Vol. 19, No. 4
April 30, 2019

“America’s caregivers deserve to be seen as valuable members of the health care team. They should be included in decision making, given opportunities to voice their concerns, and provided appropriate instruction. They should not be taken for granted—or worse, criticized for their perceived failures and inadequacies. The responsibility for meeting the challenges of the new paradigm falls on all sectors of society, but health care and social service professionals and the systems in which they work bear a special duty to bring about a culture change as well as implement new practices and policies that make a difference for family caregivers. Public policies and funding should be tailored to support these practices in diverse communities. The recommendations in this report are a good place to start. We cannot go back to the ‘good old days’—if they even existed. The future is our only path to justice and a caring society.”
Home Alone: Progress and Ongoing Challenges
In the 54 years since the enactment of Medicare and Medicaid programs, the healthcare services they made available have been enhanced as a result of periodic calls for reform that engendered particular and ongoing consequences. The Institute of Medicine’s 1986 revelations of severe quality-of-care deficiencies in America’s nursing homes, and its detailed recommendations for reform, led to a far-reaching congressional response and formation of a nursing home patient advocacy community that continues to vigorously pursue better conditions for long-term care residents. Thirteen years later, in its report “To Err is Human” the Institute ignited a second and enduring wave of reform by calling attention to the extent that medical errors affect the health and safety of the country’s entire patient population.

Seven years ago, in the midst of steadily increasing public and policymaker concerns over the societal and familial burdens associated with family caregiving, AARP’s Public Policy Institute published “Home Alone,” the first national survey seeking to document just what kinds of unpaid responsibilities family caregivers were being called upon to assume on behalf of their loved ones. The findings were startling: in ever-increasing numbers, complex medical and nursing tasks were being thrust upon caregivers seeking to maintain a spouse, parent, or child in his or her home environment. That landmark report has already had a galvanizing and mobilizing impact on the caregiving public policy and advocacy communities, including the formation of the Home Alone Alliance (AARP, the Betty Irene More School of Nursing, the United Hospital Fund, and Family Caregiver Alliance) and passage by 40 states, so far, of the Care Act. The Alliance has now updated the original report by publishing, Home Alone Revisited: Family Caregivers Providing Complex Care . The 56 pages carry forward its earlier findings and add even more statistical testimony and gravity to them.“The findings and recommendations in Home Alone Revisited mark a turning point in our understanding of family caregiving. The old paradigm—the uncomplicated world of “informal” caregiving—no longer applies to millions of family members, friends, and neighbors of diverse ages and cultural backgrounds providing complex care at home. In the current health care environment, it is presumed that every home is a potential hospital and every service that the person needs can be provided by an unpaid family member, with only occasional visits by a primary care provider, nurse, or therapist. The first Home Alone report made it clear that family members provide technically complex care such as changing wound dressings, operating medical machinery, and administering and monitoring numerous medications. The study helped fuel strategic action and a growing body of research. This new report adds to the understanding of this major shift in responsibility, underscoring, for example, the stress associated with managing pain—an especially timely issue given the opioid epidemic. It makes clear the emotional and time-consuming challenges of dealing with incontinence and preparing special diets, two tasks that have long been assumed to be relatively easy to do. The sum of all these tasks—activities of daily living (ADLs), instrumental activities of daily living (IADLs), medical/nursing tasks, care coordination, not to mention emotional support and companionship—takes a toll on family caregivers, leaving all too many of them isolated and with mental and physical health problems of their own.”
In This Issue: Spousal protection protected :: Gallup highlights health care cost burden :: HHS advances new primary care payment model :: Medicare “observation” stay court case moves forward :: CMS promises enhanced SNF quality oversight :: the Medicaid state waiver controversies gather more steam :: changing family structures impact support for seniors’ needs :: financial burdens face aging boomers :: “virtual” primary care visits, tablets, and apps for hospitalized patients :: wearable devices for at-home patients :: a mushroom cure for cognitive impairment(?) :: the complexity of the Alzheimer’s challenge :: less care for older diabetics(?) :: monitoring eskatamine anti-depression treatment :: in-house doctoring for assisted living residents :: and Krugman’s unminced take on the GOP’s healthcare stance
Congressional Action in Support of Caregivers
Against a looming March 31 deadline, the Medicaid Services Investment and Accountability Act of 2019 ( H. R. 1839) made its way into law, thereby preserving protection for recipients of Medicaid home and community based services against spousal impoverishment until September 30. The Act also provides $20 million in additional funding for the Medicaid Money Follows the Person program. Meanwhile, just starting its road to possible passage, S. 1017 , the Supporting Americans Caregivers and Families Act, has been introduced by Senators Richard Durbin and Tim Kane. The bill would provide additional support for caregiver assessment tools and establish a Family Caregiver Resource Center and Technical Assistance to facilitate funding and dissemination of best practices related to assessment, education, and assistance.
Gallup Poll on Seniors’ Healthcare Costs Concerns
“The ‘golden years’ American seniors anticipate enjoying may require actual gold, or the dollar equivalent, to pay for rising healthcare costs; a recent study has revealed seniors face a concerning cost burden due to a healthcare system in the United States that spends almost double per person what any other developed nation in the world spends.” So, reports Gallup in a new poll of more than 3,500 Americans concerning healthcare costs and value. The poll’s major findings: seniors had withdrawn an estimated $22 billion from long-term savings to pay for healthcare; 92% of seniors feel healthcare costs will not improve or will get worse; three in four seniors say the government is not doing enough to control costs; and 7.5 million seniors are unable to pay for a medicine prescribed by the doctor.
New Payment Models From HHS: CMS Primary Cares
One way Trump administration health officials are hoping to get a greater handle on Medicare costs was unveiled by HHS Secretary Alex Azar in a late April speech to the American Medical Association. After acknowledging the preparatory efforts of his recent predecessors, Azar announced that “We’re launching CMS Primary Cares—an initiative with two sets of new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures. The Primary Care First path will allow smaller primary care practices to be paid a simple, flat stream of revenue for each patient. When a patient stays healthy and out of the hospital, these practices will get paid a bonus. But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending, up to a certain share of their practices’ revenue. The other path, Direct Contracting, is more ambitious and aimed at larger practices. Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money. But if patients end up sicker, Direct Contracting practices will bear the risk for the extra health spending, not just at their own practice but throughout the system. Providers will have greater flexibility to spend these resources how they want, allowing them to come up with innovative ways to care for patients—and receive significant savings if they keep patients healthier than expected. This initiative,” Azar continued, “will radically elevate the importance of primary care in American medicine, move toward a system where providers are paid for outcomes rather than procedures, and free doctors to focus on the patients in front of them, rather than the paperwork we send them. This is the pivotal, hockey stick moment in paying for value in American healthcare. This initiative will lay the groundwork not just for better care and lower costs in the $700 billion Medicare program and the $580 billion Medicaid program, but will also help drive innovation toward a new, patient-centered approach in our entire $3.5 trillion healthcare system. This initiative is specifically designed to encourage state Medicaid programs and commercial payers to adopt similar approaches.”

Implementation of the new initiative will entail addressing numerous issues that have arisen in connection with many efforts to move from a fee-for-services payment system to a value-based one. STAT’s Casey Ross observes that “transforming to a value-based system of care is especially difficult because it requires setting a clear and universal definition of what value is, and then figuring out how to measure it. The task also requires adjusting for variability among providers’ populations of patients—some doctors take care of sicker patients, overall, than others—as well as differences in the size of their practices and the underlying social and economic needs of their patients. Past attempts to reform primary care payments have generated widespread complaints from physicians who argued that the government failed to recognize the cost of collecting and reporting a wide array of new data on patients, which made it all but impossible for smaller practices to participate.”
Hospital Observation Vs. Inpatient Distinction and Cost to Medicare Beneficiaries
The vexing problem of assigning “observation” rather than “inpatient” status to hospitalized Medicare patients, thereby effectively foreclosing Medicare coverage for post-hospital skilled care, continues to challenge patients and patient advocates. A recent HHS’s Inspector General report added fuel to the fire by focusing entirely on what it found to be erroneous SNF payments based on improper “inpatient” determinations—without including any discussion of the underlying controversy over the inpatient-observation-stay distinction. In a late March ruling, a Connecticut federal district court allowed a class-action to proceed to determine whether Medicare beneficiaries have a right to appeal their placement on “outpatient observation status” in hospitals.“The opportunity to appeal,” Justice in Aging emphasized in its summary of the court’s ruling, “is critical because of the severe ramifications that can result from the observation status categorization. Class member Ervin Kanefsky of Pennsylvania, for example, a 93-year-old World War II veteran, had to pay approximately $10,000 for nursing home care after being hospitalized for a shoulder fracture for five days. He was initially admitted as an inpatient but later was told that the ‘powers that be’ had changed his status to ‘observation’ before he was discharged.” Responding by pursuing a legislative fix , a bipartisan congressional group has reintroduced the Improving Access to Medicare Coverage Act of 2019. The legislation would require Medicare to count the time spent under observation status toward the three-day inpatient hospital stay requirement. As sponsor Representative Joe Courtney notes in his press release, “three days is three days, and quibbling over semantics should not keep Americans from accessing the care they’ve been prescribed by health care professionals, or force them to go into medical debt in order to cover the cost.” Both consumer advocates and industry groups support the legislation.
Skilled Nursing Facilities: Under the Microscope
In the wake of recent revelations at a Senate hearing of shocking examples of nursing home resident abuse and neglect, April saw several developments related to SNF quality of care. 

  • In an extensive blog post CMS administrator Seema Verma stated that “CMS is not waiting, and not settling for the status quo: I have directed my team at CMS to undertake a comprehensive review of our regulations, guidelines, internal structure, and processes related to safety and quality in nursing homes.” As Skilled Nursing News’ Alex Spanko reported, “Much of Verma’s post outlined oversight changes already made under her watch and the previous administration, including moves to implement stricter staffing requirements, reduce unnecessary use of anti-psychotic drugs, and more closely align reimbursements with performance—specifically pointing to the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program, under which operators receive penalties for failing to improve certain quality metrics. But Verma also used her platform to highlight a variety of potential initiatives that CMS may adopt in the near future, repeatedly emphasizing that the federal government isn’t done overhauling its regulations for the nation’s more than 15,000 nursing homes.” Verma focused on five major categories: strengthened oversight and coordination of state survey agencies; enhanced enforcement of standards including staffing levels and appropriate use of antipsychotic and dementia drugs; increased transparency through improvements in Nursing Home Compare; ongoing development of quality measures that score providers based on patient outcomes, rather than adherence to processes; decreases in infection rates and adverse drug events; and minimization of paperwork and other administrative cost burdens on providers.

  • With respect to the online Nursing Home Compare information resource, Modern Healthcare’s Maria Castellucci reports the star rating system has now been updated to include “new ratings for health inspection performance and stricter criteria for staffing level ratings. Unlike the Hospital Compare star ratings, Nursing Home Compare assigns more than just a single overall rating. Nursing homes are given three additional ratings based on health inspections, staffing levels and quality measures. The nursing home ratings are also refreshed monthly” As for staffing levels, Castellucci writes, “Right now, if a facility reports seven or more days per quarter with no registered nurse on-site, they are automatically assigned a one-star rating for that category. Starting in April, a facility will get an automatic one-star rating if they don't have a registered nurse on-site for four days. The CMS said the change was made in recognition of how important nursing home staffing levels are for quality of care. ‘Nurse staffing has the greatest impact on the quality of care nursing homes deliver.’”

  • A third CMS initiative came in the form of a revised guide to “Immediate Jeopardy” (IJ) citations in long-term care facilities. As detailed by the National Consumer Voice for Quality Long Term Care, the revised guidance addresses three major components of an IJ determination: noncompliance with Medicare and Medicaid requirements for participation; the occurrence or likely occurrence of serious injury, serious harm, or serious impairment or death; and the need for immediate action. “There are many positive changes in the revised guidelines,” Consumer Voice stated, including the emphasis on “likely” occurrence, on-site surveyor determination that an IJ situation has been removed, and reliance on a facility “responsibility” standard rather than a “culpability” one in initiating remedial action.

  • Finally, Modern Healthcare’s Robert King reported, CMS has proposed increasing payments to SNFs by $887 million in FY 2020 as part of its plan, beginning in October, to use a new case-mix model that will focus Medicare payments based on the patient’s condition and resulting care rather than the amount of care provided. 

  • Lest all of these initiatives, however, go without some reservations, five beneficiary advocacy organizations have urged some caution in assessing their impact. “Nursing homes face little oversight over how Medicare and Medicaid funds are used. Nursing homes too often routinely hide profit and depress their balance sheets through related party transactions, self-dealing, and complex corporate ownership. In addition to the lack of oversight, the majority of health care violations in nursing homes are inaccurately described as having caused ‘no harm’ to residents’ health, safety, or well-being. Too often, no-harm violations do not reflect the real pain, suffering, and humiliation that residents experience: maggot infestations, bruises, pressure sores, and sexual assaults, to name just a few. Before considering giving nursing homes more taxpayer dollars, let’s first improve oversight of how nursing homes use funds currently allocated for resident care and increase enforcement of the nursing home standards of care.” 
Medicaid Work Requirements Blocked, but ...
U.S. District Court Judge James Boasberg’s March 27 invalidation of Medicaid work requirements in Kentucky and Arkansas does not appear, for now, to have put the brakes on the Trump administration’s drive to approve their imposition in states requesting them. “The administration remains undeterred,” write Health Affairs Health Affairs bloggers Sara Rosenbaum and Alexander Somadevilla. “Its FY 2020 budget calls for a work mandate as an eligibility condition for working-age adults, thereby underscoring the magnitude of work mandates on coverage. And on March 29 CMS announced its approval of Utah’s partial Medicaid expansion link to a work requirement. This was a striking development not only because of its timing (48 hours after Judge Boasberg’s decisions) but because the states determination directly flies in the face of its own 2018 voter-approved referendum calling for a simple expansion to reach the entire ACA-eligible population, without added eligibility conditions. In light of the court’s dismissal of the administration’s effort to fundamentally reframe Medicaid’s objectives and thus the standard against which Medicaid eligibility reduction experiments should be evaluated, one should not expect the administration to mount a third attempt at gaining District Court approval. An appeal of the Kentucky and Arkansas rulings is more likely. To be continued.”
Tennessee Seeks to Overhaul Medicaid Program
Meanwhile Tennessee’s House has taken a legislative step towards fundamentally overhauling its Medicaid program by voting to require the state to submit a waiver within 120 days of the bill becoming law asking the federal government to send a fixed amount of money each year in the form of block grants. However, as the Associated Press reported , “the likelihood of the bill being implemented is still largely unknown. No state has ever been given permission to rely solely on block grants to pay for Medicaid. Critics say it could result in states covering fewer people or offering skimpier benefits due to the potential leniency and lack of oversight. According to supporters, on the other hand, the goal is to allow states more flexibility to shape their Medicaid programs while also being given the opportunity to rein in spending.”
Changing Family Structures: Its Impact on Seniors
George Washington University law professor Naomi Cahn pens an extensive discussion of the impact of changing family structures on seniors’ economic security and caretaking. “Our current social, legal, and economic structure for growing old is organized around the nuclear family with respect to both caretaking and financial security. As family structures change in terms of partnering (and re-partnering and non-partnering) and number of children, and with the increase in economic inequality, support for old age needs to change as well. Nonetheless, notwithstanding changing family forms and roles and economic disparities, we have not made the requisite changes to prepare for the forthcoming silver tsunami. The solutions do not necessarily involve entirely unmooring caretaking and benefits from family but do involve ‘spreading the wealth,’ assuring that those left out of current nuclear-family-based transfers are not left out of security or caretaking, and that those who provide caretaking are appropriately recognized. That means making some changes to existing qualifications for benefits, as well as developing new means for the inclusion of those left out.”
Older Boomers Reveal LTC Preferences and Financial Insecurity in Two Studies
Two recent studies offer insights into older baby boomers’ long-term care preferences and the growing financial challenges middle income seniors will face as they seek to fulfill their housing and healthcare needs. Reporting on the results of a national survey, Leading Age-NORC observed that while “some of what the respondents told us was consistent with earlier surveys of all adults or all older adults, some of what this highly targeted group told us was surprising. Asked what would be important if they were in a position of needing help with daily activities, being safe was ranked the most important consideration, higher even than being around family or friends. We found that 40% said they would want to live somewhere other than their current home or apartment if they had a physical disability that require them to need help with daily activities. Most earlier studies and surveys report that the majority (76% or more) of adults say they want to stay in their own home. These earlier studies do not target older baby boomers and they do not ask for separate responses depending on whether the impairment is physical or cognitive.”

A related NORC study published in Health Affairs looks more closely at whether middle income seniors will be able to afford senior housing during the next 10 years. “For lower-income people, state and local programs provide housing and care services via means-tested programs such as Medicaid. For higher-income people, a large private-pay assisted or independent living sector has emerged to meet the demand for housing and care services. Although some middle-income people are living in seniors housing, the industry has not primarily focused on this cohort. Unfortunately, our study revealed that most of tomorrow’s middle-income seniors will lack the financial resources required to pay for private seniors housing, regardless of their preferences. Even if we assume that seniors devote 100 percent of their annual income to seniors housing—setting aside any personal expenses—only 19 percent of middle-income seniors will have financial resources that exceed today’s costs of assisted living. Many seniors treat housing equity differently from other financial resources and attempt to liquidate other income and assets before liquidating the equity. Such housing equity may be the family home that some older adults keep as a nest egg to protect against future, unexpected financial hardship or wish to preserve for their children. However, if we assume that middle-income seniors do draw down housing equity, 54 percent (7.8 million) will still lack the resources to pay for seniors housing at today’s costs.”
New Guide: Socially Vulnerable Older Adults and Medical-Legal Partnership
The National Center for Medical-Legal Partnership, has published a detailed guide to integrating legal services into efforts to meet the needs of socially vulnerable older adults. The document explores integration with regard to advance care planning, financial planning, abuse and exploitation prevention, and poverty-related social determinants of health. Three concluding profiles of medical-legal partnerships—in San Francisco, Boston, and Gainesville, Florida—demonstrate the significant beneficial impact such ventures produce for clients receiving services.
Medicaid HCBS Examined in KFF Issue Briefs
The Kaiser Family Foundation has published several Issue Briefs examining topics related to Medicaid home and community-based services (HCBS), including enrollment and spending, waiver waiting lists, and key state policy choices. “States are using Medicaid HCBS,” KFF observes “to advance community integration and counter the historical bias toward institutional care through policies such as financial and functional eligibility and expanding the care settings where HCBS are available to work and other community settings. States also are using newer HCBS state plan authorities, including Section 1915 (i), to expand or augment the populations and services they cover under waivers. In addition, states are continuing to make policy changes in response to key federal regulations affecting HCBS. The historical bias toward institutions, requiring states to cover nursing home care while making most HCBS optional, remains in federal Medicaid law. Still, states continue to take advantage of various options to use federal Medicaid matching funds to increase HCBS eligibility and covered services and to modify their delivery systems and provider policies to support HCBS.”
Tech Advances in Healthcare: Telehealth, Tablets, Apps, and Wearable Devices
Technological advances continue to power innovations in healthcare delivery, management, and treatment:

  • Modern Healthcare’s Shelby Livingston reports that Humana and telehealth company Doctor On Demand will launch a new health plan design allowing employers and employees to receive primary care predominantly through virtual visits. “The plan, called On Hand, allows Humana members to avoid the doctor's office and access primary-care services virtually from one Doctor on Demand physician, with access to urgent care, preventive care and behavioral health services. When needed, patients will receive referrals to specialists in Humana's network for in-person doctor visits.” While not initially being made available to the insurer’s large Medicare Advantage members, the plan’s ensuing results will no doubt be of interest to policymakers working to increase telehealth options for the senior population.

  • For hospitalized patients and their family caregivers, the Washington Post’s Fran Kritz reports, “An increasing number of hospitals are offering ‘interactive patient-care systems’—a tablet with controls and apps patients can use, including one with access to their hospital medical information. Adult patients can choose to provide access to family members or other caregivers. The apps provide medical information, such as medications and dosage, procedures, daily care schedules, test results and education videos; photos of the patient’s physicians and nurses; and an expected date of discharge, often including what factors—for example, no fever—must be met for a patient go to home. While many patients appreciate the apps, not all of them use a majority of the features. Patients and family members tend to narrow their use to what works best for them. As physicians, nurses and other health-care workers get more accustomed to the apps over several years, ‘they are feeling better about the systems even though they’re not perfect,’ according to Ohio State University’s Ann Scheck McAlearney. ‘Etiquette for both patients and medical staff members will ultimately shake itself out. We will need to provide more guidance and training to both patients and clinicians about the best way to incorporate system use into the care process.’”

  • “There’s an app for that” can now refer to an FDA-approved wearable device that uses artificial intelligence to remotely track and analyze multiple vital signs while worn by patients at home. As reported by FierceHealthcare’s Heather Landi, “The AI-powered wearable remote patient monitoring device from Edinburgh, Scotland-based Current Health received Class II clearance from the FDA for post-acute care, marking the first time that an end-to-end, real-time, passive RPM wearable and platform has received clearance from the agency. The device, an upper-arm wearable, is already used in hospitals and measures a patient’s respiration, pulse, oxygen saturation, temperature and movement. According to the company, the device delivers continuous ‘ICU-level accuracy’ with analytics to derive actionable insights to enable clinicians to monitor patients’ health and intervene earlier if the data signal an emerging problem. The wearable device,” according to Current Health, “has a 90% patient adherence rate in at-home settings, nearly double the national standard, and the company has demonstrated reduced readmissions and ED visits when used at home.”
Eating Mushrooms May Reduce Mild Cognitive Impairment
In the wake of recent clinical trial failures of Alzheimer’s disease drugs, some out-of-the-box approaches to treatments have gained some notoriety (Caregiving Policy Digest February and March). We can now add one more such approach to the mix: eating mushrooms. Publishing in the Journal of Alzheimer’s Disease, “A team from the Department of Psychological Medicine and Department of Biochemistry at the Yong Loo Lin School of Medicine at the National University of Singapore (NUS) has found that seniors who consume more than two standard portions of mushrooms weekly (defined as two-three quarters of a cup of cooked mushrooms with an average weight of around 150 grams) may have 50 per cent reduced odds of having mild cognitive impairment (MCI). The researchers believe the reason for the reduced prevalence of MCI in mushroom eaters may be down to a specific compound found in almost all varieties. ‘We’re very interested in a compound called ergothioneine (ET),’ said Dr Irwin Cheah, Senior Research Fellow at the NUS Department of Biochemistry. ‘ET is a unique antioxidant and anti-inflammatory which humans are unable to synthesize on their own. But it can be obtained from dietary sources, one of the main ones being mushrooms.’”
Rethinking Alzheimer’s Disease Treatment
While the hunt for A.D. treatments vexes researchers, the challenge it imposes, writes the New York Times’ Gina Kolata, is not confined to a single element. “Almost all patients who are given a diagnosis of Alzheimer’s disease have a mixture of brain abnormalities. For researchers trying to find treatments, these so-called mixed pathologies have become a huge scientific problem. Researchers can’t tell which of these conditions is the culprit in memory loss in a particular patient, or whether all of them together are to blame. ‘Another real possibility,’ noted Roderick A. Corriveau, who directs dementia research programs at the National Institute of Neurological Disorders and Stroke, ‘is that these abnormalities are themselves the effects of a yet-to-be-discovered cause of dementia.’ These questions strike at the very definition of Alzheimer’s disease. No one knows how to begin approaching the multitude of other potential problems found in the brains of Alzheimer’s patients. So, until recently, they were mostly ignored. What to do now? Scientists are struggling the reframe the problem. Some think research should be more focused on age. ‘We can’t avoid the fact that the number one risk factor for Alzheimer’s disease is age, and many of these other pathologies are age-associated,’ said Dr. John Morris, a professor of neurology at Washington University in St. Louis. ‘We don’t see them in younger people.’ Dr. Albert Hofman, chairman of the epidemiology department at Harvard’s T.H. Chan School of Public Health, is convinced that the precipitating factor is diminished blood flow to the brain. ‘Alzheimer’s disease is a vascular disease,’ he said. Supporting this view, he added, are data from nine studies in the United States and Western Europe consistently finding a 15 percent decline in the incidence of new Alzheimer’s cases over the past 25 years. ‘Why is that? I think the only reasonable candidate is improved vascular health,’ Dr. Hofman said. The most important factor is the decline in smoking, he believes, but people in rich countries also are more likely to better control high blood pressure and cholesterol levels.”
Diabetes Treatment Guidelines in Older Patients: New Considerations
Paula Span, in her New York Times “New Old Age” blog, focuses on another disease–diabetes—and asks whether current treatment guidelines are too strict when it comes to elderly patients. “Geriatricians often encourage older and frailer patients with diabetes to ease up on efforts to achieve very low blood sugar levels (an approach called “de-intensification”), pointing out that the balance between benefits and risks shifts with age and illness. You might think those patients would be delighted to take less medication and maybe enjoy the occasional cookie. But older people with diabetes often have long histories of striving to keep their hemoglobin A1c levels (a two- or three-month average measuring blood sugar control) below the once-standard 7 percent. The Endocrine Society, in recently unveiled updated guidelines, calls for higher glucose and A1c targets for older people with diabetes, particularly those with several other chronic illnesses and cognitive impairment, or those having difficulty handling daily activities. To be clear, no one advises ignoring high blood sugar at older ages. Diabetes can lead to grim complications, from heart attacks and strokes to blindness and amputations. It’s also associated with cognitive decline. But the Endocrine Society now suggests an A1c from 7 to 7.5 percent for the healthiest older people, depending on whether they’re taking drugs that can cause hypoglycemia. The ranges increase to 7.5 to 8 percent for those with several chronic illnesses or with early dementia and other impairments, and to 8 to 8.5 percent for those in poor health. ‘Especially in a nursing home,’ says UCSF geriatrician Dr. Sei Lee, ‘the range of joys of life gets narrower, and food is one that remains. Pushing a restrictive diet simply to lower blood glucose readings can make older people miserable without measurably improving their health.’”
Esketamine: New FDA-Approved Treatment for Major Depression
There is a new FDA-approved weapon in the anti-depression medication arsenal, but as STAT’s Amitha Kalaichandran observes , there is a related treatment protocol that may challenge existing psychiatric prescribing practices. The drug is as esketamine, a derivative of anesthetic and the “party” drug ketamine. In clinical trials, “esketamine improved depression symptoms within a few hours. It’s believed that the drug acts on what’s called the NMDA/glutamate pathway, a different mechanism than the way older SSRIs work, though the exact mechanisms of action on the neurotransmitters involved in depression are unknown. Yet in its approval of esketamine, the FDA overlooked one essential issue: while psychiatrists provide ‘talk therapy’ and others dispense medications, it’s almost unheard of for a doctor to dispense a psychiatric medication and supervise the reaction for the FDA- required period of up to two hours. In a mental healthcare system where waitlists are already weeks long, will the system adapt to allow for this additional period to supervise the immediate effect of the medication? ‘There’s a growing interest in psychedelics among the medical community since they seem to work for some hard-to-treat mental health disorders,’ according to Mark Haden, executive director of the Multidisciplinary Association for Psychedelic Studies (Canada). ‘But for psychedelics like ketamine we need supervised access because the experience [of patients on ketamine] can be challenging, unlike for other drugs used in mainstream psychiatric care, where a patient can simply self-administer at home.’ It will likely take several years before a critical mass of psychiatrists obtains the training to administer esketamine and be on board with providing it and the required two-hour supervision. Haden and his colleagues have proposed that ‘psychedelic supervisors’ be involved to help guide these experiences. In addition to psychiatrists, these could be psychologists, social workers, and nontraditional practitioners such as peyote and ayahuasca traditional healers who, with the right training, can administer the drug safely. It goes without saying, though, anyone can claim to be a ‘healer’ and the consequences of visiting underground practitioners can be devastating.”
Avoiding 911 Calls and ER Visits From Assisted-Living Facilities: ‘Doctors Making Housecalls’
Is there a doctor in the house? Usually not writes Paula Span, when it comes, that is, to assisted-living facilities. Profiling one assisted-living resident who kept falling and being taken by ambulance to a hospital emergency room, Span observes that “Such ping-ponging occurs commonly in the nation’s nearly 30,000 assisted living facilities, a catchall category that includes everything from small family-operated homes to campuses owned by national chains. It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed. But most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call. Thus, many symptoms trigger a trip to an outside doctor or, in too many cases, an ambulance ride, perhaps followed by a hospital stay. Persuading most operators to provide medical care, however, likely won’t happen without a fight. They’ve built their marketing strategies on looking and feeling different from the dreaded nursing home, and they object to ‘medicalizing’ their communities.” But, Span writes, “some new models are emerging including ‘Doctors Making Housecalls,’ a company that dispatches 120 clinicians—60 doctors, plus nurse-practitioners, physician assistants and social workers—to about 400 assisted living facilities in North Carolina. The physician services clearly helped the woman with a history of falling; her new internist discovered that her hypertension medications were causing such low blood pressure that she fainted. Reducing the dose and discontinuing a diuretic, her doctor also weaned the patient off an anti-anxiety drug she suspected was causing problems, substituting a low dose of an antidepressant instead. The falls and the related emergency room visits stopped. Doctors Making Housecalls is still caring for her, and for most of the neighbors in her assisted living facility.”
Krugman Pulls No Punches
New York Times columnist and Nobel economist Paul Krugman is certainly not known for being subtle about his caustic view of the Trump-Republican approach to healthcare policy. But his April 1 column may have hit new highs (or lows, depending on one’s political persuasion) in characterizing that approach: “There are three kinds of lies: lies, damned lies and Republican claims about health care. Public opinion here is clear: Americans want everyone to have access to health care. There isn’t even that much of a partisan divide: An overwhelming majority of Republicans don’t believe insurance companies should be allowed to deny coverage or charge more to those with pre-existing conditions. This public near-unanimity is one reason Medicare is so popular. Getting older—and thus joining a group with much higher average health costs than the rest of the population—is, after all, the ultimate pre-existing condition. But there are only two ways to cover people with pre-existing conditions, and both are anathema to conservative ideology. One is to have taxpayers pay the bills directly, which is what Medicare does. The other combines regulation and subsidies. Insurance companies must be prohibited from discriminating based on medical history—a prohibition that must include preventing them from issuing bare-bones policies that will appeal only to those in good health—but that won’t do the job by itself. Healthy people must also be induced to sign up, to provide a good risk pool, which means subsidizing premiums for those with lower incomes and, preferably although not totally necessary, imposing a penalty on those without insurance. If the second option sounds familiar, it should. It’s what countries like the Netherlands and Switzerland do; it’s also a description of, you guessed it, Obamacare.”
FCA TWEETS @CaregiverAlly
Follow Family Caregiver Alliance / National Center on Caregiving @CaregiverAlly
and Executive Director Kathleen Kelly @KKellyFCA.
Professional Studies
Graduate Studies

Editor: Alan K. Kaplan, (attorney and health policy consultant)
Contributor: Kathleen Kelly (executive director)
Layout: Francesca Pera (communications specialist)

Send your feedback and/or questions to policy_digest@caregiver.org .
Help support FCA/NCC's continuing advocacy efforts today with a
donation through Network for Good (or by check) by clicking here .
We gratefully thank you for your support!
If you shop on Amazon please consider supporting FCA through AmazonSmile. Amazon will donate to FCA based on your purchase. All you need to do is use the following link when you shop: smile.amazon.com/ch/94-2687079 .
101 Montgomery Street, | Suite 2150 | San Francisco, CA 94104
(800) 445-8106 | www.caregiver.org
Are You Receiving Connections?

FCA's Connections e-newsletter focuses on issues and information important to family caregivers. The newsletter regularly covers tips, articles, and helpful advice that can assist families with the numerous daily care tasks that caregiving for loved ones presents—including the often overlooked “caring for yourself.” While much of the content can prove helpful to caregivers nationwide, the events included are local to the six-county region of FCA’s Bay Area Caregiver Resource Center.

Stay connected with FCA/NCC on social media
All rights reserved.