Health

Top Five Things Seniors Need to Know About the Affordable Care Act

– posted by Silver Planet Staff

The Affordable Care Act – “the health care law” – gives seniors the security they need and important new benefits. Signed into law in March of 2010, it will save money for seniors and ensure people with Medicare can see the doctor they know and trust.

Here are five ways the law helps you:

  1. You get cheaper prescription drugs. If you are in the “donut hole”, you will receive a 50 percent discount when buying brand-name prescription drugs covered by Medicare Part D. The discount is applied automatically when you fill your prescription – you don’t have to do anything to get it. These changes are already saving seniors billions of dollars and, by 2020, the donut hole will be closed.
  2. You get free preventive services. Medicare now covers certain preventive services, like mammograms or colonoscopies for free. You also can get a free annual wellness visit.
  3. Your doctors are supported to better coordinate your care. Many doctors, hospitals, and other providers are taking advantage of new programs to help them work better as teams to provide you the highest quality care possible. They are working to get you the care you need at the time you need it.
  4. The law fights fraud and strengthens Medicare. The Affordable Care Act builds on our efforts to combat fraud and abuse. These efforts are saving billions of dollars in money that was being stolen from people with Medicare. The life of the Medicare Trust fund will be extended thanks to these efforts and other reforms.
  5. Your Medicare coverage is protected. Under the new health reform law, your existing Medicare-covered benefits cannot be reduced or taken away. As always, you will be able to choose your own doctors.

Original posted on HealthCare.gov

New Year Resolutions That Will Stick: “Go Fish” Twice a Week

by Elaine Magee, MPH, RD -

The American Heart Association isn’t the only one suggesting healthy people should eat fish two to three times a week. More and more research is showing that omega-3 fatty acids (among many other health benefits) seem to improve arterial health in general and they help make blood less likely to form clots that cause heart attacks. According to the American Heart Association, in a statement dated November 18, 2002, the effects of omega-3 fatty acids on heart disease risk is seen in relatively short periods of time. So, if you make eating fish your New Year’s Resolution, you can potentially start reaping the benefits fairly quickly.

Unless fish is a part of your culinary culture, this can be a hard food habit to follow through on. I try to make sure I have a lower fat tuna sandwich for lunch each week. Then I’m halfway there! I try to cook a fish dish for dinner at least once a week too—which gets me to the “eating fish two times a week” goal.

I have three tips to help you with the fish for dinner option.

  1. When you eat out in restaurants, see if there is a fish entrée on the menu that interests you.
  2. Start collecting fish recipes (hopefully lower in fat and not deep fried) that you want to try. This might help motivate you to make fish for dinner more often.
  3. Add cooked fish and shellfish to your green salads or stir fry dishes. You can buy cooked shrimp frozen (deveined and without tails) or frozen grilled fish filets and then all you need to do is thaw slightly before adding them to your dishes.

You can read Elaine Magee’s bio to learn more about her. You find more articles by Elaine in the Health Nutrition section of our library.

Research Roundup: Improving Intelligence Forecasts, Vertically Integrated Health Care, and “Worrisome” Health Care Costs

by Knowledge@Wharton - 

How can intelligence agencies improve accountability and forecasting accuracy? Can hospitals become more efficient through vertical integration with home health agencies and nursing homes? Do taxpayers fully understand how the expansion of health care will be financed? Wharton professors Philip Tetlock and Barbara MellersGuy David and Evan Rawley; and Mark Pauly, respectively, examine these issues — and what they mean for business — in recent research articles.

Helping Intelligence Agencies — and Companies — Avoid the Blame Game

When business leaders fail to make accurate forecasts, profitability is at risk. When intelligence agencies miss the mark on their predictions, however, the results can be far worse. In a new analysis of behavior in the intelligence community, with implications for business managers, Wharton management professor Philip E. Tetlockand Wharton marketing professor Barbara A. Mellers present a framework to improve accountability and forecasting accuracy, particularly in a politically polarized climate.

In their article, “Intelligent Management of Intelligence Agencies: Beyond Accountability Ping-Pong,” published in the September 2011 edition of American Psychologist, the authors note that forecasts by intelligence organizations frequently are open to harsh criticism for either underreporting potential danger or overreacting to threats that never materialize. A clear recent example of underreporting would be the September 11, 2011, terrorist attacks on the United States, Tetlock says. At the other extreme, he points to reports — which later proved to be unfounded — that Iraq had developed weapons of mass destruction.

“The intelligence community is often whipsawed between these conflicting criticisms,” says Tetlock. “The question is: Is it possible in this kind of political environment to learn anything beyond avoiding the last mistake?” The authors propose three steps to end the “blame game” in intelligence predictions and improve accountability and intelligence forecasting.

First, the authors argue that intelligence agencies and constituents in government and throughout society need to come together and agree to put an end to bitter, often ideologically driven, assignment of blame. Tetlock suggests that “thoughtful moderates” with a long-term view of policy will need to drive this part of the process, especially during periods of deep division.

Next, intelligence agencies need to step up and agree to have their forecasting assessed on clear metrics. Tetlock says that meaningful forecasts could result from reports that put a hard number on predictions. For example, analysts could be required to put specific percentage odds on the likelihood that a coup, or uprising in a given country, would occur in a certain period of time. Agencies would amass large databases of predictions that could, over time, be reviewed to assess which were accurate and why.

Finally, in the authors’ view, intelligence groups and their overseers should acknowledge that ideology plays a part in forecasting. “If you want … the left and right to hold back their fire on unfair criticism, the best way to do that is to reassure people on the left and the right that their points of view are at least being used in the prediction process,” Tetlock notes.

The authors argue that the potential benefits of improved forecasting are so large that even a modest, incremental boost in accuracy could have major benefits. According to the article, “The intelligence community does not have to lower the probability of multibillion-dollar fiascos by much to recoup a multimillion-dollar investment.”

The same framework the authors outline could be useful in the business world, where deeply polarized camps can also arise. The divisions are not along liberal or conservative lines, Tetlock says, but there are often different views in the corporate suite about how a company should approach future strategy.

“There can be tension between those who prefer an expansionary strategy and people with a more cautious strategy,” Tetlock notes. With solid metrics, predictions could be assessed for relative accuracy. “When people think their accuracy is being monitored, they are a lot less extreme and a lot more reasonable,” Tetlock points out. “It depolarizes the discussion.”

Tetlock and Mellers acknowledge in the paper that their proposals may come across as “ridiculously naïve.” However, Tetlock notes that some large companies, including Hewlett Packard and Google, have developed sophisticated metrics to assess internal forecasting. “Market pressure in the private sector is driving companies toward becoming more explicit in measuring the accuracy of their expectations about the future,” Tetlock says. “I think the world is moving in this direction — haltingly.”

Vertical Integration in Health Care: When and Why It Helps Reduce Costs

To explain the results of his research into integration and task allocation, Wharton health care management professor Guy David refers back to a 2006 article he read in Modern Healthcare, a magazine covering health care business and policy news. The article’s authors argued that hospitals that are vertically integrated with post-acute outlets — i.e., home health agencies, nursing homes, rehab clinics and other facilities where patients go to recover after surgery or serious illness — end up mismanaging them.

The authors reached this conclusion, says David, because they observed that freestanding health agencies tend to make money while the home health agencies integrated with hospitals usually lose money. “The premise in the article was that if hospitals knew how to manage those entities, they would be profitable,” notes David. “I started wondering whether integrated home health agencies serve a different purpose than freestanding ones.” He and colleagues Evan Rawley, a Wharton management professor, and Daniel Polsky, a professor at Penn Medicine, explore this subject in a new research paper titled, “Integration and Task Allocation: Evidence from Patient Care,” part of the National Bureau of Economic Research working paper series.

Their paper concludes that, rather than being a detriment to efficient operations, integration can solve coordination problems between organizations. The researchers focus specifically on timing problems in the process of transitioning patients from acute hospital care to follow-up care. “We find that vertically integrated hospitals are able to shift expensive patient recovery tasks downstream to lower-cost delivery systems by discharging patients earlier and in poorer health,” write the authors.

Moreover, they note, patients in vertically integrated hospitals do not receive substandard care. On the contrary, says David, “health outcomes are no worse when patients receive care from an integrated provider, and in some cases, integration leads to better outcomes. The evidence suggests that by improving the efficiency of the timing of patient transitions, integration solves coordination problems that would otherwise arise under pure market exchange.” The paper’s findings, he adds, “have important implications for the ongoing health care reform debate, as it pertains to both clinical and financial integration of various segments of the health care continuum.” The findings are also relevant to other industries, such as the manufacturing and distribution of personal computers.

The context underlying the research by David, Rawley and Polsky is the high cost of health care, especially the expense of hospital stays. Both hospitals and home health agencies are paid prospectively — i.e., insurers reimburse them with a lump sum for each patient, regardless of how long the patient is in the facility. “This means that the hospital has an incentive to get rid of you as soon as possible,” David says, adding that both sides in this equation would like the other to cover patient recovery to the greatest extent possible. “Hospitals gain from early patient discharge, while home health agencies gain from admitting patients later in the process,’” the authors write.

But if the hospitals and home health agencies are integrated, “they can figure out the optimal timing to shift the patient from one setting to the other,” according to David. “If firms are not integrated, they will bargain over this outcome.” This situation underlies a provision in the new health care bill that would penalize hospitals for re-admissions, because under the current system, “if you come back to the hospital after already being discharged, the hospital gets an extra reimbursement. They want to get you out quickly, but they welcome you back as well.”

Costs for health care come down once a patient is released from a hospital into a home health care facility. So from a business perspective, the question David and his colleagues analyzed was whether a hospital could move sicker patients more quickly into integrated home health care, thereby saving on expensive hospital care, and then invest some of those savings in improving the home health care recovery experience. Under those circumstances, the patient would spend the same total amount of time in the hospital/home health continuum. But because more of that time would be in the less expensive facility, the costs overall would be lower.

Going back to the article he read that sparked his interest in this topic, David suggests that its argument — integration is a bad idea because hospitals are going outside of their core business and besides, they don’t know how to manage those agencies — was not valid. “The hospitals don’t want to run the agencies, but they do want to influence whom they can send there and when. Once you think in those terms, suddenly the light bulb goes on and you understand that what they are trying to achieve is lower costs. Freeing up beds on the bigger revenue generating side — e.g. the surgical wards — by moving patients out to the lower-cost home health care side means the hospitals can increase their profits, with no downside for the patients. “This story is still consistent with home health agencies losing money, but it makes a lot of sense from a business perspective, and has nothing to do with the ability of hospitals to manage those agencies,” says David.

In their paper, the researchers state that they “focus on timing problems in market exchange that arise from the misallocation of tasks between two vertically distinct stages of production.” That misallocation “has performance implications,” they note, pointing to variations in cost structures and reimbursement rates between hospitals and post-acute care providers, which “ensure that tasks will not be efficiently assigned unless the hospital and downstream providers are vertically integrated.” Approximately one-third of nursing homes and home health agencies are vertically integrated into hospitals.

The researchers were able to track patients across organizations and observe — with a significant level of detail — the clinical procedures that patients receive in post-acute care. “The evidence shows that, on average, vertical integration leads to shorter hospital stays for six out of every 10 patients who are discharged to a skilled nursing facility or home health agency. We also find that patients received higher intensity of care from vertically integrated home health providers,” the authors write.

Basically, the researchers’ theory was that if hospitals and home health agencies are integrated, they will figure out exactly when to transition a patient between the hospital and home health. But “if they are not integrated,” David states, “they will have to bargain over this outcome, and the result won’t be efficient.”

As a contrast, David notes how the situation is different with the hospice industry, which deals with patients who are terminally ill. Hospices are paid on a per diem basis because “no one wants to incentivize them to shorten a patient’s length-of-stay, which in this case is synonymous to shortening the patient’s longevity,” says David. He points to the two biggest costs associated with hospice: first, when a new patient arrives, and second, when the patient is in his or her last hours of life. “There is a big incentive for hospices to get patients into hospice sooner rather than later because that extends the period between those two big costs. The hospice makes money each day a patient is alive.”

The hospital still has an incentive to get a patient out as soon as possible, David adds. “But the hospice, unlike the home health agency, has an incentive to bring the patient in as soon as possible. The incentives are aligned; the negotiations are efficient, and integration, which has its own costs, is not needed to achieve an efficient solution. Not surprisingly, integration between hospitals and hospices is quite rare.”

Paying for Health Care Reform

Whether health care reform survives court challenges — or the next election cycle — is a debatable question. But its uncertain future hasn’t stopped Wharton health care management professor Mark Pauly from raising questions about how the landmark legislation will be financed. He outlines his concerns in an article in the soon-to-be published book, The Economists’ Voice 2.0.

The article, “How Stable are Insurance Subsidies in Health Reform?” suggests that taxpayers do not fully understand how the expansion of health care will be financed. When they do, Pauly contends, voters may reject the entire program, including parts of the law that are popular, such as allowing adult children to be covered by a parent’s policy up to age 26.

Pauly favors the controversial national health plan, which could extend coverage to more than 20 million uninsured Americans when it takes full effect in 2014, but he says its financing mechanisms are “potentially worrisome.”

About two-thirds of the costs of subsidies to cover premiums for low-income Americans are expected to come from savings in the Medicare program for older Americans, Pauly notes. However, he adds, Medicare is already inadequately financed, especially as baby boomers begin to tap into the program. To cover predicted shortfalls in Medicare funding, Congress has already proposed cuts in the program. Now, those same cuts have been shifted to cover the health care expansion. Unless new changes to Medicare are enacted, Pauly projects that the amount of taxes paid to support Medicare as a percentage of GDP will double or triple between 2035 and 2050.

Financing for health care reform is based on reductions in private Medicare Advantage plan payments to hospitals as well as reduced payments to doctors under the so-called sustainable growth rate provision, which the Obama administration itself has asked Congress to adjust in doctors’ favor. In the original version of the article published in the electronic journal The Economists’ Voice in December 2010, Pauly suggested that one way around the financing shortfall would be “a substantial additional amount of funding [to] be raised by imposing taxes on worker compensation paid in the form of benefits.”

“It is likely that there will need to be some sort of compromise at a lower level of generosity of benefits and subsidy,” the article states. “The time to start the conversation about what really is the highest priority and highest value is now.”

The health care reform legislation “was sold on the promise that nobody would pay for it,” according to Pauly. “Politicians did what you would expect them to do — emphasized the benefits of the program and deemphasized the taxes. But the problem is that the strategy of paying for health reform out of the savings in Medicare leaves Medicare in worse shape.”

Pauly says he is concerned that when true price of reform becomes apparent to voters and taxpayers, they may balk, forcing a costly unraveling of the parts of the program already in place. “I would have preferred a more straight-forward approach,” Pauly notes.

Citing prior research, Pauly points out that even those who have medical insurance benefit when others also have coverage. Aside from ethical — what Pauly calls “clean conscience” — arguments to support expanded access to health insurance, those with health coverage might have less-than-altruistic reasons to support the program. Pauly has done research showing that increasing coverage in a health care market area improves the quality of care for all of those in the same region. “I would have hoped those would be good reasons to bite the bullet and say we’re willing to pay more taxes,” Pauly says. “Now it’s going to come as a surprise.”

December 20, 2011 in Knowledge@Wharton

Better Medicare Benefits, Better Health for Seniors

by Susan Johnson -

As of January 2011, thanks to the Affordable Care Act, the vast majority of people with Medicare are seeing important new improvements to their coverage. These improvements are helping make sure that people with Medicare get the very best care when they need it from doctors they choose. Benefits include:

  • Original Medicare will no longer have out-of-pocket costs for the “Welcome to Medicare” physical exam as of January 1, 2011 and, for the first time since the Medicare program was created in 1965, Medicare will cover an annual wellness visit with a participating doctor, also at no cost.
  • In addition to annual wellness visits, most people with Medicare will be able to receive critical preventive services, including flu shots and certain cancer screenings such as mammograms, for free.
  • The Affordable Care Act takes an additional step for Medicare beneficiaries who fall into the prescription drug coverage gap, or “donut hole,” by providing them with a 50 percent discount on covered brand name medications.
  • Every year from 2012 until 2020, the Affordable Care Act will take progressive steps to close the donut hole. Nearly four million Medicare beneficiaries have already received a $250 rebate check to help with drug costs while in the donut hole.
  • The Affordable Care Act will provide qualifying doctors and other health care professionals providing primary care to people on Medicare a 10 percent bonus. This will help ensure that those primary care providers can continue to be there for Medicare patients.

People with Medicare can learn more about the “Welcome to Medicare” physical exam, other new benefits like the annual wellness visit, search for participating doctors in their areas, and find other helpful information by contacting a trained customer service representative toll-free at 1-800-MEDICARE (1-800-633-4227) or visiting www.medicare.gov.

Guest contributor Susan Johnson, Regional Director for the U.S. Department of Health and Human Services writes about improvements to Medicare in the Affordable Care Act.

Concierge Medicine: The Doctor Is (Always) In, If You Pay Enough

Knowledge@Wharton -

For anyone who has ever waited days or weeks to see the doctor, concierge medicine sounds appealing: For an additional fee, patients typically enjoy same-day appointments and 24-hour access, more face time with the doctor and extra preventative care. Doctors who offer concierge medicine say the practice frees them from the constraints imposed by insurance providers and allows them time to give patients the individualized attention they need. Skeptics argue that concierge medicine promotes a two-tiered system, improving health care for a few but worsening it for everyone else.

“It’s an attempt to formalize two-class medicine,” says Wharton professor of health care management Mark V. Pauly. “Those who can pay will get better treatment with a smile, and those who can’t will have to wait.”

Sometimes called boutique medicine, retainer-based medicine or direct care, concierge medicine is a small but growing practice. It started in Seattle in 1996, when Howard Maron, a former team doctor for the old Seattle Supersonics professional basketball team, left his traditional practice of about 3,000 patients and launched a program called MD2, providing exclusive medical care to about 50 families for a retainer. Today, concierge doctors in the United States serve almost a million patients, according to the American Academy of Private Physicians (AAPP), a national association of physicians who provide concierge medicine and fee-for-service health care. The Academy estimates there are about 3,500 concierge doctors nationwide, up from about 2,400 just 18 months ago. It expects the number to double every 12 to 18 months for the next three years.

Concierge medicine comes in many different forms, according to Tom Blue, the Academy’s executive director. About 75% of concierge physicians hold on to their traditional practice, but take additional fees from a small number of patients who receive special perks, priority treatment and services not covered by traditional insurance. On the other end of the spectrum, doctors forgo relationships with Medicare, Medicaid and insurance carriers entirely, building their practice exclusively on patients willing to pay annual retainer fees for care. Depending upon the services, fees range from as little as $60 per year up to $30,000 per year. The majority of patients still carry health insurance to pay for specialized services that their concierge doctor is unable to provide.

For doctors, concierge medicine isn’t necessarily less work, but more satisfying work that allows them to build a more profitable practice. Unlike traditional doctors, a concierge physician builds up an income stream from patient contracts, much like the business of an insurance agent or retainer-based financial planner. That makes the practice potentially more profitable when it is finally sold. “Certainly they are much more in control of their own destiny,” Blue says. “There’s actual equity in the practice and the patients.”

For patients, the much-touted benefit of concierge medicine is that the doctor has more time and can provide them greater access. Concierge doctors “have 80% to 90% fewer patients, so they can do other things that other physicians simply can’t,” Blue adds, such as house calls, email consultations, and more extensive exams and preventative tests that insurance won’t cover.

Prevention is concierge medicine’s most important benefit, according to Randy Baggesen, a concierge physician in Richmond, Va., who says he often catches disease in early stages because his practice focuses on cutting-edge preventative care. Baggesen charges $3,300 annually for his services, which on top of routine care also include tests such as a carotid intima-media thickness (CIMT) measurement, a type of ultrasound to detect plaque in artery walls. Sometimes described as a mammogram for the heart, the test is usually not covered by insurance if a patient is deemed low-risk, so most people don’t get it. The problem, according to Baggesen, is that using current national guidelines, 88% of heart attack victims would have been deemed low to moderate risk on the day before their heart attack, 75% of all heart attack victims have normal cholesterol, and 86% would have passed a stress test. “Heart attack and stroke should be a preventable issue,” he says. “We catch subclinical vascular disease all the time.”

Concierge medicine could grow as the country’s population ages and wealthy baby boomers demand more extensive care, notes Wharton health care management professor Jonathan Kolstad. Physicians, constrained by mounting paperwork, may also find the concierge option increasingly appealing. A study published in Health Affairs in August 2011 found that the average physician in the United States spends $82,975 per year to process insurance claims, coverage and billing, and that a physician’s staff spends 20.6 hours per physician per week interacting with health plans.

“The amount of time spent coding and documenting purposes is quite staggering,” Kolstad says. The growth of concierge medicine reflects “both a demand and supply effect. As more people want this kind of access, physicians see it as a way to gain autonomy.”

“Off the Grid”

One of those physicians is Steven D. Knope, a concierge physician in Tucson, Ariz., who runs a full-retainer practice that is “completely off the grid” of third-party payers such as Medicare, Medicaid and insurers. He charges an annual fee of $6,000 per individual or $10,000 per couple for full services.

He began his practice in 2000 after spending 10 years in a traditional practice and becoming increasingly frustrated with insurance companies. “When HMOs dominate the practice, for all intents and purposes, you work for them. They set the rates; they tell you what to order,” he says. “They owned 55% of my income stream…. It just really demoralized me.”

When a few of his patients approached him and suggested he shift to concierge medicine, “I said, ‘No, this sounds elitist. It sounds unethical.’” Over time, he changed his mind. “What was unethical was managing this third party system of companies rationing care.”

Today, Knope sees 12 to 15 patients per day instead of 30 or 40, giving him time for pro-bono work with veterans and the elderly. His practice consists of about 300 patients — half of whom pay the fee, and half “who either pay nothing, or sometimes give me a chicken.” A few of his long-time patients, in their 90s or older, cannot afford the annual fee but insist on paying him $5 per visit. “There’s nothing unethical about taking care of the rich because all of us who do this take care of the poor as well,” he notes. “I have this amazing commodity called time.”

Knope believes concierge medicine holds part of the answer to the country’s growing shortage of primary care physicians. “I think the only way you can make primary care attractive is to do some sort of fee-for-service medicine,” he states. “The bottom line is, people are not going to make an investment in medical school and their training to make a terrible living at it…. It’s logical to me that we go back to our roots and we act like any other professional — like a dentist, like a lawyer [and say,] ‘These are my rates; this is what I cost.’”

Arnold “Skip” Rosoff, a Wharton professor of legal studies and business ethics, disagrees. He says the spread of concierge medicine could numb people to the problems in the country’s health care system. Patients who can afford concierge medicine and doctors who choose to offer it will naturally become less interested in finding a solution that benefits the country as a whole, he suggests. “It’s going to devolve into a two-class system of care. If we don’t address the fact that we don’t have primary care physicians and all we do is put a band-aid on it for people who have concierge medicine…. You have just shifted the problem.”

A “Gun to the Head” Model?

Concerns about concierge medicine have grown as it has spread. Some insurance companies have dropped concierge doctors, saying the model violates insurance contracts. Several states have questioned whether concierge medicine goes against their insurance laws. The Office of Inspector General of the U.S. Department of Health and Human Services has warned concierge doctors that charging Medicare patients “an ‘access fee’ or ‘administrative fee’ that simply allows them to obtain Medicare-covered services” could be considered double billing.

Pauly worries about what will happen if increasing numbers of doctors see concierge medicine as an alternative to taking Medicare patients. Medicare is in financial trouble and is reducing its payments to physicians, making Medicare patients less desirable. A survey by the American Medical Association of more than 9,000 physicians in May 2010 found that 17% were restricting the number of Medicare patients in their practice. Among the top reasons: 85% said Medicare payment rates were too low, and 78% said the ongoing threat of future payment cuts makes Medicare an unreliable payer.

“The great majority of doctors still take Medicare patients, but more are refusing to take newMedicare patients,” Pauly says. “If Medicare continues to tighten the screws on doctors … some will react by saying, ‘I’m just fed up with the whole thing.’” And if more doctors shift away from traditional practices to concierge medicine, it could exacerbate the physician shortage because there will be fewer doctors to go around, he adds. That could make it increasingly difficult for non-concierge patients to find a physician.

The hybrid model of concierge medicine may offer a solution, says Wayne Lipton, founder of Concierge Choice Physicians. The private company, based in Rockville Centre, N.Y., helps physicians incorporate both concierge and traditional medicine under a single practice. Physicians usually keep about 2,000 patients but transition 75 to 100 patients into a concierge class that pays $150 to $200 per month extra for enhanced care. That is far less drastic than shifting an entire practice of 2,000 to 3,000 patients to the full concierge model, which accommodates about 350 patients on average.

Lipton calls the full-fledged concierge practice the “gun-to-the-head” model for patients, who must choose between having to pay the concierge fee and losing their doctor. “To me, that’s inherently troubling,” says Lipton. “If we were to promote that as a solution, it becomes a have and have-not environment.”

The hybrid model, Lipton notes, “rebalances the system.” Patients have the option to try out the concierge service without having to change doctors, and physicians are able to create a new revenue stream and ease into a less hectic practice without turning patients away. Patients also have a choice to stop paying for the concierge service if they can no longer afford it or decided they don’t want it anymore. “They’re not hooked in forever,” Lipton says. “They can go back to being a regular patient.”

Wharton health care management professor Guy David is skeptical. While models that trim fees down to $100 or $200 per month may make concierge medicine affordable for the middle class (that’s less than what many people shell out every month for Starbucks coffee, he points out), it’s unclear how much better care a physician could offer concierge patients on top of a full practice. It’s simple mathematics, David says. “What can a physician who has a very full clinic do for those priority patients?” David speculates that becoming a concierge patient in a hybrid practice might be like moving to zone 2 from zone 5 on an airplane — rather than upgrading from coach to first class. “If the effect on the non-concierge patient isn’t big, the effect on the concierge patient isn’t big.”

Another possible outcome: Non-concierge patients in the practice might suffer. Sometimes when firms try to differentiate services, instead of making higher-priced service better, they simply make the lower priced services worse. David points out a classic case from 18th century France, when a train company ripped the roofs off its low-priced cars to encourage customers to buy more expensive tickets. Might concierge doctors begin to resent patients who don’t pay for the extra service and skimp on health care as a result? David wonders: “Once you have this class system in your practice, what’s going to stop [such] behavior?”

David emphasizes that concierge medicine is neither good nor bad, but a natural response to problems in the health care system. He does not consider it a solution for the country. “I don’t see concierge medicine being the new model for 300 million Americans,” he notes. Most people can’t afford to pay retainer fees on top of taxes and health insurance premiums. “When you think about something that is sustainable at the national level, it’s very clear that concierge medicine will not work,” David says, returning to his airline analogy: “You can’t have everybody sit in zone 2.”

Physical Therapy Options for Elders

When insurance stops physical therapy what are the options?

By Carol Bradley Bursack

Dear Carol: What can you do when your insurance company discontinues physical therapy because a senior patient is not making enough progress? My 66-year-old sister suffered a massive stroke and was in physical therapy for several weeks. Because she was not making enough progress in her physical therapy, her insurance company discontinued her sessions. The insurance company states that there is no point in continuing the discomfort, effort, and expense of physical therapy if it is not helping, but her husband thinks she could benefit from more.
~ Amelia

Dear Amelia: Your sister and her husband should first discuss this with the primary doctor on the case. If physical therapy is not helping, what would the doctor suggest? Could the problem be with the particular therapist’s approach? Physical therapists vary in their approaches just as other medical professionals do. If this doctor is convinced that therapy is no longer going to help, the couple may want to seek a second opinion.

It’s also a good idea to look into the insurance company’s appeal process. Usually that information is included in any correspondence from the insurance company. Sometimes an appeal can get results, especially if the doctor still thinks more therapy may be helpful.

Your sister could also see a doctor who practices integrative medicine; meaning the doctor is open to both traditional medicine, as practiced by most traditional U.S. physicians, and holistic or alternative medicine. Many physicians are becoming more open minded about alternative approaches, even if their practice is traditional. The reason for this change is the studies showing many documented cases where acupuncture, yoga poses, massage, and other approaches used for centuries in eastern cultures have helped patients. Many chiropractors also incorporate alternative therapies such as acupuncture in their practices, and some join forces with massage therapists.

Unfortunately, there are, as in nearly any profession, practitioners who will promise the world. Ask around if you are looking for alternative therapies, and make sure you look for accredited credentials and licensing. Word of mouth recommendations are good as well. You would want a practitioner who can honestly tell you if there are other therapies that may help your sister, and at what cost. Most health insurance policies do not cover many of these therapies.

What I am suggesting is that your sister should not throw up her hands and say this is as good as it gets. An insurance appeal backed by a medical doctor, or alternative treatments given by a reputable practitioner, could mean a better quality of life for your sister, as well as her husband as a caregiver. If nothing else comes of it, they will know they made the rigorous and clear eyed effort to do whatever can be done.
~ Carol

Carol Bradley Bursack is the author of a support book on caregiving and runs a website supporting caregivers at www.mindingourelders.com. She can be reached at carol@mindingourelders.com.

Perfect Recreation for an Elder, Moves the Body and the Mind

Recreation is a Way to Re-Create Fun & Activity

By Dr. Marion

Recreation is one of my favorite topics. When I used to explain it to my students, I spelled it out as re-creation. Many elderly are not active in the same way they used to be. Sometimes, they’ve let their minds and bodies atrophy. So recreation is a way to re-create fun and activity where there may be none.

If there’s a disability involved, I like to deal with whatever part of an elder’s body and mind are still functioning. What does he/she still have control over? For those who don’t have disabilities, the approach is the same. I focus on doing what I can to make the elder happy. Through recreation, I tap into his/her creative energies, intellect, and talents. We often discover new talents that have never been explored.

I’m talking about recreational activities that move the body and the mind. You have to get the thought processes flowing. Make sure the activities involve your elder in the world at large in mental, physical, and emotional ways. Your elder needs to get excited and feel good in an active, not passive way. Don’t just take your elder to a movie or prop him/her in front of the TV. Create something from scratch so they can learn something about themselves while sharing with others.

One client of mine had been a very successful and creative sewer earlier in her life. She was no longer able to do that, so we decided to make cookies. She absolutely loved tapping into her creativity in this different modality. It was a way for her to be and feel alive! When she made cookies for her doorman, the icing had a door on it. When she made cookies for an entire class of graduating kindergarteners, each cookie had a mortarboard hat on it. For her friend who was a retiring detective, she made cookies with a badge on it. This recreational activity kept her involved in her community even though she had some limitations. To me, that’s the perfect recreation for an elder.

Long Distance Caregiving

Boomer challenge: caring for aging parents living far away

By Dr. Marion

A common issue facing boomers is how to care for aging parents when they live far away from you. If your parents have reached the point where they definitely require care, I would bet you are scared, overwhelmed, frustrated, and upset all at once. It’s important to realize you are not alone and you do have options.

If possible, the first thing to do is to travel to see your parents. Determine their exact medical condition by meeting with their primary physician. Then speak directly with your parents. Ask them how they are feeling and what kind of treatment they believe they need. At no time should your elders be treated like children. Be sure you keep the communication on an adult-to-adult basis. Determine exactly what their needs are and then go about meeting them before you get back on that plane to return to your “normal life.”

If your parents require care that you, a sibling, or other friend or relative cannot provide, I suggest you hire a professional Geriatric Care Manager. In today’s hectic world, very few of us have the time, energy, or expertise to care for an elder loved one who may be in ill health. You want to do all you can, but you can’t stop living your own life. Geriatric Care Managers are trained professionals who will visit your parents, make an assessment, then write a comprehensive report that prioritizes what needs to be done. They can be your eyes and ears while you return to your life. If you cannot accompany your parents to their doctor’s visits, a Geriatric Care Manager will go in your place. They can often provide doctors with key information, especially if your parents show reluctance in answering the doctor’s questions.

It is possible that you may be unable to fly back to visit your parents and assess the situation firsthand. In my many years as a Geriatric Care Manager, I often arrive at the home of an elderly person, then walk back outside to check the address. Many children have no idea how bad things are, since their parents are not always entirely honest with them. Geriatric Care Managers can provide you with a more exact picture of what is going on with your parents in their time of need. The decision to hire a Geriatric Care Manager could make a huge difference in your elder’s quality of life – and yours.

A version of this blog appeared on Dr. Marion’s Web Site.

Dr. Marion is currently on a bus tour, crisscrossing the country to talk with seniors and caregivers. Her advice: it’s never too soon to start planning for long-term care needs and costs. You can follow the tour on Dr. Marion’s blog:

As part of the campaign, Dr. Marion and 3in4 Need More are launching a nationwide “Get Your Life Back” contest to find those struggling to care for their aging loved ones. The winner will receive an ultimate caregiver makeover valued at $50,000. To enter the contest, visit http://3in4contest.com

Calcium Tips for Senior Bone Health

by Laura MacDougall

As we age, our bones become weaker due to a loss of minerals, causing what we all know as osteoporosis. Women are more prone than men to have weak bones, especially over the age of 50. Exercise (weight bearing) and diet can help prevent bone loss as can supplements. Adults over the age of 50 need 1200 mgs of calcium a day for good health. Don’t overdo it though – more than 2500 mgs can be harmful.

We all know dairy can be a great source of calcium – milk, yogurt and cheese. But there are a lot of nondairy foods that offer a great punch of calcium too – especially important if you are lactose-intolerant. Salmon, tofu, rhubarb, sardines, dark greens, okra, beans, broccoli, peas, Brussel sprouts sesame seeds, bok choy and almonds are all great nondairy sources of calcium. There are also a lot of calcium fortified foods available, like orange juice, cereals, and breads. Read your labels to see if your favorite brand is fortified.

Vitamin D and C are very important in absorbing calcium, Vitamin D-rich foods include egg yolks, saltwater fish, liver, and fortified milk. Vitamin C helps the body absorb calcium and is available in many forms including citrus, tomatoes and berries. On the flip side, caffeine can inhibit your body’s ability to absorb calcium and should be avoided for at least 30 mins after taking calcium for maximum absorption.

Having said this – a perfect bone healthy breakfast includes vitamin D fortified milk over a healthy fortified cereal, strawberries and almonds with a glass of orange juice. Try a cheese omelette made with whole eggs and spinach with a side of vitamin D fortified toast and almond butter. Yogurt over whole grain waffles with berries and almonds instead of syrup is delicious too.

For lunch, try anchovies or sardines in a white bean salad with low fat pudding. Salmon burgers made with red peppers, scallions and topped with a yogurt dill sauce is divine. Grilled cheese sandwiches and tomato soup is a classic, healthy combo.

For dinner try spinach lasagna or a tofu stir fry with broccoli, peas, carrots and sesame seeds. Strawberry rhubarb pie a la mode for dessert, or try vanilla yogurt layered with fresh fruit and toasted almonds for creamy goodness.

Yogurt or soft tofu can work blended into your salad dressings, and as a topper for baked potatoes. Soft tofu can replace ricotta in stuffed shells, baked pasta dishes and even cheesecake. Experiment with different cheeses for more flavor and variety. Muenster, Swiss, gruyere all melt nicely. Try gorgonzola with pears, or manchego or goat cheese in a salad. Use 2% or evaporated skim milk in your favorite cream soup and sauce recipes to cut the fat but not the flavor.

Whether you are lactose intolerant or live on a dairy farm, calcium comes in many forms and flavors. Adding vitamin D and C for maximum punch and a few weights for strong bones helps ensure you will enjoy a healthier retirement. Bon Appetit!

Be a Proactive Caregiver

and methodically determine ways to help!

By Dr. Marion

Caregivers often ask me about how to be proactive when it comes to the future health needs of aging parents, or other elders in their care. If we all took care of just a few of the many issues your elders will surely face as they grow older, caregiver stress could be greatly reduced. The best thing you can do is to first understand at a baseline level exactly what issues your elders are dealing with. Lay out what I call the 4 basic categories in everyone’s life – medical, financial, emotional, and social – and methodically determine ways to help.

When it comes to medical issues, talk with your elders and be sure they are honest with you. If there are medical issues to face, speak with their doctor (with their permission of course). Figure out what medications they are taking, see if those medications can be cut back, if there are any side effects, and if any of the meds are contra-indicated. Before meeting with their doctor, be sure to do your homework and have intelligent questions ready. Write them down. Doctors will take more time if you are well informed and prepared.

Financial issues can also be tough to broach, but you have to do it. Make sure your elders have a realistic understanding of their monthly income and expenses. Their generation is living longer than any others before it, and many elderly are outliving their savings. Suggest ways to cut back expenses where possible. Something as minor as having the newspaper delivered instead of purchased at a newsstand every day can make a difference.

Emotional issues vary from family to family and individual to individual. But I have found that most elderly want to know they’ll be supported in their quest to maintain their independence for as long as possible. Communicate that to them. Let them know you are on their side and will be there when their time of need arrives. If there are any old family grudges or hurts that haven’t been resolved (and there usually are), try to bring them into the open. Your elders will want to let go of this emotional baggage before they pass on. The sooner it is dealt with, the better.

I say every generation has a 100% mortality rate. If someone’s exit from this world has been planned and lovingly guided, the process can actually be an enjoyable one. Peace comes to those whose interests have been considered, protected, and embraced. And you can really help make this happen.

A version of this article first appeared on Dr. Marion’s Web Site

Dr. Marion is currently on a bus tour, crisscrossing the country to talk with seniors and caregivers. Her advice: it’s never too soon to start planning for long-term care needs and costs. You can follow the tour on Dr. Marion’s blog @ http://drmarion.com/blog

As part of the campaign, Dr. Marion and 3in4 Need More are launching a nationwide “Get Your Life Back” contest to find those struggling to care for their aging loved ones. The winner will receive an ultimate caregiver makeover valued at $50,000. Enter the contest.

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