Senior Alerts – APRA

Which to Choose: Medicare or Medicare Advantage?

Peter Hunt — Sun, 04 Dec 2022 19:15:23 +0000

By Paula Span, The New York Times.

It’s open enrollment season again. From now through Dec. 7, about 65 million Americans are facing the annual question of which Medicare options will give them the best health coverage. An onslaught of television and radio ads, emailed promotions, texts and mailers serve as reminders, though not necessarily clarifying ones.

“It’s a very consequential decision, and the most important thing is to be informed,” said Jeannie Fuglesten Biniek, a senior policy analyst at the Kaiser Family Foundation and a co-author of a recent literature review comparing Medicare Advantage and traditional Medicare.

If you are navigating this decision for yourself or for a loved one, here are some of the important factors to consider.

Why the marketing barrage?

Medicare — the federally funded health care program — has been in place since 1965. Since then, an expanding array of Medicare Advantage plans have become available. For 2023, the typical beneficiary can choose from 43 Advantage plans, the Kaiser Family Foundation has reported.

Medicare Advantage plans, like traditional Medicare, are funded by the federal government, but they are offered though private insurance companies, which receive a set payment for each enrollee. The idea is to help control costs by allowing these insurers, who must cover the same services as traditional Medicare, to keep some of the federal payment as profit if they can provide care less expensively.

The biggest providers of Advantage plans are Humana and United Healthcare, and they and others market aggressively to persuade seniors to sign up or switch plans. A new U.S. Senate report found that some of these Advantage plan practices are deceptive; for example, some marketing firms sent Medicare beneficiaries mailers made to look like government websites or letters. This has confused many seniors, and Medicare officials have promised to increased policing.

But the marketing has paid off for insurers. The proportion of eligible Medicare beneficiaries enrolled in Medicare Advantage plans has hit 48 percent. By next year, most beneficiaries will likely be Advantage enrollees.

Which is better: Medicare or Medicare Advantage?

The two plans operate quite differently, and the health and financial consequences can be dramatic. Each has, well, advantages — and disadvantages.

Jeannie Fuglesten Biniek, a senior policy analyst at the Kaiser Family Foundation, is a co-author of a recent literature review comparing Medicare Advantage and traditional Medicare. One important finding, Dr. Biniek said: “Both Medicare Advantage and traditional Medicare beneficiaries reported that they were satisfied with their care — a large majority in both groups.”

Advantage plans offer simplicity. “It’s one-stop shopping,” she added. “You get your drug plan included, and you don’t need a separate supplemental policy,” the kind that traditional Medicare beneficiaries often buy, frequently called Medigap policies.

Medicare Advantage may appear cheaper, because many plans charge low or no monthly premiums. Unlike traditional Medicare, Advantage plans also cap out-of-pocket expenses. Next year, you’ll pay no more than $8,300 in in-network expenses, excluding drugs — or $12,450 with the kind of plan that permits you to also use out-of-network providers at higher costs.

Only about one-third of Advantage plans (called P.P.O.s, or preferred provider organizations) allow that choice, however. “Most plans operate like an H.M.O. — you can only go to contracted providers,” said David Lipschutz, the associate director of the Center for Medicare Advocacy.

Advantage enrollees may also be drawn to the plan by benefits that traditional Medicare can’t offer. “Vision, dental and hearing are the most popular,” Mr. Lipschutz said, but plans may also include gym memberships or transportation.

“We caution people to look at what the scope of the benefits actually are,” he added. “They can be limited, or not available, to everyone in the plan. Dental care might cover one cleaning and that’s it, or it may be broader.” Most Advantage enrollees who use these benefits still wind up paying most dental, vision or hearing costs out of pocket.

What are the downsides to Medicare Advantage?

One big downside is that these insurers require “prior authorization,” or approval in advance, for many procedures, drugs or facilities.

“Your doctor or the facility says that you need more care” — in a hospital or nursing home, say — “but the plan says, ‘No, five days, or a week, two weeks, is fine,’” said David Lipschutz, the associate director of the Center for Medicare Advocacy. Then you must either forgo care or pay out of pocket.

Advantage participants who are denied care can appeal, and those who do so see the denials reversed 75 percent of the time, according to a 2018 report by the Department of Health and Human Services’s Office of Inspector General. But only about 1 percent of beneficiaries or providers file appeals, “which means there’s a lot of necessary care that enrollees are going without,” Mr. Lipschutz said.

Another report this spring by the inspector general’s office determined that 13 percent of services denied by Advantage plans met Medicare coverage rules and would have been approved under traditional Medicare.

Advantage plans can also be problematic if you are traveling or spending part of each year away from home. If you live in Philadelphia but get sick on vacation in Florida, all local providers may be out of network. Check to see how the plan you’re using or considering treats such situations.

So maybe I should just go with traditional Medicare?

“The big pro is that there are no networks,” Jeannie Fuglesten Biniek, a senior policy analyst at the Kaiser Family Foundation, said of traditional Medicare. “You can see any doctor that accepts Medicare,” as most do, and use any hospital or clinic. Traditional Medicare beneficiaries also largely avoid the delays and frustrations of prior authorization.

But traditional Medicare sets no cap on out-of-pocket expenses, and its 20 percent co-pay can add up quickly for hospitalizations or expensive tests and procedures. So most beneficiaries rely on supplemental insurance to cover those costs; either they buy a Medigap policy or they have supplementary coverage through an employer or Medicaid. Medigap policies are not inexpensive; a Kaiser Family Foundation survey found that they average $150 to $200 a month.

The Kaiser literature review found that traditional Medicare beneficiaries experienced fewer cost problems than Advantage beneficiaries if they had supplementary Medigap policies — but if they didn’t, they were more likely to report problems like delaying care for cost reasons or having trouble paying medical bills.

Traditional Medicare also provides somewhat better access to high-quality hospitals and nursing homes. David Meyers, a health services researcher at Brown University, and his colleagues have been tracking differences between original Medicare and Medicare Advantage for years, using data from millions of people.

The team has found that Advantage beneficiaries are 10 percent less likely to use the highest quality hospitals, four to eight percent less likely to be admitted to the highest quality nursing homes and half as likely to use the highest-rated cancer centers for complex cancer surgeries, compared to similar patients in the same counties or ZIP codes.

In general, patients with high needs — people who were frail, limited in activities of daily living or had chronic conditions — were more apt to switch to traditional Medicare than those who were not high-need.

“When you’re healthier, you may run into fewer of the limitations of networks and prior authorization,” Dr. Meyers said. “When you have more complex needs, you come up against those more frequently.”

Another downside to traditional Medicare, though, is that it does not include drug coverage. For that, you need to buy a separate Part D plan.

What should I know about drug plans?

Unlike most Medicare Advantage plans, traditional Medicare does not include drug coverage. For that, you must buy a separate Part D plan.

For 2023, beneficiaries can typically choose between 24 stand-alone Part D plans, at premiums that range from $6 to $111 a month and average $43 for policies available nationwide, said Juliette Cubanski, the deputy director of the program on Medicare policy at the Kaiser Family Foundation.

“If you’re the person who doesn’t take many medications or only uses generics, the best strategy might be to sign up for the plan with the lowest premium,” Dr. Cubanski said. “But if you take a lot of medications, the most important thing is whether the drugs you take, especially the most expensive ones, are covered by the plan.”

Different plans cover different drugs (which can change from year to year) and place them in different pricing tiers, so how much you pay for them varies. And, to make comparisons more dizzying, certain pharmacy chains are “preferred” by certain plans, so you could pay more at CVS than at Walmart for the same drug, or vice versa.

How does Part D work? First, most stand-alone plans have a deductible: $505 in 2023. You pay that amount out of pocket before coverage kicks in.

Then, a Part D plan, either stand-alone or as part of a Medicare Advantage plan, usually establishes five tiers for drugs. The cheapest two tiers, for generic drugs, could be free or run up to about $20 per prescription. Next comes a tier for preferred brand-name drugs, probably $30 to $45 per prescription in 2023.

Drugs on the next highest tier, for nonpreferred brand-name drugs, usually involve coinsurance — paying a percentage of the drug’s list price — rather than a flat co-pay. For national stand-alone plans, that ranges from 34 to 50 percent, Dr. Cubanski said.

Drugs that cost more than $830 a month are considered specialty drugs, the highest-priced tier. You only pay 25 percent of the price, but because these are so expensive, your costs rise.

Once your total drug costs reach $4,660 (for 2023), including out of pocket costs and what your plan paid, you have entered the so-called coverage gap phase and will pay 25 percent of the cost, regardless of tier.

Finally, when your costs reach $7,400 — including what you’ve paid, plus the value of manufacturer discounts — you have hit the threshold for catastrophic coverage. After that, you pay just 5 percent.

After I pick a plan, can I switch if I don’t like it?

You can, but be careful.

Switching between Medicare Advantage plans is fairly easy. But switching from traditional Medicare to an Advantage plan can cause a major problem: You relinquish your Medigap policy, if you had one. Then, if you later grow dissatisfied and want to switch back from Advantage to traditional Medicare, you may not be able to replace that policy. Medigap insurers can deny your application or charge high prices based on factors like pre-existing conditions.

(There are some exceptions. For instance, people who drop a Medigap policy to enroll in an Advantage plan for the first time can repurchase it, or buy another Medigap policy, if they switch back to traditional Medicare within a year.)

“Many people think they can try out Medicare Advantage for a while, but it’s not a two-way street,” said David Lipschutz, the associate director of the Center for Medicare Advocacy. Except in four states that guarantee Medigap coverage at set prices — New York, Massachusetts, Connecticut and Maine — “it’s one type of insurance that can discriminate against you based on your health,” he said.

The fact is, few consumers do any real comparison shopping, or shift their coverage in either direction. Dozens of lawsuits charging Medicare Advantage insurers with fraudulently inflating their profits apparently haven’t made much difference to consumers, either.

In 2020, only 3 in 10 Medicare beneficiaries compared their current plans with others, a recent Kaiser Family Foundation survey reported. Even fewer beneficiaries changed plans, which might reflect consumer satisfaction — or the daunting task of trying to evaluate the pluses and minuses.

Where can I find help with these decisions?

You will find plenty of information on the Medicare.gov website, including the Part D plan finder, where you can input the drugs you take and see which plan gives you the best and most economical coverage. The toll-free 1-800-MEDICARE number can also assist you.

Perhaps the best resources, however, are the federally funded State Health Insurance Assistance Programs, where trained volunteers can help consumers assess both Medicare and drug plans.

These programs “are unbiased and don’t have a pecuniary interest in your decision making,” said David Lipschutz, the associate director of the Center for Medicare Advocacy. But their appointments tend to fill up quickly at this time of year, and the annual open enrollment period ends on Dec. 7. Don’t delay.

Government Watchdogs Attack Medicare Advantage for Denying Care and Overcharging

Peter Hunt — Mon, 08 Aug 2022 21:24:22 +0000

Article Summary: Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year.

By Fred Schulte, KHN.

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday.

Witnesses sharply criticized the fast-growing health plans at a hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care, particularly those with high rates of patients who were disenrolled in their last year of life while likely in poor health and in need of more services.

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors should not be “required to jump through numerous hoops” to gain access to health care.

The watchdogs also recommended imposing limits on home-based “health assessments,” arguing these visits can artificially inflate payments to plans without offering patients appropriate care. They also called for the Centers for Medicare & Medicaid Services, or CMS, to revive a foundering audit program that is more than a decade behind in recouping billions in suspected overpayments to the health plans, which are run mostly by private insurance companies.

Related to denying treatment, Erin Bliss, a Department of Health and Human Services assistant inspector general, said one Medicare Advantage plan had refused a request for a computed tomography, or CT, scan that “was medically necessary to exclude a life-threatening diagnosis (aneurysm).”

The health plan required patients to have an X-ray first to prove a CT scan was needed.

Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress, said seniors in their last year of life had dropped out of Medicare Advantage plans at twice the rate of other patients leaving the plans.

Rep. Frank Pallone Jr. (D-N.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to hear that some patients are facing “unwarranted barriers” to getting care.

Under original Medicare, patients can see any doctor they want, though they may need to buy a supplemental policy to cover gaps in coverage.

Medicare Advantage plans accept a set fee from the government for covering a person’s health care. The plans may provide extra benefits, such as dental care, and cost patients less out-of-pocket, though they limit the choice of medical providers as a trade-off.

Those trade-offs aside, Medicare Advantage is clearly proving attractive to consumers. Enrollment more than doubled over the past decade, reaching nearly 27 million people in 2021. That’s nearly half of all people on Medicare, a trend many experts predict will accelerate as legions of baby boomers retire.

James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could lower costs and improve medical care but “is not meeting this potential” despite its wide acceptance among seniors.

Notably absent from the hearing witness list was anyone from CMS, which runs the $350 billion-a-year program. The agency took a pass even though committee Republicans invited CMS Administrator Chiquita Brooks-LaSure to testify. Rep. Cathy Rodgers (R-Wash.) said she was “disappointed” CMS had punted, calling it a “missed opportunity.”

CMS did not respond to a request for comment in time for publication.

AHIP, which represents the health insurance industry, released a statement that said Medicare Advantage plans “deliver better service, access to care, and value for nearly 30 million seniors and people with disabilities and for American taxpayers.”

At Tuesday’s hearing, both Republicans and Democrats stressed a need for improvements to the program while staunchly supporting it. Still, the detail and degree of criticism were unusual.

More typically, hundreds of members of Congress argue against making cuts to Medicare Advantage and cite its growing popularity.

At the hearing, the watchdogs sharply criticized home visits, which have been controversial for years. Because Medicare Advantage pays higher rates for sicker patients, health plans can profit from making patients look sicker on paper than they are. Bliss said Medicare paid $2.6 billion in 2017 for diagnoses backed up only by the health assessments; she said 3.5 million members didn’t have any records of getting care for medical conditions diagnosed during those health assessment visits.

Although CMS chose not to appear at the hearing, officials clearly knew years ago that some health plans were abusing the payment system to boost profits yet for years ran the program as what one CMS official called an “honor system.”

CMS aimed to change things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation,” or RADV. Health plans were directed to send CMS medical records that documented the health status of each patient and return payments when they couldn’t.

The results were disastrous, showing that 35 of 37 plans picked for audit had been overpaid, sometimes by thousands of dollars per patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still has not completed audits dating as far back as 2011, through which officials had expected to recoup more than $600 million in overpayments caused by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to compel the agency to release audits from 2011, 2012, and 2013 — audits the agency contends still aren’t finished. CMS is scheduled to release the audits later this year.

Article link: https://khn.org/news/article/medicare-advantage-congress-hearing-care-overcharging/

Looking to Tackle Prescription Overload

Peter Hunt — Thu, 08 Jul 2021 22:18:33 +0000

Article Summary: Most older adults are prescribed with an overload of drugs that may not be beneficial or could lead to drug interactions affecting their quality of life. This article explores the benefits of “deprescribing”.

By Paula Span, The New York Times, Jun 07, 2021.

The last straw, for Leslie Hawkins, was her mother’s 93rd-birthday gathering in 2018.

Her mother, Mary E. Harrison, had long contended with multiple health problems, including diabetes and the nerve pain it can cause; hypertension; anxiety; and some cognitive decline. She was prone to falling.

Still, she had been a sociable, churchgoing nonagenarian until Ms. Hawkins, who cared for her in their shared home in Takoma Park, Md., began seeing disturbing changes.

“She was out of it,” recalled Ms. Hawkins, 57. “She couldn’t hold a conversation or even finish a sentence.” On her mother’s birthday, she said, “A bunch of us went to Olive Garden, and Mommy sat there asleep, slumped over in her wheelchair. I decided, nope.”

Ms. Hawkins and one of her brothers took their mother to see a geriatrician at Johns Hopkins Hospital, where she could supply only three correct answers on the 30-question test commonly used to assess dementia. “She didn’t really participate,” said the geriatrician, Dr. Stephanie Nothelle.

Fortunately, Ms. Hawkins had brought a list of the 14 medications Ms. Harrison was taking, several of which alarmed her new doctor. “I started chipping away at them,” Dr. Nothelle said.

She recommended stopping oxybutynin, prescribed to treat an overactive bladder, because “it’s notorious for precipitating delirium and causing confusion in older adults,” she said. She also suggested eliminating the pain medication Tramadol, which has similar effects and contributes to unsteadiness and falls.

At their next visit in three months, Dr. Nothelle told the family, they would discuss stopping several more drugs, including gabapentin for neuropathy; a diabetes medication that lowered Ms. Harrison’s blood sugar to unnecessary levels; and a reflux drug that nobody could remember her needing.

The follow-up visit did not happen as scheduled. Ms. Harrison fell and broke her hip, requiring surgery and six weeks in rehab.

Still, her daughter had gotten the message: Her mother’s many drugs might be harming her. “I went online and looked everything up and I started questioning her doctors,” Ms. Hawkins said.

Fourteen prescriptions? “Unfortunately, that’s pretty common” for older patients, Dr. Nothelle said. The phenomenon is called polypharmacy, sometimes defined as taking five or more medications, as two-thirds of older people do.

More broadly, polypharmacy refers to an increasing overload of drugs that may not benefit the patient or interact well with one another, and that may cause harm including falls, cognitive impairment, hospitalization and death. It has sparked interest in “deprescribing”: the practice in which doctors and patients regularly review medication regimens to prune away risky or unnecessary drugs.

For older patients, the most commonly prescribed inappropriate medicines include proton pump inhibitors like Nexium and Prilosec, benzodiazepines like Xanax and Ativan, and tricyclic antidepressants, according to an analysis of Medicare data published last year. Over-the-counter products and supplements can also prove problematic.

“We spend hundreds of millions every year to bring meds to market and figure out when to start using them, and next to nothing trying to figure out when to stop them,” said Dr. Caleb Alexander, an internist and epidemiologist at the Johns Hopkins University School of Medicine. Yet among older people, adverse drug reactions account for one in 11 hospital admissions.

Hence the Drive to Deprescribe campaign, launched last month by the Society for Post-Acute and Long-Term Care Medicine, known as AMDA, which represents medical directors and administrators of long-term care facilities, where polypharmacy is particularly prevalent.

The initiative calls for a 25 percent reduction in medication use within a year, with AMDA monitoring the results. “An ambitious goal,” said Dr. Sabine von Preyss-Friedman, co-chair of the Drive to Deprescribe work group. “But if you do a little here and a little there, you don’t move the needle.”

To date, 2,000 facilities have enrolled, along with three major consulting pharmacies that serve them. That represents a fraction of the nation’s 15,000 nursing homes, with several large chains unrepresented, but “we are still recruiting,” Dr. von Preyss-Friedman said.

Another milestone in the polypharmacy battle: the U.S. Deprescribing Research Network, established in 2019 and funded by the National Institute on Aging. So far, it has awarded nine grants to test effective deprescribing strategies.

“Stopping a medication is not just the reverse of starting one,” said Dr. Michael Steinman, a geriatrician at the University of California, San Francisco, and co-director of the network. “It’s often much harder.”

The barriers reflect a fragmented health care system, in which a patient’s endocrinologist, for example, pays scant attention to what her cardiologist or neurologist has prescribed, while her primary care doctor hesitates to overrule any of them.

Deprescribing discussions also require time, a luxury during a brief office visit with a senior who may have many competing needs.

“There’s a general bias toward doing things in medicine,” said Dr. Ariel Green, a geriatrician and researcher at Johns Hopkins. “If we prescribe something, that’s seen as a positive action. If we stop something, or don’t start it, that’s not.”

So, inertia can easily take over, with prescriptions being refilled year after year without anyone exploring why they were initially written, whether one drug duplicates another or whether the medications remain necessary or effective.

Most older adults say they are willing to reduce their medications, according to a 2018 study published in JAMA Internal Medicine — yet paradoxically, participants also said that all their medications were necessary.

Seniors may resist deprescribing, unwilling to see a drug routine they have been accustomed to for years as dangerous. “How do we talk about taking fewer medications without it looking like we’re withdrawing care, or like the person isn’t worthy of treatment?” Dr. Green said. Her own studies indicate that older patients respond well to discussions focusing on drugs’ possible side effects.

A dispiriting number of interventions aimed at deprescribing have had little impact, according to a review of 38 studies published last year. But one recent Canadian clinical trial showed significant results.

The study enlisted pharmacists, who handed or mailed patients a deprescribing brochure before refilling certain risky prescriptions. The pharmacists also contacted the prescribing doctors with forms explaining why the drugs might be harmful, providing safer alternatives and allowing doctors to change or eliminate prescriptions by simply checking a box.

Within six months, 43 percent of those using sedative-hypnotic drugs (benzodiazepines and the related “Z-drugs” like Ambien) were able to discontinue them. So were 30 percent of the patients using the older diabetes drug glyburide and 57 percent of those using nonsteroidal anti-inflammatories, or NSAIDs.

“It was spectacular,” said Dr. Cara Tannenbaum, a geriatrician at the University of Montreal and senior author of the study. Now, she added, “How do we scale it up and get it out of research projects and into everyday practice?”

One way is for patients themselves to combat polypharmacy, by regularly asking their doctors to reassess their medications — sometimes bringing every pill bottle, including supplements, to an appointment for a “brown bag review.” A short list of potentially inappropriate drugs, published by the American Geriatrics Society, can help them spot problems.

That is essentially what Leslie Hawkins did for her mother, Dr. Nothelle said. “Every time she had a health care interaction, she asked, ‘Do we need this? Can we lower this? Can we stop this?’”

Ten months passed before Ms. Harrison could see her geriatrician again, and by then, “she was a completely different person,” Dr. Nothelle said. “She was awake, she answered my questions. It was night and day.”

Ms. Harrison’s score on the 30-question cognition test jumped from three to 25. She is starting physical therapy to improve her mobility. And she is taking four drugs — insulin, a blood pressure medication and two anti-depressants — instead of 14.

Ms. Harrison, now 95, still needs considerable assistance. But at her 94th-birthday celebration in a downtown Washington, D.C., restaurant, with 20 family members including great-grandchildren, “She was the life of the party,” her daughter said. “We had a ball.”

Article link

1-In-3 Seniors Prescribed ‘Potentially Inappropriate’ Medications

Peter Hunt — Sat, 31 Oct 2020 20:58:02 +0000

By John Commins, Health Leaders Media, Oct 26, 2020.

One-in-three older Americans is prescribed inappropriate medications and that leads to increased hospitalizations and an additional $458 a year in per-patient healthcare spending, according to new research.

“Although efforts to de-prescribe have increased significantly over the last decade, potentially inappropriate medications continue to be prescribed at a high rate among older adults in the United States,” lead investigator David Jacobs, PharmD, PhD, an assistant professor of pharmacy practice in the UB School of Pharmacy and Pharmaceutical Sciences, said in a media release.

The study, published in the Journal of the American Geriatrics Society, used the 2011–2015 Medical Expenditure Panel Survey to examine the prescription of 33 potentially inappropriate medications or classes of medications to adults 65 and older.

The list of potentially inappropriate medications includes antidepressants, barbiturates, androgens, estrogens, nonsteroidal anti-inflammatory drugs, first-generation antihistamines, and antipsychotics.

Of the more than 218 million older adults surveyed, more than 34% were prescribed at least one potentially inappropriate medication, and also spent an additional $458 on healthcare, including an extra $128 on prescription drugs.

On average, those 34% of patients were prescribed twice as many drugs, were nearly twice as likely to be hospitalized or visit the emergency department, and were more likely to visit a primary care physician compared to older adults who were not prescribed potentially inappropriate medication, the study found.

“De-prescribing is currently at an early stage in the United States,” Jacobs said. “Further work is needed to implement interventions that target unnecessary and inappropriate medications in older adults.”

Read the Original Article

Common Meds Tied to Faster Mental Decline in Seniors

Peter Hunt — Fri, 23 Oct 2020 01:03:20 +0000

By Amy Norton, US News, Sep 03, 2020.

A group of widely used medications might speed up older adults’ mental decline — especially if they are at increased risk of dementia, a new study hints.

The medications in question are called anticholinergics, and they are used to treat a diverse range of conditions — from allergies, motion sickness and overactive bladder to high blood pressure, depression and Parkinson’s disease.

The drugs are known to have short-term side effects such as confusion and fuzzy memory.

But studies in recent years have turned up a more troubling connection: a heightened risk of dementia among long-term users.

The new findings, published Sept. 2 in Neurology, add another layer: Healthy older adults on these medications had an increased risk of developing mild cognitive impairment. That refers to subtler problems with memory and thinking that may progress to dementia.

And the link, researchers found, was strongest among two groups of people already at heightened risk of Alzheimer’s disease: those who carry a gene variant that raises the odds of the disease, and people with certain biological “markers” of the disease in their spinal fluid.

The results do not prove anticholinergic drugs are to blame, cautioned Heather Snyder, vice president of medical and scientific relations at the Alzheimer’s Association.

“This study shows an association in a very specific population, but it does not prove causation,” said Snyder, who was not involved in the research.

However, it is biologically plausible that the drugs could increase dementia risk, said Dr. Allison Reiss, an associate professor at NYU Long Island School of Medicine.

The medications, she said, block a chemical called acetylcholine, which transmits messages among nerve cells. Acetylcholine is involved in memory and learning, and is typically low in people with Alzheimer’s.

“The preponderance of evidence suggests it’s better to avoid these medications in older adults,” said Reiss, who is also an advisory board member at the Alzheimer’s Foundation of America.

That’s especially true, she added, when alternatives exist.

Many medications sold for allergies, colds and coughs have anticholinergic properties — and are available over-the-counter. So it’s important, Reiss said, that older adults be aware that non-prescription drugs are not automatically “safe.”

“You don’t want to add any medications that aren’t necessary,” said Reiss, who had no role in the study.

Meanwhile, certain prescription drugs for depression, high blood pressure, Parkinson’s disease and schizophrenia have anticholinergic properties, as do medications for overactive bladder and urinary incontinence.

Reiss said that people with questions about their prescriptions should talk to their doctor.

For the new study, researchers led by Lisa Delano-Wood, from the University of California, San Diego, followed 688 older adults who initially had no problems with memory or thinking skills. One-third said they’d been regularly taking anticholinergic drugs for more than six months — usually far more than one.

In fact, they were taking an average of almost five medications per person.

Over the next 10 years, people on anticholinergics were more likely to develop mild cognitive impairment, which was gauged through yearly tests. Over half — 51% — developed the condition, versus 42% of older adults not taking anticholinergics.

The researchers did consider other factors that affect dementia risk — such as people’s education levels and history of heart disease or stroke. And after adjusting for those factors, older adults on anticholinergics were still 47% more likely to develop mild impairment.

The link was even stronger among people who carried a gene variant that raises Alzheimer’s risk: Anticholinergic use more than doubled their risk of impairment. A similar pattern was seen among study participants with Alzheimer’s-linked proteins in their spinal fluid.

That, Reiss said, suggests the medications might have “accelerated a process that was already in place.”

Snyder said the results “illustrate that we need better treatments — not only for Alzheimer’s and other dementias, but for other common conditions associated with aging.”

Article link: https://www.usnews.com/news/health-news/articles/2020-09-03/common-meds-tied-to-faster-mental-decline-in-seniors

More Than 200 Doctors Stay on Medicare Rolls Despite Disciplinary Actions

Peter Hunt — Sun, 19 Apr 2020 17:26:51 +0000

By Matt Wynn, MedPage Today and John Fauber, Milwaukee Journal Sentinel May 17, 2018 | Updated Dec. 31, 2018.

Doctors who land in hot water with state regulators have a helping hand when it comes to keeping their practices running: the federal government.

At least 216 doctors remained on Medicare rolls in 2015 despite surrendering a license, having one revoked, or being excluded from state-paid health care rolls in the previous five years, a Milwaukee Journal Sentinel/MedPage Today investigation found. In all, these doctors were paid $25.8 million by taxpayers in 2015 alone.

Among them: Glen Marin, a family practice doctor from New York City.

According to New York Department of Health disciplinary records, Marin didn’t contest charges that he was sexually inappropriate with a female patient. In California, as a result, he surrendered his license in 2014 rather than go through a full disciplinary hearing.

He was allowed to keep practicing in New York, but only if he had a chaperone present when he met with female patients.

BAD MEDICINE: Prescription for secrecy

Since 2007, Marin settled at least three separate malpractice cases, including one for failing to diagnose the cancer that eventually killed a patient.

Despite that, taxpayers helped foot the bill for him to practice medicine. In 2015, the year after he surrendered his California license, he was paid more than $280,000 through Medicare.

Other individual doctors who faced serious sanctions were paid as much as $1.4 million that year.

The Journal Sentinel/MedPage Today analysis focused on 2015 because that is the last year for which payment details from the annual $720 billion Medicare program are available.

To identify these cases, reporters from the Journal Sentinel and MedPage Today worked from a list compiled by TruthMD, a Los Angeles-based company that collects information on doctors from state boards, courts and other sources. The news organizations focused on the most serious cases — those in which doctors were stripped of their ability to practice, or barred from state-run health care payments — then compared those names to Medicare payment data to gauge the total cost of looking the other way.

On its website, the U.S. Centers for Medicare and Medicaid Services, which oversees the Medicare program for the elderly and Medicaid program for disabled and low-income residents, pledges to “put patients first.”

But the Journal Sentinel/MedPage Today analysis found a repeated failure on the part of the federal government to connect obvious dots.

Medicare is part of the U.S. Department of Health and Human Services — the same department that operates the National Practitioner Data Bank, which tracks discipline against doctors, including sanctions by state medical boards. Yet connection after connection is missed.

“That’s astonishing to me that HHS allows that to happen,” said Michael Carome, a physician with the watchdog group Public Citizen. “If someone has a pattern of such adverse actions, that ought to be a red flag.”

Attempts to reach Marin were unsuccessful. His profile on the New York Department of Health website shows that he is now retired, but retains hospital credentials. The website says prospective patients can “contact the doctor’s office to see if this doctor is taking new patients.”

The Department of Health and Human Services is required to drop doctors from payment rolls if they are convicted of several specific charges, such as abusing patients, defrauding the system, or are caught improperly prescribing controlled substances.

But there are 16 categories of problems where officials can allow doctors to keep getting payments — including failing to meet basic standards of care or even having a medical license revoked. As a result, while more than 1,500 doctors had licenses suspended, revoked or were put on probation in 2015 by state medical boards, only 305 were prohibited from billing Medicare that year.

George Annas, a professor of health law and bioethics at Boston University, said Medicare officials are enabling bad doctors to continue practicing.

“The last thing you want is Medicare patients to be seeing the worst doctors in the country,” said Annas, who spent six years on the state medical board in Massachusetts. “That’s not right. They should be protecting Medicare patients. That should be their number one job.”

A day’s work, more than a day’s pay

Even when doctors are caught overbilling the Medicare program, they can continue getting money from it.

In 2012, the U.S. Attorney’s office in Colorado accused doctor Steven Spillers of violating Medicare rules by billing for more hours than he actually worked on numerous days — including cases where he billed for more than 24 hours a day.

Spillers performed a service that can be done remotely involving electronically monitoring a patient’s nervous system during surgery. Under Medicare rules in place at the time, a doctor only could bill for monitoring one patient at a time.

“But Dr. Spillers billed Medicare for monitoring multiple patients at one time — in essence, billing each minute of his time double or triple, contrary to the clear rules,” Denver-based U.S. Attorney John Walsh said in a statement issued at the time of the settlement.

On more than 100 days, Spillers billed for more than 24 hours.

As part of the settlement, Spillers was forced to repay $747,000 to the federal government. He was allowed to continue to bill Medicare but was required to have his paperwork monitored by department officials for five years.

Spillers, who has licenses in more than 20 states, received more than $240,000 in Medicare payments in 2013, 2014 and 2015 — the first three years after agreeing to repay the money.

In an interview, Spillers said he agreed to settle the case because prosecutors threatened a $13 million lawsuit and the prospect of banning him from the Medicare program.

He said the rules on billing for multiple cases at one time varied in different parts of the country, with some states allowing for multiple billing — although it is not allowed by Medicare. He also said he was paid by a private company, which handled the billing with Medicare.

“It wasn’t under my control, but the government came after me,” he said.

Todd Echols, an official in the Inspector General’s office who reviews such cases, said regulators can only act in cases where a state takes disciplinary action.

“Clearly, there’s a lot more out there that we can do,” he said.

Echols said the pace of enforcement comes down to one thing: Staffing.
His office oversees a variety of health professionals and outlets beyond doctors — nurses, dentists, therapists, clinics, adult care centers, nursing homes.

The agency has over two dozen staff, including investigators, to cover the whole country. California, which alone has more than 150,000 physicians, is overseen by one investigator.

Critics say if the office doesn’t have the resources to investigate cases, it should go to Congress and get additional funding.

“A bad doctor can harm a lot of patients,” said Carome, the physician with Public Citizen.

Comparing databases

The Journal Sentinel and MedPage Today were able to find examples by simply comparing two kinds of information the Health and Human Services department already maintains.

That turns up doctors such as Victoria Gaus, who practices in Florida.

In 2012, the Florida medical board said Gaus had prescribed inappropriate and excessive amounts of controlled substances — opioids and tranquilizers — to five patients. That same year, a $50,000 malpractice claim was submitted to the Florida Office of Insurance Regulation involving a patient who died of an overdose.

In 2013, Gaus agreed to a reprimand, a $20,000 fine, a permanent ban from practicing in a pain management clinic, and a permanent ban from prescribing certain opioid drugs as well as a type of tranquilizer known as benzodiazepines.

She did not lose her license in Florida, but Illinois refused to renew her license based on the Florida action and Pennsylvania indefinitely suspended her license.

In 2015, Medicare paid her a total of $60,000. Gaus could not be reached by phone or email and did not respond to a certified letter.

The review also turned up David Martini, who practices in Maryland.

In 2013, Maryland reprimanded Martini and fined him $5,000 after allegations that he performed back and abdominal liposuction on a woman who died as a result of the procedure. Martini is an ear, nose, and throat doctor who was not trained in plastic surgery on other parts of the body, according to a complaint filed with the Maryland Board of Physicians. The board eventually found that Martini failed to properly supervise a nurse anesthetist and that he violated the law by performing liposuction in his office, which was not an accredited facility.

Based on Maryland’s action, Martini permanently surrendered his licenses in New York and Pennsylvania in 2014.

In 2015, he received $272,000 from Medicare. Martini would not comment for this story.

The review also found Sarkis Aghazarian, a surgeon who also practices in Maryland.

In 2003, Aghazarian was reprimanded by the Maryland Board of Physicians in a case in which he allegedly failed to diagnose and treat a serious infection that led to a man’s death.

In a 2011 malpractice lawsuit, he was accused of the 2008 death of a 70-year-old Maryland man after complications arose following an angioplasty he performed.

In each case, Aghazarian paid settlements of $250,000. The doctor says he did so because it was cheaper than going to trial.

In 2012, a Maryland hospital suspended him for 90 days after complaints that included abusive language, angry and intimidating behavior, and rudeness in the operating room toward staff members and patients — in one case yelling at a woman while she was on the operating table.

In Maryland, the allegations led to a reprimand, two years probation, and a $5,000 fine. Based on Maryland’s case, California took action that led to the surrender of his license there in 2014.

In 2015, Aghazarian was paid $321,000 from Medicare.

In an interview, Aghazarian said Medicare has reviewed his record and allowed him to continue seeing those patients.

“I never mistreated any of my patients,” he said.

He said the allegations that he was abusive and disruptive in the hospital were “pure dirty politics” that came about because he complained about patient safety.

“Rather than fixing the problems, they labeled me as disruptive,” he said. “I was trying to protect patients.”

More protections in the private sector

Private insurance companies spend money to make sure they don’t pay doctors more than needed or support bad medicine, said Leslie Paige, vice president for policy and communications for Citizens Against Government Waste, a nonprofit watchdog group that lobbies for reduced government spending.

Medicare doles out far more money and isn’t even using the data the department already gathers on bad doctors, she said.

“They need to do a better job of tracking these people down and stopping them before they abscond with taxpayer dollars or hurt patients,” Paige said. “Seniors should not be sitting ducks for predators simply because they’re on Medicare.”

Consider the case of James McGuckin, who was the target of a Washington state investigation and an FDA letter into his use of a risky and unproven vein-opening procedure on people with multiple sclerosis. McGuckin was part of an earlier Journal Sentinel/MedPage Today investigation that found states often did not take immediate action against doctors who performed the procedure.

In a statement to an evaluator for an ethics course that was required as part of his Washington state discipline, McGuckin noted that several private insurers had cut ties with him.

But he has not lost his license and is still eligible for payments from the Medicare system. In 2015 alone, he was paid $8.8 million, the Journal Sentinel/MedPage Today analysis found.

According to Echols of the Inspector General’s office, workers managing Medicare payment rolls can be overwhelmed by a flood of information about shady health providers — in part because computers are now involved.

For decades, the process was driven by relationships investigators had with state medical boards. The state boards kept an eye out for cases that fit the criteria for exclusion from the federal system, then passed them along.

Last year, the Inspector General’s office started getting a data feed from the Federation of State Medical Boards. In the first year alone, the group sent more than 2,000 referrals — actions that might lead to a doctor being kicked off Medicare rolls — to investigate.

“We can’t get through 2,000,” Echols said. “There are some actions that we just don’t even have a chance to get to.”

Even if they could, though, under the law they likely wouldn’t be able to take action in the vast majority of those cases.

Some of the situations that require kicking a physician out of Medicare only come into play if the doctor’s behavior impacted a patient on Medicare or Medicaid.

Echols said documents in such cases — whether they be from state medical boards, court filings, or other sources — have to clearly indicate that a doctor’s action affected a patient in one of the two programs.

The problems must also match those in the federal law describing the exclusion process. They have to document issues with “professional competence” or “financial integrity” to result in an exclusion.

“We have seen variation across the country as to when a licensing board will take action,” Echols said. “They know if they put these actions in there, it’s going to hurt (physicians).”

Echols said his investigators pursue cases that demonstrate a doctor is dangerous or fraudulent, not merely incompetent.

Consider Lindsay Brathwaite, a dermatologist in Delaware.

According to medical board filings from Delaware and California, Brathwaite ran an office in Delaware where investigators say health care took a backseat to profit. He didn’t use diagnostic tests or sterilize instruments. His office had open bottles with needles in them and allowed for cross-contamination of blood products.

“Respondent exposed patients to the possibility of contracting hepatitis, AIDS and other blood-borne pathogens,” said a complaint filed by Kimberly Kirchemeyer, executive director of the Medical Board of California, where Brathwaite also had a license.

Two of the three states where he was licensed revoked his privileges in 2015.

That year, Medicare still paid him $100,000 to treat seniors.

He was prevented from receiving money through the program in May 2016.
“We take our time, we’re really careful,” Echols said. “We want to make sure we’re excluding physicians that deserve to be excluded.”

Still waiting

Federal regulators have not excluded Adelfo Pamatmat, a doctor who was part of an elaborate pill mill operating in the Detroit suburbs.

His office, Compassionate Doctors, purported to be a physician’s practice. In actuality, “marketers” paid people to pose as patients, who then received fraudulent prescriptions for controlled substances, mostly opioid painkillers. The drugs were then sold on the streets.

According to federal charges following his 2013 arrest, Pamatmat illegally prescribed 200,000 dosages of oxycodone and 1 million units of hydrocodone. All told, he was behind $4 million in health care fraud between 2009 and 2013.

Pamatmat was arrested in 2013 and barred from Michigan’s federally-funded Medicaid program for low-income patients. While on bond, he was ordered not to prescribe controlled substances.

Federal records show he kept right on doing so. Medicare underwrote prescriptions he gave out for tranquilizers and amphetamines after his arrest.

In 2014, taxpayers paid him $114,000; the next year, $118,000.

Last May, he was sentenced to 19 years in prison and is currently behind bars.

His name still does not appear on the list of doctors barred from Medicare payments.

John Fauber is a reporter for the Milwaukee Journal Sentinel. Matt Wynn is a reporter with MedPage Today.

This story was reported as a joint project of the Journal Sentinel and MedPage Today, which provides a clinical perspective for physicians on breaking medical news at medpagetoday.com.

Home Health Care Is Suddenly Harder To Come By For Medicare Patients

Peter Hunt — Tue, 04 Feb 2020 17:43:06 +0000

The decision came out of the blue. “Your husband isn’t going to get any better, so we can’t continue services,” an occupational therapist told Deloise “Del” Holloway in early November. “Medicare isn’t going to pay for it.”

The therapist handed Del a notice explaining why the home health agency she represented was terminating care within 48 hours. “All teaching complete,” it concluded. “No further hands on skilled care. Wife states she knows how to perform exercises.”

That came as a shock. In May 2017, at age 57, Anthony Holloway was diagnosed with ALS (amyotrophic lateral sclerosis): The Frederick, Maryland, man can’t walk, get out of bed or breathe on his own (he’s on a ventilator). He can’t use the toilet, bathe or dress himself. Therapists had been helping Anthony maintain his strength, to the extent possible, for two years.

“It’s totally inhumane to do something like this,” Del said. “I can’t verbalize how angry it makes you.”

Why the abrupt termination? SpiriTrust Lutheran, which provides senior services in Pennsylvania and Maryland, said it could not comment on the situation because of privacy laws. “In every client situation SpiriTrust Lutheran is committed to insuring the safety and well-being of the individual,” wrote Crystal Hull, vice president of communications, in an email.

But its decision comes as home health agencies across the country are grappling with a significant change as of Jan. 1 in how Medicare pays for services. (Managed-care-style Medicare Advantage plans have their own rules and are not affected.)

Agencies are responding aggressively, according to multiple interviews. They are cutting physical, occupational and speech therapy for patients. They are firing therapists. And they are suggesting that Medicare no longer covers certain services and terminating services altogether for some longtime, severely ill patients.

Altogether, about 12,000 home care agencies (most of them for-profit) provided care to 3.4 million Medicare beneficiaries in 2017, the most recent year for which data is available.

To qualify for services, a person must be homebound and in need of intermittent skilled care (less than eight hours a day) from nurses or therapists.

Previously, Medicare’s home health rates reflected the amount of therapy delivered: More visits meant higher payments. Now, therapy isn’t explicitly factored into Medicare’s reimbursement system, known as the Patient-Driven Groupings Model (PDGM).

Instead, payments are based on a patient’s underlying diagnosis, the presence of other complicating medical conditions, the extent to which the patient is impaired, whether he or she is referred for services after a hospitalization or a stay in a rehabilitation center (payments are higher for people discharged from institutions) and the timing of services (payments are higher for the first 30 days and lower thereafter).

Agencies now have a stronger financial incentive to serve patients who need short-term therapy after a stay in the hospital or a rehabilitation facility, said Kathleen Holt, associate director of the Center for Medicare Advocacy. Also attractive will be patients who need nursing care for complex conditions such as post-surgical wounds.

At the same time, there are fewer incentives to serve patients who need extensive physical, occupational and speech therapy.

The new system encourages a “holistic” assessment of patients’ needs, and there’s convincing evidence that home health agencies sometimes provided too much therapy under Medicare’s previous system, said Jason Falvey, a postdoctoral research fellow in the geriatrics division at Yale School of Medicine. Between 2000 and 2016, Medicare home health therapy services soared 112%, according to the most recent data published by the Medicare Payment Advisory Commission.

But the risk now is that too little therapy will be offered, Falvey said.

“We are very concerned about that potential,” said Kara Gainer, director of regulatory affairs for the American Physical Therapy Association.

Early reports from the field substantiate reason for concern.

Last fall, the National Association for Home Care and Hospice asked 1,500 agencies how practices would change under PDGM. One-third said “categorically, across the board, we’re going to reduce our therapy services,” said William Dombi, the association’s president.

Dombi said his group has advised agencies that these cuts “may not be a good move” medically (patients might deteriorate without therapy and end up in the emergency room or the hospital) or “from a business perspective.” (If more patients end up worse off and going to emergency rooms or are hospitalized, that will reflect poorly on agencies and may affect referrals.)

The American Occupational Therapy Association is also surveying members. Based on 526 responses to date, occupational therapists and assistants are being laid off, asked to decrease the number of visits to clients and directed to provide services for less than 30 days, said Sharmila Sandhu, vice president of regulatory affairs.

In an email, a spokesman for the Centers for Medicare & Medicaid Services said the federal agency is “monitoring the implementation of the PDGM, including therapy service provision, at the national, regional, state, and agency level.” (A similar system for skilled nursing facilities that provide rehabilitation was implemented in October.)

“We do not expect home health agencies to under-supply care or services; reduce the number of visits in response to payment; or inappropriately discharge a patient receiving Medicare home health services as these would be violations of [Medicare] conditions of participation,” the spokesman wrote.

Yet that appears to be happening.

Carrie Madigan, an occupational therapist who worked for Kindred at Home in Omaha, Nebraska, said she was laid off in November as the company — the largest U.S. home health provider — cut therapy positions nationwide. Her agency lost four occupational therapists and three physical therapists last year as it implemented layoffs and cut back on therapy visits in anticipation of PDGM, she said.

A company spokesperson wrote in an email that Kindred at Home doesn’t discuss staffing decisions. The person maintained that its “focus always has been, and will remain, on providing the right care at the right time for our patients.”

Several large agencies said they had prepared extensively for PDGM. The Visiting Nurse Service of New York has trained coaches to work with Medicare home health patients and is bringing remote monitoring equipment into people’s homes to track their progress, said Susan Northover, senior vice president of patient care services. The agency provided home health services to more than 30,000 Medicare beneficiaries in and around New York City last year.

Under PDGM, there are 432 ways of classifying patients. For each, the group is recommending “the amount of time we think a patient should be receiving care,” based on extensive analysis of historical data, Northover said. “I absolutely see no change in how we will provide therapy going forward.”

Encompass Health of Dallas serves about 45,000 home health patients in 33 states, most of them covered by Medicare. It’s using an artificial intelligence tool to predict what kind of services, and how many, patients will need. “We’ve been able to eliminate some wasted visits” and become more efficient, said Bud Langham, chief strategy and innovation officer.

Langham said he was disturbed by reports he was hearing that “agencies are taking a very draconian approach to PDGM.”

“That’s dangerous, and it’s going to lead to worse outcomes,” he said.

In Frederick, Maryland, the Holloways have struggled since SpiriTrust terminated Anthony’s services Nov. 11. Four other agencies rejected Anthony as a patient. Without help stretching his limbs and strengthening his core muscles, he’s in more pain and has four new bedsores on his backside.

“He’s developing scoliosis, and he’s slumping in his wheelchair,” Del said. “And he can’t get comfortable at night. We spend hours trying to reposition him so he’s able to sleep.”

Before his services were cut off, Anthony had been getting three hours of physical therapy, two hours of occupational therapy, one hour of speech therapy per week, plus a visit every other week from a registered nurse.

In an email, Hull of SpiriTrust wrote that “individualized plans of care are developed specific to the needs of each client” and that “PDGM did not influence any decision made specific to this particular client’s plan of care.”

Before retiring in 2016 because of ill health, Anthony was chief of police for the U.S. Bureau of Engraving and Printing. “It seems to me nobody cares about what’s happening to me,” he told me. “It makes me feel terrible — awful, less than human.”

Several times, health care providers have suggested that Anthony move to a nursing home, Del said.

“He’d have to go to a ventilator facility, and there’s only one in my area, and everyone in it was really old and drugged when I visited,” she said. “How can he live in a place like that when he can’t use his arms or hands or operate a call button?”

There is a glimmer of hope. A few days before I spoke with the couple, a fifth home care agency said it would initiate services: two hours each of physical and occupational therapy, one hour of speech therapy and one hour for a home health aide every week.

“I’m relieved, but I also feel I’m walking on eggshells,” Del said, “since they can terminate you at any time.”

The Hidden Drug Problem: Seniors Medication Overload

APRA — Mon, 30 Sep 2019 18:56:41 +0000

By Terry Fulmer, PhD, RN, FAAN, the President of The John A. Hartford Foundation. August 20, 2019.

An Interview with the Institue for Healthcare Improvement.

In a recent Health Affairs article, you and Shannon Brownlee of the Lown Institute refer to the problem of “medication overload.” What is medication overload?

Medication overload is when people use multiple medications and the harm, or potential harm, of taking those medications outweighs the benefits. While there isn’t a strict cutoff or a specific number of medications that are a problem, we know that the risk for harm increases with the number of medications a person is taking.

In our work with IHI, we focus on elements that we call the 4Ms — what matters to the older person, medication, mentation, and mobility — because they’re critical to creating Age-Friendly Health Systems. Getting medications right is essential because when your medication is wrong, your mentation can be off, your mobility can be compromised, and what matters to you will not be front and center.

Why does medication overload pose a problem for older adults?

Medication overload is problematic for older adults because normal aging leads to a decline in some vital organ functions. Lung function, kidney function, and liver function all weaken over time. This means that you clear medication less well, less quickly, and less readily. This puts an older person at greater risk [for side effects]. You may have an upset stomach or a serious problem with your gastrointestinal tract. You can have constipation or diarrhea. Acute or chronic disease can make the situation even worse.

Medication overload also puts older people at greater risk because they experience a higher proportion of cognitive impairment and osteoporosis. I’m a practicing nurse and I see how taking multiple medications can cloud a patient’s cognition. If they fall, they’re more likely to suffer a hip fracture than a younger person.

What are some keys to addressing medication overload?

There are some simple, straightforward things we can do. [Clinicians] can consider deprescribing. This means taking a thoughtful look at prescribed medications and deciding which ones are no longer needed or warranted. It’s very sensitive work because — especially if we’ve been taking a medication for a long time — many of us would worry that something bad will happen if we stop.

Another tricky situation is deprescribing for a different prescriber. Clinicians often hesitate to stop a medication that someone else prescribed. Clinicians need to talk with one another about what’s in the best interest of the older adult and be less sensitive about how their fellow clinicians might react. It’s a good practice.

When deprescribing, you’re literally taking something away from a patient. How do you address an older adult’s perception that this is a loss, especially if they’re concerned that deprescribing is to save money?

That is absolutely something that is in the minds of people these days. Clinicians need to explain carefully and sensitively about why they want to deprescribe a medication. Communication is so important. If a patient is concerned about being taken off a medication, clinicians should learn the reason for their concern.

Sometimes older adults share medications, for example. They might initially tell me that they’re taking their medications as prescribed, but they may be embarrassed to say that they’re sharing medications with a sibling or a neighbor. Unless we build a trusting relationship and unless I ask, I won’t necessarily know what’s going on.

You’ve said that medication overload is largely invisible in this country. What are other countries doing to address the problem?

Canada and Australia have established deprescribing networks. This means researchers, clinicians, pharmacists, and patient advocates come together to share information and develop strategies. We can learn a lot from them. In the European Union (EU), they have a health program they call the SIMPATHY (Stimulate Innovation in the Management of Polypharmacy and Adherence in The elderly) project. It conducts systematic reviews of EU polypharmacy policies.

Drugs Causing Hearing Loss and Tinnitus

APRA — Sat, 28 Sep 2019 14:10:57 +0000

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Millions Of Diabetes Patients Are Missing Out On Medicare’s Nutrition Help

APRA — Fri, 20 Sep 2019 14:52:01 +0000

By Phil Galewitz, Kaiser Health News, Sep 09, 2019.

Louis Rocco has lived with diabetes for decades but, until he met with a registered dietitian in August, he didn’t know eating too much bread was dangerous for him.

“I’m Italian, and I always eat a lot of bread,” he said. After two hour-long visits with a dietitian — including a session at his local grocery store in Philadelphia — Rocco, 90, has noticed a difference in his health.

“It’s helped bring down my sugar readings,” he said of changes in his diet including eating less bread. “I wish I knew I could have had this help years ago.”

After getting a referral this summer from his doctor, Rocco learned that Medicare covers personal nutritional counseling for people with diabetes or kidney disease.

The estimated 15 million Medicare enrollees with diabetes or chronic kidney disease are eligible for the benefit, but the federal health insurance program for people 65 and older and some people with disabilities paid for only about 100,000 recipients to get the counseling in 2017, the latest year billing data is available. The data does not include the 20 million enrollees in private Medicare Advantage plans.

Health experts say the little-used benefit represents a lost opportunity for beneficiaries to improve their health — and for the program to save money by preventing costly complications from the diseases.

An estimated 1 in 4 people 65 and older have diabetes and 1 in 3 have chronic kidney disease. Kidney disease is often a complication of diabetes.

The prevalence of diabetes has risen markedly in the past 20 years and the condition is more common as people age.

Nationwide, there are 100,000 registered dietitians — more than enough to meet demand, said Krista Yoder Latortue, executive director of Family Food in Philadelphia, which employs about 50 dietitians including the one who visited Rocco. Medicare data showed about 3,500 dietitians billed the program for nutritional counseling in 2017.

The problem may be that not enough physicians know about the Medicare benefit. Doctors have to refer patients to a dietitian.

Congress approved the benefit, which began in 2002, after studies found medical nutrition counseling leads to improved health outcomes and fewer complications for older patients. Under the preventive health provisions of the Affordable Care Act, the counseling has been available without out-of-pocket costs to Medicare beneficiaries since 2011.

Medicare pays for three hours of dietary counseling during the first year the benefit is used and two hours in subsequent years. A doctor can appeal to Medicare for additional nutritional therapy if the physician believes it is medically necessary.

Larry Lipman, 70, of Falls Church, Va., said he was shocked to learn he had diabetes earlier this year because he’s relatively thin and is an avid cyclist. When his doctor recommended meeting with a dietitian, he not only said yes but also brought along his wife, who does most of the cooking. “It was great because I could ask specific questions and get into the nitty-gritty about how I eat, what I eat and when I eat,” said Lipman, a retired journalist.

“I’ve learned I needed to cut down on portion sizes of rice and other things to keep my carbohydrates down,” he said. “I’m thinking more about what I eat every time and staying away from Doritos and ice cream.”

Doctors shoulder some of the blame for patients not getting dietary counseling by failing to refer them to dietitians. “It’s a lot easier to prescribe a medication than it is to discuss the importance of nutrition and get patients to meet with a registered dietitian,” said Dr. Holly Kramer, a Chicago nephrologist and president of the National Kidney Foundation.

“I don’t understand how we have this burgeoning obesity and diabetes epidemic and we are not using dietitians in our clinics for all these patients, yet we are paying for all these things that mediate from the disease process such as arthritis, dialysis and amputations,” she said.

Jennifer Weis, a registered dietitian in Philadelphia, said the limited hours Medicare covers is frustrating given how difficult it is to change behaviors in older adults. “It’s better than nothing, but in my mind is not sufficient,” she said.

Doctors might not be aware of the Medicare option since “it’s a challenge to keep up with what is a covered benefit and what is not,” said Dr. Michael Munger, chairman of the American Academy of Family Physicians who practices in Overland Park, Kan. He said that many doctors who don’t practice with a large health system may not be familiar with dietitians in their community.

For convenience, Munger said, he refers his diabetes patients to a nurse practitioner in his office for nutritional counseling. But only registered dietitians are covered under the Medicare benefit, so his Medicare patients face a copayment for that service.

Nutritional counseling is not the only underused Medicare benefit that can prevent health complications.

Fewer than 5% of Medicare beneficiaries use their 10 to 12 hours of diabetes self-management training benefit, which can cover individual and group sessions providing tips for eating healthily, being active, monitoring blood sugar, taking drugs and reducing risks.

Part of the problem, said Yoder Latortue in Philadelphia, is there is a lot of misinformation about whom the public can trust on nutrition advice. “Everyone eats and everyone has an opinion,” Yoder Latortue said.

Lauri Wright, a Jacksonville, Fla., registered dietitian and spokeswoman for the Academy of Nutrition and Dietetics, said the federal Centers for Medicare & Medicaid Services sends out notices to health providers once a year but more information is needed.

About 10,600 registered dietitians have enrolled to treat Medicare patients, a CMS spokeswoman said. She said the agency has been advising health providers about the benefit and promoting it to enrollees on its website and its annual handbook that it sends to beneficiaries.

Still, “I think because only two diseases are covered by Medicare and the rest aren’t, it falls off everybody’s radar,” Wright said.