Dr. Bill Thomas
ChangingAging.org is a platform to attack conventional attitudes towards aging in our society and to provide positive, growth-oriented alternatives for a life worth living.
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I am always looking for new ways to communicate the ideas that are important to me. Here is the latest:
Imagine a paraplegic person–spinal cord injury, permanently paralyzed from the waist down. He rolls his wheelchair up to a building with an entrance stairway. Thanks to the Disability Act, he can now access most buildings with the help of a ramp. He doesn’t have to disengage from society because of his disability.
Here’s my question: Where is the “ramp” for people with dementia??
Next imagine that when the man gets to the stairs, his care partners push him out of the wheelchair and expect him to walk up the steps, like they do. He falls, of course. Now imagine that when he gets upset because he can no longer walk as they want him to, they respond by giving him psychiatric medications for his distress.
Dementia is a shift in the way a person perceives and interacts with the world. Medicating those who get upset when we try to make them conform to our world view is futile. We need to create “ramps” to enable them to function, by transforming the care environment around their needs, not ours.
The executives of a healthcare organization with over 1200 employees have renegotiated the health insurance plan terms and costs for the new fiscal year. There are several plans offered by this employer, one plan (HMO) has by far the lowest monthly premiums and is the plan that over 95% of the employees opt for. The employer contributes significantly to the cost of the premiums, making it very affordable: A single person pays a monthly premium of only $35, a full family pays $103 monthly. In comparison, the monthly premiums of this popular HMO plan are roughly one-half of the next plan offered (POS) and only one-tenth of the most expensive plan offered (PPO).
In an effort to keep the total cost of the premiums of the popular HMO plan (and the employee’s share of the premium as well) to a minimum, all deductibles and co-pays have increased as would be expected. For instance, co-pays to the Primary Care Physicians are now $15 and Specialists $20, an increase of $5 each. Emergency Room co-payments, however, have increased from $35 to $100. Undoubtedly, this is an effort to decrease inappropriate utilization of the ER as a “clinic.” Furthermore, under the prior plan, the $35 ER co-pay would be waived or refunded if the ER visit resulted in a hospital admission. This has now changed with the new policy; the person pays $100 whether or not they are admitted to the hospital.
The majority of employees in this organization are CNAs, aides, housekeepers, etc. who make far less than $30,000 and many of whom are single parents struggling to make ends meet. The higher ER co-payment may very well cut down on “inappropriate use” but will it have any negative unintended outcomes?
Anonymous
In a community pilot program, elders receive home repair, transportation,
referral and social work services. Most participants consent to
participate in extensive surveys aimed at measuring program outcomes.
Survey participants are assured that funders and evaluators do not receive
personally identifiable information. Halfway through the trial period,
the funders email to ask that the program staff select and obtain the
consent of a participant for a home visit by 4-6 funder staff members.
The program staff diverge in their opinion of this practice. The program
coordinator believes that not allowing this could impact future funding,
and that this gives a participant a positive avenue for expressing
appreciation. The service coordinator sees this as an impingement on the
participant's privacy, that participants may not feel comfortable with
declining a visit (quid pro quo), and that many of the repairs are too
personal (raised commodes, cleaned-out basements, etc.). He also
expresses concern that funders might be inclined to ask about the social
work services. Another staff member thinks that this could damage the
program's relationship with participants if they feel the request violates
what participants initially agreed to.
How should the program respond to the funder's request?
~Christy B.
Claudia is a 78 year-old woman in the late stages of Alzheimer’s disease. She resides in an Assisted Living Memory Support unit on a Catholic CCRC campus and her healthy 80-year old husband resides in the Independent Living apartments, a short distance away on the same campus. Claudia has severe cognitive impairment and no longer recognizes her husband most of the time.
There is a new gentleman, Ed, living on Claudia’s Memory Support unit that is also in the late stages of Alzheimer’s. He and Claudia have become friendly and can often be seen walking the hallways together hand-in-hand and usually seek each other out during activities and meals. This, of course, is quite perplexing for Claudia’s husband as well as their two adult daughters who visit at least twice weekly. Claudia’s husband sees her daily but he is quite active with his Independent Living neighbors and often goes out golfing, has lunch and plays cards with his social network of friends.
The staff on Claudia’s unit accepts the innocent “friendly relationship” that she and Ed have had for the past few months. Lately, however, there seems to be a more intimate relationship developing and they are shocked and embarrassed when they find Claudia and Ed in his bed one night both undressed and fondling each other. They calmly but firmly attempt to redirect them, telling Claudia she must leave Ed’s room and go back to hers. The next morning, the administrator has the unpleasant task of informing Claudia’s husband of the incident. He feels hurt and embarrassed and shares the information with his daughters who are extremely upset that the staff allowed this to happen. They know that their “real” mother would be absolutely appalled by her own behavior and demand that it can never happen again. Besides, this is extremely embarrassing for their father as everyone at the community knows him. The staff is unsure how to prevent such a situation from occurring again and the fact that it is a Catholic community compounds the issue.
Anonymous
Three elder stories from the past week:
1) At Enoteca Maria on Staten Island, NY, Italian grandmas are put to work sharing their culinary skills. The restaurant hires a rotating group of elder ladies to cook their evening meals, for a truly authentic Italian dinner. Talk about spontaneity–each featured “chef” chooses her own ingredients and cooks whatever she feels like making that day – just like at home! 2) Lori Lorraine, our Volunteer Manager, told me this story:
“Yesterday at church we had 3 recognitions; first two babies were baptized, the second was recognition of our high school graduates and the third was of elders. We’ve never recognized elders before. Our pastors asked one woman who has been a member for 45 years to reflect on the church family. She had written a paragraph which they read. Then anyone who would admit to being an elder received a hand-painted rock from our pastor Margaret Scott. She ran out of rocks and had to make promises to deliver them at a later date.
I thought it was neat.”
3) We had a photo shoot to promote our future Green Houses, but since we haven’t built any yet, we took 5 elders to the home of our CFO, John Toscano, to use his living room, dining room, kitchen and garden. Some of the elders had a fair degree of dementia, but were able to attend to the instructions.
John’s wife Carol and the other staff were amazed at what happened to the elders during 5 hours of preparing food, helping in a garden, sitting and sharing a meal in a home together. It was like they discovered long-repressed energy and joy. Context and engagement are truly powerful, and this is a great example of why we need to continue this journey of aging in community.
I am a big fan of unobtrusive “invisible” technology that can actually improve people’s lives.
 The stealth bomber is the soul of "unobtrusiveness" (at least until the bombs start to fall) but it is also very "bad for children and other living things," as Dr. Spock used to say. The standard of excellence in this area is, oddly, the degree to which the technology goes unnoticed by the people who are using it.
 This sweater seems peaceful enough, now imagine that it had one millionith of the technology that the bomber has. I see that a group of UK scientists are on the right track.
Housecoats and electronics are set to meet in a research project led by Northern Ireland academics.
University of Ulster researchers are examining how hi-tech clothing could improve the lives of older people.
The three-year project could see electronic devices built in to clothing that could provide information ranging from heart rate to bus timetables.
The research, funded by the New Dynamics of Ageing Programme, is driven by teams from several UK universities.
The University of Ulster’s Computer Science Research Institute has been doing work on assistive technologies for independent living and healthcare monitoring.
Its director, Professor Bryan Scotney, said they would be looking at sensor technologies.
“This project is particularly exciting as we will be working with partners with complementary expertise that will enable our research in sensor technologies, data fusion and intelligent data analysis to have a real impact on people’s everyday lives,” he said.
Read the whole article here
Medicare is the best model for how a public option can and should work inside a healthcare reform package.
This blog post has an excellent rundown of the fundamental conflicts…
Currently, our health care system has high-cost and low-cost areas; the high-cost areas have no better outcomes than the low-cost areas. So theoretically we can solve our health care cost problem by making the high-cost areas behave like the low-cost areas.
However, the market incentives go in the other direction; the economically rational thing for providers (doctors, hospitals, etc.) to do is to run up procedures and thereby costs. It would be better if providers focused more on patient outcomes or organized themselves into accountable care organizations, as Gawande prefers; but there is no economic reason for them to do so. People are not magically going to become more altruistic overnight. Even shame has only a temporary effect on behavior.
[snip]
What is the lesson of McAllen, Texas, the focus of Atul Gawande’s celebrated article (discussed here and here)? This is my attempt at an answer:
Currently, our health care system has high-cost and low-cost areas; the high-cost areas have no better outcomes than the low-cost areas. So theoretically we can solve our health care cost problem by making the high-cost areas behave like the low-cost areas.
However, the market incentives go in the other direction; the economically rational thing for providers (doctors, hospitals, etc.) to do is to run up procedures and thereby costs. It would be better if providers focused more on patient outcomes or organized themselves into accountable care organizations, as Gawande prefers; but there is no economic reason for them to do so. People are not magically going to become more altruistic overnight. Even shame has only a temporary effect on behavior. Here’s Gail Wilensky from a Health Affairs roundtable:
It’s only by being able to offer compelling evidence that it’s the physician that is the outlier relative to his or her peers, that the patients really aren’t different, and in fact they are not having better outcomes, that you are able to pull back physician behavior — although there seems to be a high recidivism rate.
(Emphasis added.)
[snip]Remember all the people who said that you can’t blame mortgage brokers and investment bankers for being greedy, because that’s how a capitalist economy works? Well, you could make the same defense for the McAllen doctors. We long ago stopped expecting lawyers and accountants to behave contrary to their economic interests; now we simply expect them to conform to the law and to certain professional codes of conduct, and otherwise make as much money as possible. Why should we expect anything different from doctors?
In a capitalist economy, the thing that is supposed to keep prices in check is the buyers. If someone offers me a product that costs more than it is worth to me, then I won’t buy it. But we can’t count on patients to play this role in health care, because there is no way to make patients internalize all of the costs of their care; they simply don’t have the money. Furthermore, most people don’t understand the health production function (the relationship between treatments and outcomes), so they don’t have the ability to select treatments that provide benefits that are worth their costs.
The only payer with any real negotiating power is Medicare. The private payers have little ability to control costs. Or, if they have the ability, they aren’t exercising it.
In short, prices will only go up. As a result, the cost of health insurance goes up, and the market finally kicks in in the crudest possible form: people who can’t afford it become uninsured. At some point, if we have enough uninsured people, the health care industry will hit a point where it cannot increase revenues anymore, because it has fewer and fewer paying customers.
The proposed public health insurance plan would have the power to negotiate lower rates with providers. That’s why some providers don’t like it. That’s also why private payers don’t like it; they would be at a cost disadvantage to the public plan. (They can live with Medicare because Medicare leaves them the entire under-65 market.) Maybe that’s unfair. But the current situation isn’t working.
The past may not repeat itself but it sure does rhyme.
This clever blog is a news summary from the corresponding day in 1930.
For example,
J. Westerfield of the NY Stock Exchange lectures civics clubs of Yonkers on the causes of the current business recession. Says the effort to attribute it to any single cause is superficial; criticizes sanguine statements of “new era” economists that “the vast amount of reliable statistical information had practically abolished the old-time evils of large inventories and overproduction.” Concludes that an illusion grew popular that “paper profits in … quoted values for real estate, commodities, securities, and other forms of property increased fortunes and thereby spending power.”
Senator Glass is heading a subcommittee considering extensive changes to banking regulations. Among the changes considered are restricting speculative loans by banks to brokers and stock exchange members, removing the Secretary of the Treasury as a member of the Federal Reserve Board because of undue influence, making it easier for banks to expand nationwide, etc. Anticipated the committee will have meetings all of next year’s session and submit recommendations December 1931.
Congressman Fiorello La Guardia (Republican, NY) objects strongly to revisions of the Wagner bill to relieve unemployment by planned public works. Urges passage of the bill in its original form and the establishment of a national employment agency.
Navy Department asks for bids for construction of aircraft carrier number 4, a 13,800 ton ship. Total cost not to exceed $19M; $4.05M appropriated to start construction.
The new Price Brothers skyscraper, tallest building in Quebec, now in full use – all 17 floors occupied.
French scientist to test device for converting warmth of Gulf Stream into electricity.
Census indicates New York City contains “300,000 unemployed and 100,000 drifters.”
New York State had 156 dead from industrial accidents in May, down from a 5-year average of 169.
It’s worth a look…
Aging in Community: Caring from a Distance
A few weeks ago, I got “THE CALL.” The call will likely come to each of you one day, most likely out of the clear blue when you least expect it, although you may have seen the handwriting on the wall that it would be coming.
I saw the warning signs spray-painted in day-glow colors – but it did not stop the first fall that my stepmother Lucile took; nor the second fall she had a day later that took my father tumbling down with her. Lucile, 86 years old, ended up in the hospital for a week and is now in a skilled nursing facility trying to regain enough strength and mobility to come back home. Dad ended up with 2 cracked ribs, and while he can recuperate at home, has limited mobility – which for an active person, is its own internment.
Both Lucile and dad are equally helpless, bored and lonely. Should Lucile not be able to come home, it will get worse for both of them. For the first time, I have not been able to be physically there for a family crisis. My sister Alice went for the first two weeks, but now they are each on their own. We call daily to support them the best we can from a distance, but there are few visitors; there is no aging in community infrastructure to support them in Tampa.
I am brewing a plan, one that will require me to invite in family, neighbors, friends, acquaintances, even strangers. Can one build an environment for aging in community from a distance? Stay tuned… we shall see!
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