home, a physician or NP provided home-based acute care services, including physical examination, illness and vital signs monitoring, intravenous infusions, wound care, and education regarding the patient’s illness. Nurses visited patients once or more a day to provide most of the care, and a physician or NP saw patients at least daily in person or via video call facilitated by the nurse. A social worker visited each patient at least once. Durable medical equipment, phlebotomy, and home radiography were provided as needed.” The researchers point out that in September 2017 the Physician Focused Payment Model Technical Advisory Committee (P-TAC) unanimously recommended that the secretary of HHS fully implement an alternative payment model (APM) for HaH care. In contrast to existing programs the HaH model considered by the P-TAC bundled acute HaH care with a 30-day period of postacute home-based transitional care. Creation of an APM for such a model of HaH care would establish Medicare billing codes, allowing clinicians to bill directly for HaH services and paving the way for broad scale adoption of the HaH program in the United States.” In that connection, Modern Healthcare’s Maria Castellucci reported , HHS Secretary Alex Azar in a June 13 letter directed CMS to work with Mount Sinai and other stakeholders to amend the model for possible implementation in Medicare.
Home-Based Primary Care Shows Positive Results
While the Mount Sinai model focuses on acute care patients, the move to provide primary care in the home is also developing momentum. The Home Centered Care Institute has issued a policy paper noting that “home-based primary care (HBPC) is gaining traction as an effective, compassionate way to care for patients with mobility issues and multiple chronic conditions. However, payment model challenges need to be addressed, and more clinical and practice management data is needed to support the HBPC model.” HCCI reviewed the positive results thus far of the CMS independence-at-home demonstration, which Congress extended for two years in February 2018. “The IaH demonstration showed impressive savings in the first two years, in which IaH sites successfully cared for nearly 10,000 patients annually with savings totaling more than $32.8 million. In the first year, 17 participating practices serving more than 8,400 patients, spent $25 million less on patient care than CMS expected would be spent without the program.”
Building a Next-Generation Platform for Care at Home
Adding to this growing home care resource base is a publication from CareCentrix that emphasizes the need for Medicare reimbursement policies and home care requirements to evolve in order to permit expansion of a home-based primary care model. “Restricting home-based care to the homebound,” the paper points out, “excludes patients with limited resources, particularly those with financial constraints, transportation challenges, food insecurities, language barriers, and other social factors. Replacing Medicare’s homebound requirement with a scale that measures activities of daily living or the number of chronic conditions would create a need-based home health benefit. In today’s era of value-based care, a needs-based approach would ensure that patients get the care they need to avoid unnecessary and costly readmissions. In addition, in order to realize the promise of home health, reimbursement schedules must embrace telehealth and remote technology, including live video, shared transmissions, remote patient monitoring, and mobile health.”
Three Wishes Project: Honoring Patients at the End of Life
End-of-life care at the Ronald Reagan UCLA Medical Center has embraced a new component, the Three Wishes Project, which, as reported by Modern Healthcare’s Maria Castellucci, “offers a way to dignify and celebrate a patient’s life as death nears by fulfilling three of their wishes. Patients with a 95% or higher chance of dying during an ICU stay are approached about the program. Clinicians tell patients and families the project is a way to honor the patient’s life. They are then asked what UCLA can do to make the experience easier. If the patient is no longer conscious, family members are asked how they want to honor their loved ones. Sometimes nurses will even bring up the project to the patient and suggest wishes for them. The wishes are often inexpensive and doable. One family member’s grandmother asked for potato chips, pictures of her family on the ICU walls, and support to be flown back to Las Vegas so she could die at home.”
Adult Children Often Perceive Their Mother’s Caregiver Preferences Wrongly
An intriguing study in The Gerontologist concludes that adult children’s perceptions of their mothers’ caregiver preferences among her offspring are very often inaccurate and result in the mother experiencing increased stress during serious health crises. “Our findings reveal that adult children are more likely to hold inaccurate perceptions of their mothers’ preferences, and that those most likely to hold such inaccurate perceptions are offspring who will be expected to be especially knowledgeable about their mothers’ preferences—adult children who are already serving as primary caregivers. These findings underscore the need for intervention efforts to encourage practitioners and clinicians to collect information directly from mothers regarding preferences for particular offspring as caregivers before, or at the time when, major health events occur.”
Living Will, DNR, and POLST Misinterpretation in the ER
Kaiser Health News’ Judith Graham explores some unintended consequences of emergency room staff interpretations of living wills. “A new report out of Pennsylvania,” Graham reports, “which has the nation’s most robust system for monitoring patient safety events, treats mix ups involving end-of-life documents as medical errors—a novel approach. It found that in 2016, Pennsylvania healthcare facilities reported nearly 100 events relating to patients ‘code status’—the wish to be resuscitated or not, should their heart stop beating and they stop breathing. In 29 cases, patients were resuscitated against their wishes. In two cases, patients weren’t resuscitated despite making it clear they wanted this to happen. The rest of the cases were ‘near misses,’ problems caught before they had a chance to cause permanent harm. ‘The problem,’ explained Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, ‘is that doctors and nurses receive little, if any, training regarding understanding and interpreting living wills, DNR orders and physician orders for life-sustaining treatment (POLST) forms, either on the job or in medical and nursing school. At the same time, said Dr. Arthur Darce, director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin, ‘while attention to these problems is important, they shouldn’t be overblown. Are there errors of misunderstanding or communication? Yes. But you’re more likely to have your wishes followed with one of these documents than without one.’”
Need for Patient-Centered EHR Use by Providers
Regardless of where healthcare is delivered, the push to digitalize medical records is increasingly putting stress on doctor-patient, face-to-face encounters. Reporter Sara Heath notes that “electronic health records (EHRs) may be doing more harm than good during the clinical encounter, as providers continue to assert they takes away limited time for patient provider communication, according to a survey from Stanford medicine. The poll results revealed 59% of healthcare providers believe EHRs need a major overhaul. This may be due to the challenges the technology presents providers during patient interactions. During a 20 minute primary care appointment a provider usually spends about 12 minutes interacting with the patient and eight minutes documenting on the EHR. This does not include the typical 11 minutes of documenting the provider does once the patient has left the exam room. Medical and patient engagement experts say that maintaining eye contact, explaining why the provider is using the EHR, and the tool’s benefits are simple strategies for patient-centered EHR use. Taking a moment away from the computer, perhaps at the top of the appointment, will show the patient that the clinician is there for them and help establish a positive rapport before integrating the EHR into the care encounter. The EHR is not going away; its promise for clinical improvement and ability to maintain and protect patient health records has cemented its use in clinical encounters. Thus it is essential for providers to identify key strategies that will facilitate positive patient provider communication while still meaningfully utilizing the EHR.”
The Rise of Membership-Fee Direct Primary Care
Physician burnout, whatever the cause, is no doubt fueling the growth of membership-fee primary care practices, reports the Chicago Tribune’s Lisa Schencker. At the same time, she writes, patients increasingly frustrated by insurance costs and restrictions are warming to the membership model. “Advocates of the model hail it as better for patients looking for more personal, convenient care and as a solution for harried doctors who want to focus on patients, not paperwork. Direct primary care doctors tend to see far fewer patients than traditional primary care physicians. Critics, however, caution that it’s no replacement for traditional health insurance and worry about its implications. They warn that patients who have such memberships, as well as insurance, are overpaying for their healthcare. They are also concerned that a proliferation of the practices could worsen a shortage of primary care doctors and/or attract healthy people away from the individual insurance market, thereby making individual insurance coverage more expensive for those who continue to buy it. The concept is similar to concierge medicine that for years has allowed wealthy patients to pay fees for more personal, accessible care. Direct primary care advocates however, say the model is different because it caters to patients across the economic spectrum. And they say that concierge doctors often bill insurance on top of collecting patient fees, while direct primary care physicians generally do not. ‘This is a way for the middle class to have clinicians on speed dial,’ said Matthew Bates a managing director of consulting firm Huron in Chicago.”
Trend Away From High Intensity Care Deserves Caution
New York Times op-ed writers Dr. Dhruv Khullar and Professor Austin Frakt seek to reconcile two recent, possibly contradictory research findings. As discussed above, the benefits of increased care at home have been documented in the Mount Sinai Hospital hospital at home study, while, at the same time, researchers looking at clinical outcomes in academic medical centers vis-a-vis less intensive settings have offered evidence of the benefits of the centers’ generally higher intensity care. Clearly, the writers observe, “there is a broad trend away from high intensity care settings. The use of inpatient care is declining across the United States, including a 6% drop in inpatient admissions for Medicare patients from 2004 to 2010. The trend, however, may not serve all patients well. There is concern, for example, that outpatient surgical centers don’t always have the resources and staff needed to handle potential complications of the increasingly complex operations that are taken on. Sometimes less is more, but sometimes more is more. Given the high—and sometimes unjustifiable—cost of some healthcare settings,” the writers conclude, “it seems reasonable to pursue payment parity for comparable care delivered in different settings. And all other things equal, a shift toward lower intensity, lower-cost settings is a worthy goal. But in some cases outcomes may not be equal, and it seems we should make sure were not cutting quality when we’re cutting cost.”
Adjusting Value-Based Payment Models to Patients’ Social Risk
Dr. Khullar takes on another source of possible policy conflict—value based reimbursement measures—when he asks: “Is it getting harder to care for poor patients?” Khullar acknowledges that payers are starting to consider adjusting payment for social risk. “In my more exasperated moments of my residency,” Khullar writes, “what strained my ability was not patients’ medical complexity, but their social problems: they were poor, less educated, more isolated, from rougher neighborhoods. We quickly learned that while it’s hard to dose insulin, it’s harder still for a patient who speaks no English, has no refrigerator and regularly has his medications stolen. A growing recognition that social factors influence health outcomes, however, has coincided with a policy push to hold medical providers more accountable for the care they deliver. These value-based payment models try to measure quality, outcomes and cost—and reward or penalize providers based on their performance. They generally adjust for patients’ medical problems, but not social ones. While most experts agree that value-based purchasing is a better way to pay doctors, it also has the potential to worsen health disparities by discouraging providers to care for vulnerable populations. If I’m paid for how many stents I put in or how many patients I see, it doesn’t really matter if my patients live on the street or can’t read the instructions on a pill bottle. But if I’m paid based on how well their blood pressure is controlled and how frequently they are admitted to the hospital, those things start to matter quite a bit. Whatever model we might end up adopting, selecting the right types of measures will be important. It probably doesn’t make sense to adjust for social risk when assessing whether a patient got aspirin for a heart attack or the right antibiotics for infection, but it does when measuring how well the patient’s diabetes is controlled over time. Clinicians can also be rewarded for improvements in care—compared to similar providers or compared to their own prior performance—instead of for meeting absolute thresholds. Paying doctors to do better—instead of to do more—is essential for a higher value health system. But if not done carefully, we risk leaving some patients behind. Better care for those who’ve been dealt a bad hand will mean making sure doctors aren’t playing against a stacked deck.”
Supported Decision-Making Laws Help Individuals Maintain Independence
Four US jurisdictions—Texas, Delaware, Wisconsin, and the District of Columbia—have enacted “supported decision-making laws.” “Most of us,” writes the Washington Post’s Teresa Vargas, “have friends or relatives we turn to for advice. This is the same as that—but more. The DC law formalizes those relationships and requires institutions and organizations to recognize the role of people who serve in those supportive positions. 87-year-old ‘Dolores’ (she wishes to remain anonymous) has become the first DC resident to take advantage of the recently passed measure. After being thwarted in discharging a guardian who had helped her regain financial stability, Dolores sought court intervention. She and her attorneys successfully argued that with help from people in her life, she could make her own decisions and not need the court appointed guardian to do that for her. When Dolores tells people she is not far from 90, they show genuine surprise. She has not yet let her hair turn white and she speaks with a well earned wit. She also takes care of most of her needs by herself, getting dressed on her own, taking the right amount of medications as needed, and making appointments that she gets to herself using public transportation. She recently enrolled in a college class after deciding she wanted to learn Italian. Despite all that, she had still been deemed an incapacitated individual—unable to make choices for herself. Dolores recognizes that she is not able to do everything alone now. But she said that for every problem she encounters, she knows whom to call. ‘It makes you feel powerful to be in charge of your own life,’ she said. ‘You can have a lot of help everywhere, but you are your own boss.’”
California Assembly Aging and Long-Term Care Committee Hearing on Final Report of the California Task Force on Family Caregiving
This Thursday, July 19, 1 p.m. to 3 p.m. , the California Assembly Aging and Long-Term Care Committee will meet at the University of Southern California Leonard Davis School of Gerontology for the final report of the California Task Force on Family Caregiving .

The report, Picking Up the Pace of Change in California, details recommendations designed to provide for the evolving needs of family caregivers in California. These recommendations include: providing more financial support, creating and distributing education materials that are tailored to diverse populations, and integrating caregivers into the hospital process.

The hearing will include two expert panels and an opportunity for public comment. Family Caregiver Alliance Executive Director Kathleen Kelly is a member of the Task Force appointed by the California Legislature and Senate.
Follow Family Caregiver Alliance / National Center on Caregiving @CaregiverAlly
and Executive Director Kathleen Kelly @KKellyFCA.
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Editor: Alan K. Kaplan, (attorney and health policy consultant)
Contributor: Kathleen Kelly (executive director)
Layout: Francesca Pera (communications specialist)

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