Drug Coverage Denied by Medicare and Fighting Back

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Man ConcernedKenneth Buss had taken a blood thinner, for over a year when his mail-order pharmacy refused a request to refill his prescription. He immediately contacted his physician who urged his Medicare plan insurer to approve the medication. 

The request was denied. But Buss, 79, did not let the matter drop. Without coverage, a 90-day supply of Xarelto costs about $1,300 at a local pharmacy — more than 10 times what Buss had been paying.

“That killed me,” said Buss, who remembers phoning his Medicare plan and saying, “Excuse me, are you saying my doctor is wrong and you know better?”

With his physician’s help, this determined Arizona resident persuaded his plan to renew his prescription. But many similarly frustrated older adults are not sure how to appeal Medicare drug plan denials.

“A lot of cases fall through the cracks,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. “People simply do not know exactly how to proceed or they try to go through the process; but it’s complicated, time-consuming and people just give up.”

Concerns about Medicare drug coverage are common: More seniors call the Medicare Rights Center’s national hotline (800-333-4114) about this topic each year than any other Medicare organization.

Here is some essential information about the appeals process:

The Basics

Nearly 41 million Medicare beneficiaries receive drug coverage through stand-alone drug plans or privately run Medicare Advantage plans — Kenneth’s type of coverage.

Some rules apply across the board. Notably, plans must cover substantially all drugs in six categories: HIV/AIDS treatments, antidepressants, antipsychotic medications, anti-convulsive treatments for seizures, immunosuppressive medications and treatments for cancer. In other categories, at least two medications from each class must be offered.

Plans are not allowed to cover such drugs as those for weight loss, coughs and colds, fertility, cosmetic purposes, sexual difficulties and non-prescription medications, among others.

Beyond these generalities, Medicare drug plans have considerable flexibility in choosing which drugs to cover (their formularies), capping the amount filled per prescription (quantity limits), requiring preapproval before a medication is supplied (prior authorization), asking people to try other lower-cost treatments first (step therapy) and assigning medications to different classes with different costs attached (cost-sharing tiers).

A failure to meet any of these requirements may result in a denial. In Buss’ case, his plan requires annual prior authorization of Xarelto. Although his doctor submitted the proper request, as he did in 2016, this time the plan deemed his rationale for prescribing the medication as insufficient.

Persistent Problems

The latest government audit of Medicare’s drug program confirms that plans often impose limits on drug coverage without advance approval from the Centers for Medicare & Medicaid Services (CMS), as required.

Notably, 64 percent of plans applied quantity limits that had not been approved by CMS, while 41 percent improperly dealt with requests for prior authorization or exceptions to plan requirements.

Also, insurance plan representatives were deficient in communicating with members and providers: 70 percent of denial notices did not offer adequate explanations for the actions taken, were incorrect or were written in a manner that was difficult for most people to understand.

About 45 percent of the insurance plans did not reach out to Medicare members or physicians to acquire the necessary additional information to make a coverage decision.

The takeaway for seniors: You must take the initiative in supplying relevant materials. Your chances are best if your physician clearly and comprehensively states, in writing, why you must take a particular medication and the likely harm of not doing so while referring to your particular medical circumstances.

Appeals Process

Seniors tend to think that when they are unable to get a medication at a pharmacy, they have grounds to appeal. But that is not true.

Another step awaits: An individual needs to request a formal “coverage determination” from the Medicare drug plan before the appeals process can start. Included should be an “exceptions request” asking that a plan’s rules be waived so a senior can obtain a medication or pay less for a drug.

Once a coverage determination is issued, there are five steps to the appeals process: a “redetermination” by the drug plan; a “reconsideration” by an independent review entity (MAXIMUS Federal Services serves this purpose across the U.S.); a hearing before an administrative law judge; a review by the Medicare Appeals Council; and a review by a federal district court.

Breakdowns in the process can occur right at the start: Individuals are supposed to get a notice from the pharmacy informing them of their right to appeal when a prescription cannot be filled, but much of the time this does not happen, said Casey Schwarz, senior counsel at the Medicare Rights Center.

Appeals can be processed on an expedited, fast-track timetable or at the standard, slower pace. But even expedited appeals can drag on, as plans and other entities miss decision-making deadlines.

Tips For Seniors

Older adults can become discouraged as they go through the early steps of this process, but “we encourage them not to give up — people are often successful at higher levels of appeal,” Schwarz said.

In 2015, the latest year for which data are available, independent reviewer MAXIMUS reversed drug plan decisions 30 percent of the time. That year, appeals to MAXIMUS climbed 47 percent over 2014 levels.

Some other tips from advocates: Keep careful records of every person you have spoken with and what they told you. Work closely with your physician’s office. Keep a record of any out-of-pocket drug expenses; these can be recovered later if your appeal is successful. Be persistent.

For help, call the Medicare Rights Center national hotline (800-333-4114).

“The complexity is awful, but hang in there if you can,” said Buss, who hopes he will not face similar difficulties when it’s time to renew his Xarelto prescription next year.

 

 

Caregiver ‘Boot Camp” for Dementia Patients

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Boot camp alzheimer caregiversGary Carmona thought he could do it all. He has headed companies and chaired nonprofit boards. But since his wife was diagnosed with dementia, Gary, 77, has felt exceedingly overwhelmed. 

 

 

“I really see myself crashing at times,” he said. “In my mind, I’m saying, ‘You know, I can’t really handle all this.’”

There was the time his wife, Rochelle, wandered outside and fell down. And the time she boiled water and walked away, leaving the burner on.

“I’m always double-, triple-, quadruple-checking everything that she’s around,” he said.

Carmona was among about 25 people who went to a Los Angeles-area adult day care center on a recent Saturday for a daylong “caregiver boot camp.” In the free session, funded in part by the Archstone Foundation, people caring for patients with Alzheimer’s or another form of dementia learned how to manage stress, make their homes safe and handle difficult patient behaviors. They also learned how to keep their loved ones engaged, with card games, crossword puzzles or music.

Doctors and researchers increasingly recognize that caring for people with dementia compromises the physical and mental health of the caregivers. And that, in turn, jeopardizes the well-being of the people in their care. Some studies have shown that the burden on caregivers may increase the likelihood that the loved ones in their charge will be placed in a nursing home.

“People with Alzheimer’s who have stressed caregivers have been shown to have poor outcomes,” said Zaldy Tan, the medical director of the UCLA Alzheimer’s and Dementia Care Program who created the boot camp. “Their caregivers have essentially thrown in the towel.”

People with dementia are also more likely to visit the emergency room and be hospitalized if their caregivers are not prepared for the task, Tan said.

That’s one of the main reasons why UCLA Health and its geriatrics division started its caregiver boot camps in 2015.

UCLA holds four boot camps a year at community and senior centers in Southern California and hopes to expand over the next year to meet the growing need. About 5 million Americans, 1 in 10 people over 65, have Alzheimer’s disease — a number that could balloon to 16 million by 2050, according to the Alzheimer’s Association.

Similar caregiver training programs have taken place in New Jersey, Florida and Virginia.

Tan started the recent session by explaining the progression of dementia, noting that in its later stages people often do not remember their loved ones.

“Do they all reach that stage?” asked one woman, who takes care of her sister.

“They do, if they live long enough,” Tan said. “I know it’s heartbreaking.”

He also warned the group that their actions can inadvertently provoke anxiety or aggression in their loved ones.

“Many times, when you see someone shift from being calm to agitated, happy to angry, typically there’s a trigger,” Tan said. “A trigger is just like a trigger on a gun. Something is pushed and you get a reaction.” He told them that as caregivers they were in the best position to identify and avoid those triggers.

Leon Waxman, who also attended the boot camp, said he tries not to upset his wife, Phyllis. But sometimes she gets angry, as she did the day he dropped her off for day care while he attended the session for caregivers.

Taking care of Phyllis the past few years has been trying, he said. She can still dress herself, but she gets easily confused and can no longer make decisions.

“The hardest part for me is I don’t have my wife anymore,” said Waxman, who has been married to Phyllis for 58 years. “She’s not the same person she was 10 years ago.”

During the boot camp, recreational therapist Peggy Anderson demonstrated a game caregivers could play at home: music bingo. Each square had the name of a song, and she played music.

“What’s this song?” Anderson asked the group.

“Bye blackbird,” one yelled out.

“If you have that one, mark it off,” she said.

Anderson said that even people with dementia can sometimes recognize songs and read their titles. “There’s a lot of good things that come out of this activity — just listening to music, clapping your hands, reminiscing,” she said.

In another room, occupational therapist Julie Manton explained how to prevent people with dementia from falling. She advised the group to ensure their homes have good lighting and bed rails, as examples. She also urged them to remove throw rugs.

Manton warned the participants that their loved ones might wander off and suggested the use of monitoring devices. “The key thing is to know where your loved one is at all times,” she said.

 

Making Homes User Friendly for Wheelchairs and Walkers

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Lady in wheelchairWhen Dan Bawden teaches contractors and builders about aging-in-place, he has them sit in a wheelchair to feel what it’s like to function from this perspective. That’s when previously unappreciated obstacles snap into focus. 

Bathroom doorways are too narrow to navigate through. Hallways do not allow enough room to turn around. Light switches are too high and electrical outlets too low to easily reach. Cabinets beneath a kitchen sink prevent someone from rolling up close and wash dishes, etc.

It’s an “aha moment” for most of his students, who have never actually experienced these examples of limitations or realized so keenly how home design can interfere with — or promote — the daily functions for an individual.

About 2 million older adults in the United States use wheelchairs, according to the U.S. Census Bureau; another 7 million use canes, crutches or walkers.

That number is set to increase with the aging population: Twenty years from now, 17 million U.S. households will include at least one mobility-challenged older adult, according to a December 2016 report from Harvard University’s Joint Center for Housing Studies.

How well has the housing industry accommodated this population?

“Very poorly,” said Bawden, chairperson of the remodelers division at the National Association of Home Builders and president of Legal Eagle Contractors in Bellaire, Texas. “I give them a grade D.”

Researchers at the Harvard center found that fewer than 10 percent of seniors live in homes or apartments outfitted with basic features that enhance accessibility — notably, entrances without steps and extra-wide hallways or doors needed for people with wheelchairs or walkers.

Even less common are features that promote “usability” — carrying out the activities of daily life with a measure of ease and independence.

Laws that guarantee accessibility for people with disabilities are limited. The Americans with Disability Act applies only to public buildings. And while the Fair Housing Act covers apartments and condominiums built after March 1991, its requirements are not comprehensive and enforcement is inconsistent.

We asked several experts to describe some common issues mobility-challenged seniors encounter at home, and how they can be addressed. The following is what the experts suggested may need attention with alterations, however is not a comprehensive list.

 Getting inside.

A ramp will be needed for homes with steps leading up to the front or back door when someone uses a wheelchair, either permanently or temporarily. The estimated price for a five-to-six foot portable nonslip version is $500 to $600.

One consideration is to take out the weather strip at the bottom of the front or back door and replace it with an automatic door bottom. “You want the threshold to be as flat as the floor,” Bawden said. Consider installing an electronic lock that prevents the need to lean forward and insert a key.

Doors.

Getting through doorways easily is a problem for people who use walkers or wheelchairs. They should be 34 to 36 inches wide to allow easy access.

Widening a doorway structurally is expensive, with an estimated cost of about $2,500. A reasonable alternative is swing-free hinges, which wrap around the door trim and add about 2 inches of clearance to a door.

Clearance.

Ideally, people using wheelchairs need a five-foot-wide path in which to move and turn around, Bawden said. Often that requires removing some furniture in the living room, dining room, and bedroom.

Another rule of thumb: People in wheelchairs have a reach of 24 to 48 inches. That means they will not be able to reach items in cabinets above kitchen counters or bathroom sinks.

Also, light switches on walls will need to be placed no more than 48 inches from the floor and electrical outlets raised to 18 inches from their usual 14 inch height.

Older eyes need more light and distinct contrasts to see well. A single light fixture hanging from the center of the dining room or kitchen most likely will not offer enough illumination.

It is suggested to distribute balanced lighting throughout each room and repaint the walls so their colors contrast sharply with the floor materials.

“If someone can afford it, I place recessed LED lights in all four corners of the bedroom and the living room and install closet rods with LED lights on them,” Bawden said. LED lights do not need to be changed as often as regular bulbs.

Kitchen.

Mark Lichter, director of the architecture program for Paralyzed Veterans of America, recommends that seniors who use walkers or wheelchairs take time to navigate around in the kitchen of a unit they are thinking of moving into and imagine preparing a meal or other tasks.

Typically, cabinets need to be removed from under the sink, to allow someone with a wheelchair to get up close, Lichter said. The same is true for the stovetop, understanding that the area underneath needs to be open and control panels placed in front.

Refrigerators with side-by-side doors are preferable to those with freezer areas on the bottom or top. Slide out full-extension drawers maximize storage space, as can carousel shelves in bottom corner cabinets.

Laundry.

A side-by-side front-loading washer and dryer works best to allow for easy access, instead of stacked machines.

Bathroom.

When Jon Pynoos’ frail father-in-law, Harry, who was in his 80s, came to live in a small cottage in back of his house, Jon put in a curbless shower with grab bars, a shower seat and a handheld shower head that slides up and down on a pole.

Even a relatively small lip at the edge of the shower can be a fall risk for someone whose balance or movement is compromised.

Also, Pynoos, a professor of gerontology, public policy and urban planning at the University of Southern California, installed nonslip floor tile and grab bars around a “comfort height” toilet.

Cabinets under the bathroom sink should be removed and storage space for toiletries placed lower for better accessibility. A free-standing toilet paper holder is better than a wall-based unit for someone with arthritis who has trouble extending their arm sideways.

“It really would not take much effort or expense to design homes and apartments appropriately in the first place, to make aging-in-place possible,” Pynoos said. Although “this still does not happen very often,” he noted the awareness of requirements is growing and well-designed, affordable products are becoming more widely available.

The housing industry has failed to accommodate an aging population, experts say.

The Big Wave Of Aging Baby Boomers

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Couple on motor cycleWill the world be ready if or when aging boomers [born between 1946 and 1964] hang up their car keys? Most plan to stay in their suburban house even though their home may become unsuitable. It’s surprising that this huge generation is not being addressed by the housing industry.

Thoughtfully designed housing for older adults is not being created on a scale commensurate with the growing need. It’s not a market many architects or developers have embraced. Conversely, a disproportionate amount of attention has been focused on the presumed desires of millennials. We hear all the time that it’s this group craving walkability, good transit and everything-at-their-doorstep amenities — and that it can only be provided by cities.

There are a number of reasons for this: most of the people who do marketing are young. Doing stuff for old people is not fun. One marketing consultant who founded the Boomer Project noted:

It’s as if marketers all wear the same blinders. Because so many marketing executives are under 40 — or even under 30 — many presume most consumers not only think like them, but want to be like them. Most marketing that targets Boomers presumes there is something wrong with them that needs fixing, such as age spots or wrinkles. It’s malady-based. And, for the most part, it’s not accurate.

Sure, things will go wrong, but not in the order one would think

So when the companies do think about designing for those growing older, their thinking is malady-based too; by considering malady-based design issues like “step-free entrances, single-floor living, under-counter appliances, and halls and doorways that accommodate wheelchairs.”

But, by not really knowing for sure what kind of housing aging boomers need, these mobility-based problems are the last to consider; the first are household-based activities like driving, food shopping, taking medication and meal preparation. These start hitting in significant numbers in the mid 70s, and the boomers are not there yet.

These are also problems that are solved by community — being able to walk to shop, moderately priced restaurants where one can get prepared food, neighbors who might look in and check if a person is taking their medication.

Right now, boomers feel pretty good

The fact is that right now, most of the baby boomer cohort is still pretty healthy. According to a Del Webb study, they all feel a lot younger than they are, and until any health problems start hitting them, they will think they are much younger. So it should be no surprise that there are not too many of them worrying right now about giving up their cars; they all think they are fine.

Every day for the next 12 years, 10,000 people will reach age 65. That companies are not scrambling to exploit this market is not only unfortunate for their bottom line, but almost certainly treacherous, eventually, for everyone.

The power of boomers

Baby boomers buy 60 percent of packaged goods, spend 75 percent more on vacations, and buy half of all new cars. They own a third of all the iPhones and half of the Macs. Baby boomers, because they get out and vote in higher numbers, just elected the new American government and pretty much control it. President Trump is 70, Wilbur Ross, U.S. Secretary of Commerce, is 79, and the average age of the cabinet is 62. The baby boomers own America, and now they rule it.

There is an importance of living in walkable communities, those things that the millennials want, such as good transit and everything-at-their-doorstep amenities. People have to start thinking seriously about these issues, but most baby boomers simply haven’t yet. Most who have decent jobs or own businesses are not seeing any retirement barrier at age 65 either.

Technology can be part of the solution, with Uber, home delivery, apps and wearables. Summoning these cars is a no-brainer for heavy users of smartphones, but for older people with declining vision and motor skills, it’s a puzzle. But not for the baby boomers; they just upgrade to the iPhone 7 Plus and get a bigger screen. Again, conflating seniors with tech-savvy boomers who have fine, well-practiced index finger skills, along with Siri and Alexa.

In fact,  the biggest problem for boomers might well be over-reliance on technology. Most older seniors could easily park themselves in front of the television with only the 50 channels the cable company gave them. Now we can get endless streaming of Netflix and every other service to fill our time. Soon we all might be wearing Oculus headsets and never leaving our chairs.

Perhaps that is what happens when people are trapped in their homes, or when they lose their car keys. Which is maybe why we have to think community first, interior design second. And in the end, we’re talking about timing. The baby boomer demographic bulge is just getting into its senior years. As one senior living expert, Bob Kramer notes:

“Some of this is like surfing — you have to time the wave,” Kramer says. “You paddle too soon, and you wipe out spectacularly.”

The oldest boomers are just 70 or 71 now. But they are the leading edge with many, many millions to follow. We are 10 years away from the real crisis here. The question is, do we fix our cities and towns now so that they are ready for this wave, or will it drown us all?

 

Want To Live Past 100?

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Centarians

Gertrude Siegel is 101 and hears it all the time. “Everyone says ‘I want to be just like you.’ I tell them to get in line,” she said.

John and Charlotte Henderson, 104 and 102, often field questions from wannabes eager to learn their secrets.

“Living in moderation,” he said. “We never overdo anything. Eat well. Sleep well. Don’t overdrink. Don’t overeat. And exercise regularly.”

Mac Miller, who is 102, has a standard reply.

“People ask me ‘What is the secret?’ The answer is simple. Choose the right grandparents. They were in their 80s. My mother was 89, and my father was 93,” he said.

Genetics and behaviors do play roles in determining why some people live to be 100 or older while others don’t, but they aren’t guarantees. And now, as increasing numbers are reaching triple digits, figuring out the mysteries of longevity has taken on new importance among researchers.

Although those 100 and older make up a tiny segment of America’s population, U.S. Census reports show that centenarian ranks are growing. Between 1980 and 2010, the numbers rose from 32,194 to 53,364, an increase of almost 66 percent. The latest population estimate, released in July 2015, reflects 76,974 centenarians.

“The number of centenarians in the U.S. and other countries has been doubling roughly every eight years,” said James Vaupel, founding director of the Max Planck Institute for Demographic Research in Rostock, Germany.

“When the baby boomers hit, there’s going to be acceleration, and it might be doubling every five or six years,” he said.

Henderson and his wife of 77 years live in Austin in the independent living section of Longhorn Village, a community of more than 360 seniors, many of whom have ties to the University of Texas at Austin. Henderson is UT’s oldest-living former football player, arriving in 1932 as a freshman. They’re the only centenarians in the complex and are a rare breed: married centenarians.

Charlotte Henderson said she believes being married may have helped them reach these 100-plus years.

“We had such a good time when John retired. We traveled a lot,” she said. “We just stay busy all the time, and I’m sure that helps.”

Bernard Hirsh, 100, of Dallas agrees. His wife, Bee, is 102. They married in 1978 when both were in their early 60s and each had been widowed, she for the second time.

“I think it’s been such a wonderful marriage, and we’ve contributed to each other’s benefit,” he said.

Little research exists on the effects of marriage on longevity. One 2015 Belgian study of centenarians born between 1893 and 1903 did focus on their living arrangements during ages 60 and 100 and found “in very old age, living with a spouse is beneficial for men but not for women, for whom living alone is more advantageous than living with a spouse.” The study explained that “living with one’s spouse at the oldest ages does not provide the same level of protection as it does at younger ages. This may be explained by the decline of the caregiver’s own health as the needs of his or her spouse increase. Caregiving could also have negative consequences for the health and economic condition of the spouse who is the primary caregiver, especially for older women.”

However, Vaupel, who directs the Institute’s International Research Network on Aging, said being married is a positive for both.

“Especially if you’re quite old, it’s very helpful to have a spouse. If you’re very old and don’t have a spouse, the chance of death is higher,” he said.

Siegel, who lives in a senior living community in Boca Raton, Fla., outlived two husbands. She never smoked and occasionally has a glass of dry, red wine.

“I am not a big eater. I don’t eat much meat,” said Siegel, who said she weighs 90 pounds and used to be 5 feet tall but is shrinking.

She stays active by walking inside the building about a half-hour each day, playing bridge twice a week and exercising.

“I feel that’s what really keeps my body pretty good. It wasn’t sports. It was exercises,” she said of the routine she does daily twice a day for about 20 minutes.

Miller, of Pensacola, Fla., also outlived two wives.

He was a fighter pilot in the Marine Corps during World War II and spent eight years in active duty, which Miller said “was not so good for me because I sat in the cockpit of a plane for 5,000 hours.”

But, he was active as a youth — running track, playing football and spending hours surfing while living in Honolulu.

Miller is gluten-free because of allergies and doesn’t eat many carbohydrates. He also never smoked. And, he still enjoys a scotch in the evening.

The Hendersons usually have wine or a cocktail before dinner. She never smoked. He quit in 1950.

Hirsh, of Dallas, another non-smoker, attributes his long life to “good luck.”

“I was very active in my business and did a lot of walking during the day. I was not sedentary,” he said.

Now, exercise is limited to “some knee bends every morning to keep my legs stronger.”

“My father died of a heart attack in his early 50s, and my mother died in her early 60s of a stroke, so I don’t think my genes are very good,” Hirsh said.

Geriatrician Thomas Perls, director of the New England Centenarian Study at Boston Medical Center, said research shows that behaviors have had a greater influence on survival up until the late 80s, since he said most people have the right genes to get there as long as their behaviors aren’t harmful. But once people reach the 90s and beyond, genetics play a more significant role.

“To get to these very oldest ages, you really have to have the right genes in your corner,” he said.

As an international leader in the field, Perls’ focus is on finding the right mix of behavior, environment and genetics to produce long lives. His work includes a National Institute on Aging study called the Long Life Family Study.

“There are always questions about environment versus genes,” said endocrinologist Nir Barzilai, founding director of the Institute for Aging Research at the Albert Einstein College of Medicine in Bronx, N.Y. “ It’s really 50-50, no matter how you look at it.”

Barzilai’s studies include centenarians and their children, as well as efforts to slow the process of aging.

Perls said his research and that of Barzilai and others has found commonalities among those who reach the 100-year-old milestone: Few smoke, nearly all of the men are lean, and centenarians have high levels of the “good cholesterol.” Studies show that whatever their stress level, they manage it well. And they’re related to other centenarians or have a parent or grandparent who lived past 80.

These lessons of long life are playing well with the public, who have made changes for the better in the 21st century, Vaupel said.

“We don’t smoke or drink so much, and we’re better at exercise. People are taking better care of themselves. People are better educated, and the more educated know when to go to the doctor and follow the doctor’s advice,” he said, adding that people now tend to have higher income and can spend more on health care and improved diet.

“The most important thing is we’re living longer and living longer healthily,” Vaupel said.

 

Putting A Lid On Needless Medical Tests

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Doctors desk with patients test results, samples, stethoscope and blood pressure gaugeIt is common knowledge in medicine: Doctors routinely order tests on hospital patients that are unnecessary and wasteful. Sutter Health, a giant hospital chain in Northern California, thought it had found a simple solution.

The Sacramento-based health system deleted the button physicians used to order daily blood tests. “We took it out and could not wait to see the data,” said Marie Giusto, a Sutter Health executive.

Alas, the number of orders hardly changed. That is because the hospital’s medical-records software “has this cool ability to let you save your favorites,” Giusto said at a recent presentation to other hospital executives and physicians. “It had become a habit.”

There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system — but, as the Sutter example illustrates, it is often not as simple as it seems.

Some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care can also harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year.

“The changes that need to be made do not appear unrealistic, yet they seem to take an awful lot of time,” said Dr. Jeff Rideout, chief executive of the Integrated Healthcare Association, an Oakland, Calif., nonprofit group that promotes quality improvement. “We have been patient too long.”

In California, that sense of frustration has led three of the state’s biggest health care purchasers to band together and promote care that is safer and more cost-effective. The California Public Employees’ Retirement System (CalPERS), the Covered California insurance exchange and the state’s Medicaid program, known as Medi-Cal — which collectively serve more than 15 million patients — are leading the initiative.

Progress may be slow, but there have been some encouraging signs. In San Diego, for instance, the Sharp Rees-Stealy Medical Group said it cut unnecessary lab tests more than 10 percent by educating both doctors and patients about overuse.

A large public hospital, Los Angeles County-University of Southern California Medical Center, eliminated preoperative testing deemed superfluous before routine cataract surgery. As a result, patients on average received the surgery six months sooner.

These efforts were sparked by the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit.

The campaign, also backed by Consumer Reports, encourages medical providers to hand out wallet-sized cards to patients with questions they should ask to determine whether they truly need a procedure.

Critics have blamed Choosing Wisely for playing it too safe and not going after some of the more lucrative procedures, such as certain spine operations and arthroscopic knee surgeries.

Daniel Wolfson, chief operating officer at the ABIM Foundation, said the Choosing Wisely campaign has been successful with unwarranted care. “I think we need massive change and that could take fifteen or more years,” Wolfson said.

Initially, the group focused on  reducing opioid use and avoiding overtreatment for patients suffering low-back pain.

Dr. Richard Sun, co-chairman of the Smart Care group and a medical consultant at CalPERS, said he is pursuing safer, more affordable treatments for low-back pain, a condition that cost the state agency $107 million in 2015. “One challenge is developing metrics that everyone can agree upon to measure improvement,” he said.

For patients, overtreatment can be more than a minor annoyance. Galen Gunther, a 59-year-old from Oakland, said that during treatment for colorectal cancer a decade ago he was subjected needlessly to repeated blood draws, often because the doctors could not find documentation of earlier results. Later, he said, he was overexposed to radiation, leaving him permanently scarred.

“Every doctor I saw wanted to run the same tests, over and over again,” Gunther said. “Nobody wanted to take responsibility.”

At Cedars-Sinai Medical Center in Los Angeles, officials said that economic incentives still drive hospitals to think that more is better.

“We have excellent patient outcomes, but it is at a very high cost,” said Dr. Harry Sax, executive vice chairman for surgery at Cedars-Sinai. “There is still a continued financial incentive to do that test, do that procedure and do something more.”

In addition to financial motives, Sax said, many physicians still practice defensive medicine out of fear of malpractice litigation. Also, some patients and their families expect antibiotics to be prescribed for a sore throat or a CT scan for a bump on the head.

To cut down on needless care, Cedars-Sinai arranged for doctors to be alerted electronically when they ordered tests or drugs that run contrary to 18 Choosing Wisely recommendations.

The hospital analyzed alerts from 26,424 patient encounters from 2013 to 2016. All of the guidelines were followed in 6 percent of those cases, or 1,591 encounters.

Sax said Cedars-Sinai studied the rate of complications, readmissions, length of stay and direct cost of care among the patients in whose cases the guidelines were followed and compared those outcomes with cases where adherence was less than 50 percent.

In the group that did not follow the guidelines, patients had a 14 percent higher incidence of readmission and 29 percent higher risk of complications. Those complications and longer stays increased the cost of care by 7 percent, according to the hospital.

In 2013, the first year of implementation of Choosing Wisely guidelines, Cedars-Sinai said it avoided $6 million in medical spending.

For perspective, Cedars-Sinai is one the largest hospitals in the nation with $3.3 billion in revenue for the fiscal year ending June 30, 2017. It reported a net income of $301 million.

In Northern California, Sutter has incorporated more than 130 Choosing Wisely recommendations as part of a broader effort to reduce variation in care. In all, Sutter said, it has saved about $66 million since 2011.

That is a significant sum. However, during the same period, Sutter reported $2.7 billion in profits. Last year alone, it posted an operating profit of $554 million on revenue of nearly $12 billion.

Giusto said her team of employees tasked with changing physician behavior and eliminating these variations is separate from administrators who are focused on maximizing reimbursement. She said there can be conflicting forces within a hospital.

“We get really excited about a project with [emergency department] doctors on reducing CT scans for abdominal pain,” said Giusto, director of Sutter’s office of patient experience. “Then I can hear the administration say, that was a [Medicare] fee-for-service patient and we just lost money, right?”

Giusto meets with doctors to present data on how many tests or prescriptions they order and how that compares to others. At one clinic, she shared slides showing that some doctors were ordering more than 70 opioid pills at a time while others prescribed fewer than 20. In response, Sutter set a goal of 28 tablets in hopes of reducing opioid abuse.

“Most of the physicians changed,” Giusto said. “But there were still two who said, ‘Sorry, but I’m going to keep doing it the same as always.’

New Federal Rules for Home Health Agencies

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Man and CaretakerHome health agencies will be required to become more responsive to patients and their caregivers under the first major overhaul of rules governing these organizations in almost 30 years. 

The federal regulations, published in January 2017, specify the conditions under which 12,600 home health agencies can participate in Medicare and Medicaid, serving more than 5 million seniors and younger adults with disabilities through these government programs.

They strengthen patients’ rights considerably and call for caregivers to be informed and engaged in plans for patients’ care. These are “real improvements,” said Rhonda Richards, a senior legislative representative at AARP.

Home health agencies also will be expected to coordinate all the services that patients receive and ensure that treatment regimens are explained clearly and in a timely fashion.

The new rules are set to go into effect in July 2017, but they may be delayed as President Donald Trump’s administration reviews regulations that have been drafted or finalized but not yet implemented. The estimated cost of implementation, which home health agencies will shoulder: $293 million the first year and $234 million a year thereafter.

While industry lobbying could derail the regulations or send them back to the drawing board, that is not expected to happen, given substantial consensus with regard to their contents. More likely is a delay in the implementation date, which several industry groups plan to request.

“There are a lot of good things in these regulations, but if it takes agencies another six or 12 months to prepare let’s do that, because we all want to get this right,” said William Dombi, vice president for law at the National Association for Home Care & Hospice (NAHC).

Home health services under Medicare are available to seniors or younger adults with disabilities who are confined to home and have a need, certified by a physician, for intermittent skilled nursing services or therapy, often after a hip replacement, heart attack or a stroke.

Patients qualify when they have a need to improve functioning (such as regaining the strength to walk across a room) or maintain abilities (such as retaining the capacity to get up from a chair), even when improvement is not possible. These services are not for patients who need full-time care because they are seriously ill or people who are dying.

Several changes laid forth in the new regulations have significant implications for older adults and their caregivers:

Patient-Centered Care

In the past, patients have been recipients of whatever services home health agencies deemed necessary, based on their staffs’ evaluations and input from physicians. It was a prescriptive “this is what you need and what we’ll give you” approach.

Now, patients will be asked what they feel comfortable doing and what they want to achieve, and care plans will be devised by agencies with their individual circumstances in mind.

“It’s much more of a ‘help me help you’ mentality,” said Diana Kornetti, an industry consultant and president of the home health section of the American Physical Therapy Association.

While some agencies have already adopted this approach, it’s going to be a “sea change” for many organizations, said Mary Carr, NAHC’s vice president for regulatory affairs.

Patient Rights

For the first time, home health agencies will be obligated to inform patients of their rights — both verbally and in writing. And the explanations must be communicated clearly, in language that patients can understand.

Several new rights are included in the regulations. Notably, patients now have a right to receive all the services deemed necessary in their plans of care. These plans are devised by agencies to address specific needs approved by a doctor, such as speech therapy or occupational therapy, and usually delivered over the course of a few months, though sometimes they last much longer. Also, patients must be informed about the agency’s initial comprehensive assessment of the patient’s needs and goals, as well as all subsequent assessments.

A patient’s rights to lodge complaints about treatment and be free from abuse, which had already been in place, are described in more detail in the new regulations. The government surveys home health agencies every three years to make sure that its rules are being followed.

NAHC officials said they planned to develop a “notice of rights” for home health care agencies, bringing greater standardization to what has sometimes been an ad hoc notification process.

Caregiver Involvement

For the first time, agencies will be required to assess family caregivers’ willingness and ability to provide assistance to patients when developing a plan of care. Also, caregivers’ other obligations — for instance, their work schedules — will need to be taken into account.

Previously, agencies had to work with patients’ legal representatives, but not “personal representatives” such as family caregivers.

“These new regulations stress throughout that it’s important for agencies to look at caregivers as potential partners in optimizing positive outcomes,” said Peter Notarstefano, director of home and community-based services for LeadingAge, a trade group for home health agencies, hospices and other organizations.

Plans Of Care

Now, any time significant changes are made to a patient’s plan of care, an agency must inform the patient, the caregiver and the physician directing the patient’s care.

“A lot of patients tell us ‘I’ve never seen my plan of care; I don’t know what’s going on; the agency talks to my doctor but not to me,’” said Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy. The new rules give “patients and the family a lot more opportunity to have input,” she added.

In another notable change, efforts must be made to coordinate all the services provided by therapists, nurses and physicians involved with the patient’s care, replacing a “siloed” approach to care that has been common until now, Notarstefano said.

Discharge Protections

Allowable reasons for discharging a patient are laid out clearly in the new rules and new safeguards are instituted. For instance, an agency cannot discontinue services merely because it does not have enough staff.

The government’s position is that agencies “have the responsibility to staff adequately,” Carr of NAHC said. In the event a patient worsens and needs a higher level of services, an agency is responsible for arranging a safe and appropriate transfer.

“Agencies in the past have had the ability to just throw up their hands and say ‘We can’t care for you or we think we’ve done all we can for you and we need to discharge you,’” Holt said. Now a physician has to agree to any plan to discharge or transfer a patient, and “that will offer another layer of protection.”

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