adia news room

Music is good for you at any age

It may be easier to learn young, but it may be more fun to learn later.

Let’s face it: Many of us looking to sharpen our intellectual edges have already passed the age when becoming a prodigy is an option.  We missed the opportunity to start clarinet lessons at 5.  We lacked the discipline to practice for hours on end.  We were told we couldn’t carry a tune in a bucket.

It’s never too late, say researchers.

Just as second languages are more easily learned young, neuroscientists point to periods of heightened sensitivity – particularly before the age of 8 or 9 – when minds are more readily shaped by musical instruction.

With age, the “plasticity” that allows experience to mold the brain so easily declines.  But it doesn’t disappear.  At any age. learning a challenging new set of skills such as instrumental music is likely to return cognitive dividends, says Harvard University neurologist Gottfried Schlaug.  And for adults, he added, the prospect of making music can be a far more effective motivator to practice than nagging parents are to younger musicians.

“Music is sort of the perfect activity that people can engage in from young to older years.  It affects how the brain develops and affects how the brain changes in structure” at any age, Schlaug says.

For the mature brain, even listening to beloved music may have what scientists call a “neuroprotective” effect.

Dr. Antonio Damasio, director of USC’s Brain and Creativity Institute, is an expert on emotion and a committed musicophile.  Even if music did little more than lift our spirits, he says, it would be a powerful force in maintaining physical and mental health.  The pleasure that results from listening to music we love stimulates the release of neural growth factors that promote the vigor, growth and replacement of brain cells.

In that way, Damasio says, just the simple act of absorbing music may help keep older minds healthy, active and resilient against injury and illness.

Healy, M. (2010, March 1). Music is good for you at any age. Los Angeles Times, Web.

Tips to prevent medical bills from getting overdue

To avoid damaging your credit score and hearing from a collection agency, open all mail from your doctors and insurers and work out any issues over bills with your doctor’s billing office.

Got a medical bill lying around in a kitchen drawer or office file?

Quick, go get it and then make some effort to pay or settle it, especially if the date on the bill goes back beyond 30 days.  Without some attempt to resolve the bill, it will damage your credit rating, often badly.  And that poor credit rating can mean higher rates for credit cards, cars and mortgages.  It can even keep you from getting a needed loan or credit card.

“Medical bills are the most commonly reported non-revolving credit account sent to collection and reported on a U.S. consumer’s credit report,” says Mark Rukavina, director of the Access Project, a health advocacy group based in Boston.  “But credit bureaus and lenders don’t extend sympathy just because a bill was incurred for a medical necessity.”

They key thing consumers should do, says Rukavina, is prevent the medical bill from being sent to a collection agency.  Physicians and hospitals may be unlikely to report a patient to a credit bureau, but the collection agencies to whom they turn usually won’t hesitate to do so.

Even if eventually paid in full, a bill that’s been sent for collection remains on your record for up to seven years can affect your credit worthiness, says U.S. Rep. Mary Jo Kilroy (D- Ohio).  She’s introduced legislation, the Medical Debt Relief Act, that would prohibit lenders from factoring in fully paid or settled medical debt when determining a consumer’s credit score.

Those scores are used by banks and other lenders when making decisions on whether to lend money or extend a credit card or mortgage to a borrower.  The legislation would require that delinquent medical accounts be removed from a consumer’s credit report within 30 days of being paid in full.

With so many Americans unemployed or uninsured, it seems likely that many consumers might have a hard time paying health costs.  In 2007 alone, more than 28 million Americans were contacted by debt collectors, according to a report from the Commonwealth Fund.  Sara Collins, a vice president at the fund, says the number has almost certainly climbed since then.  But you can take some steps to keep the debt from being turned over to a collection agency.

Open and read all mail from doctors and insurers.

Insurers send so many pieces of mail that aren’t bills that consumers sometimes overlook the real thing, says Tom Billet, a healthcare consulting firm Towers Watson in Stamford, Conn. Janice King, a healthcare analyst for research firm IDC in Framingham, Mass., says the rate of unpaid bills  is currently at 30%, a loss that pushes some doctors and hospitals to turn bills over to collection bureaus if they go unpaid just 30 days.

Ask for help if confusion about the bill is keeping you from making payments.

A survey from Intuit of Mountain View, Calif., which published Quicken health expense software, found that more than half of respondents said they were puzzled by medical jargon on their bills, and 1 in 4 said the confusion led them to let bills go 90 days past due or be sent to a collection agency.

Confused?  Start with the healthcare provider’s office.  The staff would much rather explain the bill than let it go unpaid.  If no one there can clear up the confusion, call the customer service number on your insurance card and ask for help.  If that doesn’t work, file a formal complaint or an appeal, Rukavina says.  The insurer’s website or its customer service line should have information on how to do so.

Talk to the provider.

If the bill is in dispute, ask the doctor or the hospital to hold off sending it to a collection bureau while you unravel any issues.  You’re likely to get a positive response, Billet says.  Providers lose a percentage of the bill when it goes to a collection agency, so they’d prefer to work out a deal.

Negotiate payment.

If the bill is beyond your budget, talk to your provider’s billing office and try to negotiate a repayment plan.  You won’t be off the hook, but the provider maybe willing to work with you, especially if you offer to pay at least something on a regular basis.  It’s best to have the agreement in writing and to stay current with your payments.

In addition to working out a payment plan, providers may agree to drop some fees or even refer you to assistance sources.

“Most providers will be flexible if you demonstrate good faith in paying off the bill,” Rukavina says.

Once a bill goes to collection, however, providers may not be able to take it back, and actions taken by collection agencies may be costly to your long-term financial health.

Kritz, L. (2010, March 1). Tips to prevent medical bills from getting overdue. Los Angeles Times, Web.

There are lifestyle changes you can adopt that may reduce your chance of developing dementia by as much as 20 percent.  A panel of independent experts evaluated more than 70 research papers and articles to come up with this series of tips for reducing your risk.

Exercise

What is good for the heart is good for the brain.  Exercise can have a beneficial effect at any age to help protect against dementia.  There is also growing evidence that regular exercise promotes cell and tissue repair mechanisms including growth of new cells in the brain.

Avoid Obesity

Being seriously overweight is a risk factor for developing dementia.  Obesity is associated with type 2 diabetes, high cholesterol, and high blood pressure – all known risk factors.

Normalize Blood Pressure

High blood pressure increases your chance of dementia by causing damage to your brain.  This may happen as a result of a stroke, or because of microvascular disease, a condition which slows the flow of blood through your body, thereby damaging cells and nerves in your brain.

Avoid all Tobacco

As well as raising the risk of vascular disease – a risk factor for dementia – smoking can result in low oxygen levels in your brain, which in turn can promote the production of the protein found in brain plaques.

Follow a Mediterranean Diet

Several recent studies have highlighted the potential for this diet to reduce the risk of Alzheimer’s disease.  Further long-term research is needed to confirm the effects of eating this way.

Be Socially Active

Some evidence suggests that an active social life throughout life can be protective, with both the social ties one enjoys with others and non-physical leisure time deemed important.

Brain Training

There is some evidence that intensive brain training can improve reasoning and problem solving.

http://articles.mercola.com/sites/articles/archive/2010/02/23/an-expert-guide-to-reducing-your-dementia-risk.aspx 
Retrieved 25 Feb 2010

Avenues to correct medical billing problems

There are several state and nonprofit organizations that can help patients who feel they are victims of mistakes.

Ever had a claim denied by your insurer because of something like RAD Code 0022?  If so, you’re not alone.

Wading through healthcare bills is a daunting task – and appealing them can be an impossible one.  But if you think you’ve been overcharged of that a claim has been wrongfully denied, there’s no reason to take it lying down.  You might want to call in reinforcements, though.  “The healthcare system is so complex it is almost impossible for a layperson to navigate through some of the stuff,” said Lynne Randolph, deputy director of communications at the California Department of Managed Health Care.  “I think it’s extremely valuable for consumers to have an advocate on their side.”

Check first with your provider or insurer to see if the problem can be resolved.  If it can’t, a wide range of groups – state agencies, nonprofits, consumer advocates – can help explain your policy or help you file a complaint.

Insurance appeals

If you think an insurer should pay a bill that was denied, you can file a complaint with the insurance company.  Doing so immediately prevents the account from being sent to the collections department until the insurer makes a decision, typically within 30 days, and gives consumers time to deal with the situation, said Jessica Rothhaar, medical debt program manager at Health Access California, a statewide advocacy group.

On its website, Health access offers details on navigating the insurance system.  They include checking with the doctor to make sure the insurance company was billed in the first place, calling the insurer for an explanation of why the bill was not paid and, if neither of those steps work, filing a complaint.  You can find out how to file a complaint, or grievance, by looking in your insurance documents or by calling your insurer.  More detailed information can be found at hospitalbillhelp.org, a service of health Access and other consumer groups.

Be sure to keep copies of all documentation and related correspondence, including copies of bills, canceled checks and denial letters.  Write down the name of phone number of anyone you speak with at the insurance agency.  This can help the compaint process go more smoothly.

The specific way to appeal an insurance denial differs depending upon the kind of insurance plan and the insurer.

HMOs

Almost 20 million Californians are covered under health maintenance organization (HMO) plans, Randolph said.  The California Department of Managed Health Care, which regulates the state’s HMO plans and functions as policy group and consumer advocate, helps resolve complaints against these insurers.

The department’s help center is staffed by attorneys and nurses who can answer questions about health plans or the complaint process, but the staff also assists simply by helping you get through to the right person at the insurance company.  Sometimes the staff will set up a three-way call with you, an attorney (or nurse) and the insurer to work together to try to resolve the issue informally.

If the agency’s staff cannot help resolve the issue, you can file a complaint with the department.  A one-page form with your information goes to one of the department’s attorneys, who has 30 days to resolve the dispute.  In an emergency situation, the attorney deals with the issue within 72 hours.

If a complaint is still denied, you can request an independent medical review, in which a panel of doctors familiar with the condition looks at the case.  The doctors review relevant medical data and render a decision that the health plan and consumer must follow.  Randolph said consumers have a success rate of less than 50% when the complaint goes to a review board, but when they are successful, the process is worth the effort.

“With state departments, we have the force of the law behind us,” she said.  “If they [insurers] are not following the law, we have strong enforcement units.”

PPOs

The California Department of Insurance has regulatory authority over preferred-provider organizations (PPOs), which provide health insurance for approximately 6 million Californians.  The department regulates licensing, marketing and policy administration.  It, too, receives numerous complaints dealing with coverage, said Darrel Ng, senior press secretary for the department.

The consumer assistance process is similar to that of the Department of Managed Health Care.  You can contact the department’s call center for help understanding bills and for answers on what should be paid for under your policy.

“We as a regulator contact them [insurers] to make sure they have fulfilled their contract with the covered person,” Ng said.  “If it should be paid for, we will contact the insurance company and give them our point of view.  Generally at that point, the problem will be solved.”

If an insurer does not respond to a complaint within 30 days or continues to deny the claim related to issues including medical necessity, experimental treatments or denial of urgent medical services, you can file for an independent medical review through the department.  A review board looks at the case, and a decision that is binding upon the insurance company is provided.

Medicaid (called Medi-Cal in California)

There are nearly 6.5 million California consumers covered under Medi-Cal.  Information on how to file an appeal if a claim is denied is provided by the insurer when coverage begins and then annually thereafter.

If talking with the physician and health plan doesn’t resolve a dispute, you can file a complaint through the California Department of Health Care Services, which finances and administers the Medi-Cal program.  The department can send a complaint from in the mail or you can fill it out online.

If a complaint is filed and the insurer refuses to pay for the service, you can request an independent medical review within six month of the time the claim was denied.  The Department of Managed Health Care handles reviews.

More detailed information on how to file an appeal can be found at the Health Consumer Alliance’s website at www.healthconsumer.org.  The Los Angeles-based organization, whose goal is to help low-income people receive needed healthcare services, can also be contacted at (310) 204-4900.

Medicare

Though few people actually file Medicare appeals, more than half of those who do get a decision in their favor, according to California Health Advocates, a nonprofit group that provides Medicare education and advocacy to California residents.

Each quarter, Medicare patients receive a notice that lists claims for the previous 90 days.  If a consumer thinks that a claim has been wrongly denied, there are appeal details on the back of the notice.

Groups such as California Health Advocates and the state Department of Aging’s Health Insurance Counseling and Advocacy Program (HICAP) are equipped to assist Medicare recipients in filing an appeal.  HICAP’s local centers in California can be contacted at (800) 434-0222.  the group offers information on rights and benefits and coverage denials, and can provide legal help at hearings.  HICAP staff will come to the homes of individuals who cannot get to their office.

More information on how to appeal a denied Medicare claim can be found at the California Health Advocate website.

Other plans

If you’re not covered under a government plan or a managed-care HMO or PPO, Rothhaar said there is, unfortunately, little recourse if you are denied coverage.

But Randolph, from the California Department of Managed Health Care, said plans issued in California are regulated by the state and should provide some form of consumer protection, including complaint assistance and an independent medical review.  If you have an individual plan and are not sure how it is regulated, her department can tell you where to go for help.

If you are covered by an employer who has an out-of-state policy, the plan will be regulated by that state.  The state’s department of insurance should be able to provide assistance on the grievance process.

Providers

Although there is an organization to help almost all consumers navigate issues with insurers, relatively few assist people with a billing problem from a physician or hospital.

“There is no regulation of physician pricing in this country unless they are being paid for by a public entity,” said Rothhaar, of Health Access California.

Hospitals are required by state law to publish prices for their 25 most common inpatient and outpatient procedures.  If you have received one of these and feel that you have been overcharged, you can find the correct price online from the Office of Statewide Health Planning and Development.

For an issue with a hospital, Rothhaar recommends contacting her organization, writing a letter to the chief executive, copying a local legislator and, in general, trying to get some attention.

“Raise a stink, because is it fundamentally about the hospital’s reputation,” she said.

If the issue is with a doctor, there are even fewer options.

Candice Cohen, spokeswoman for the California Medical Board, recommends finding out the price before visiting the physician and taking the provider to small claims court if there is a problem.  Her agency typically deals with complaints that are related only to some sort of fraud, rather than billing disputes, she said.

Worth, T. (2010, February 15). Avenues to correct medical billing problems. Los Angeles Times, Web.

Decode your medical bills

People with health insurance who get a medical bill this early in the new year may also get some sticker shock.  Few will have satisfied their plan’s annual deductible this soon, meaning they’ll be responsible for a hefty portion of the bill, if not all of it.

That’s especially true for patients who go out of network – that is, use a doctor who doesn’t accept their insurance or is not part of their managed-care plan.

I know this firsthand.

My portion of a bill from an out-of-network physician – for an hourlong checkup that included lab work, an EKG and chest X-ray – recently came to just over $1,000. 

Regardless of the amount, all bills should be read carefully. 

“Much of a doctor’s bill and insurer’s explanation of benefits can seem indecipherable, and often they are,” says Tom Billet, a senior consultant on healthcare issues in the Stamford, Conn., office of benefits consulting firm Watson Wyatt.  “Reviewing the doctor’s bill to be sure they didn’t add in services you didn’t have, and reviewing the insurer’s document to make sure the charges match what’s in the doctor’s bill, could save some people some money.”

In my case, a review of the bill found no blatant mistakes, padded charges or unjust refusals by the insurer.  But it did find that the doctor’s office had charged for separate lab tests done with just one blood draw.  The insurer flagged and allowed only a bundled test, the fee for which was much lower than the individual tests on the doctor’s bill.

Reviewing medical bills and reimbursement notices – challenging them if necessary – is crucial.  Billet and other consultants offered these suggestions:

Pay attention to the details.

Whether or not you’re insured, the doctor’s office should give you an itemized bill accounting for any professional encounters and tests.  Make sure you received all the services for which you were billed.

After breaking a toe several years ago, Billet was told he didn’t need an X-ray because the treatment – taping the toe to its neighbor – is the same regardless of what the films show.  But Billet’s bill included an X-ray charge.

Even if you receive the bill in the office – and must pay before leaving – take the time to look it over and fix any mistakes.  As Candy Butcher, chief executive of Medical Billing Advocates of America in Salem, Va., notes, getting a refund can be difficult.  If the bill is complex, ask to take it home to review before making payment arrangements.  If the office balks, ask if paying a small percentage of the bill will suffice.

Learn the terminology.

Insurers offer glossaries in their handbooks and on their websites explaining such terms as “deductible” and “co-payment / co-insurance.”  It’s good to be comfortable with the terms, Billet says, so that you can explain discrepancies or overcharges.  For example, people who are used to paying a flat-fee co-payment can be confused if they switch insurers and are now paying co-insurance, or a percentage of the fee.  “Understanding the terms helps put you on a more equal footing with the insurance representative when you have your conversation,” Billet says.

Read the remarks.

Insurers include number codes, typically explained at the end of the document, to let you know why they refused a particular charge.  Dr. Geni Bennets, formerly a pediatric oncologist and now a billing advocate based in Napa, says a common reason for refusal may be that a physician simply billed for generic lab tests and that the insurer needs to see specific tests listed, such as “lipid panel” or “complete blood screening” to determine whether the charge is eligible.  In those cases, check with your insurer to see how a more detailed breakout would be resubmitted.  The doctor’s office may have to redo the numbers before the bill can be resubmitted.

Use customer service.

Don’t hesitate to call your insurer about a charge you think should have been paid, or paid at a higher rate.  For example, many insurers now charge a large share of an emergency room bill if there was no actual emergency – sometimes a hard thing to determine at the time.

“If you think you had a medical care that was justified but your insurer turns you down, call customer service, but then also ask for a supervisor if you think you’re not being well served,” says Helen Darling, head of the National Business Group on Health, an association that helps large corporations tame high healthcare costs.  Other encounters worth an appeal to customer service include an appointment with an out-of-network specialist if the plan’s network did not have someone with the same specialty or an emergency room visit for chest pains that turned out to be gas if the patient had a family history of heart disease.

No satisfaction from customer service?  Insurers allow appeals, usually within 90 to 180 days of the date of payment for a denied claim.  Check the manual or customer service number to find out how to file an appeal.

Consider a billing advocate.

For particularly expensive bills, such as for a major operation or long hospital stay, for which you paid completely out of pocket or got little reimbursement, billing advocates may be able to go to bat for you.  Advocates may charge by the hour or take a percentage – often 20% to 30% – of any money they are able to reclaim from the insurance company.  A few firms offer this service free to their employees.  More likely, the person who handles insurance at your company can refer you to a billing advocacy firm; so too can a hospital’s patient advocate office.

Deal with a doctor’s office.

My biggest blunder: I should have asked the doctor if I could have the lab work done at an in-network lab instead of at his office.  Less convenient for sure, but billing specialists say I could have saved $400 or more.

Even if I’d decided to stick with the in-house tests, doctors often will give a discount to patients paying in full, perhaps as high as 35%.  In my case, that would have been over $350.  Butcher says I likely would not have had to bring it up with the doctor at all; many office managers are authorized to adjust bills for patients.  And they’ll often discount a bill even for patients paying in installments.

Kritz, F. (2010, February 15). Decode your medical bills. Los Angeles Times, Web. 

http://www.latimes.com/features/health/la-he-yourmoney15-2010feb15,0,3539107.story

Residents of Nursing Home Dying of Thirst, Hunger

(CBS)  The old lady crawls in the dirt, wailing for her pills.  The elderly man lies motionless as rats pick at his overflowing diaper.

There is no food, water or medicine for the 85 surviving residents of the Port-au-Prince Municipal Nursing Home, barely a mile from the airport where a massive international aid effort is taking shape.

“Help us, help us,” 69-year-old Mari-Ange Levee begged Sunday, lying on he ground with a broken leg and ribs.  A cluster of flies swarmed the open fracture in her skill.

One man has already died, and administrator Jean Emmanuel said more would follow soon unless water and food arrive immediately.

“I appeal to anybody to bring us anything, or others won’t live until tonight,” he said, motioning toward five men and women who were having trouble breathing, a sign that the end was near.

The dead man was Joseph Julien, a 70-year-old diabetic who was pulled from the partially collapsed building and passed away Thursday for lack of food.

His rotting body lies on a mattress, nearly indistinguishable from the living around him, so skinny and tired they seemed to be simply waiting for death.

With six residents killed from the quake, the institution now has 25 men and 60 women camped outside their former home.  Some have a mattress in the dirt to lie on.  Others don’t

Madeleine Dautriche, 75, said some of the residents had pooled their money to buy three packets of pasta, which the dozens of pensioners shared on Thursday, their last meal.  Since there was no drinking water, some didn’t touch the noodles because they were cooked in gutter water.

Dautriche noted that many residents wore diapers that hadn’t been changed since the quake.

“The problem is, rats are coming to it,” she said.

Though very little food aid has reached Haitians anywhere by Sunday, Emmanuel said the problem was made worse at the nursing home because it is located near Place de la Paix, an impoverished downtown neighbourhood.

Thousands of homeless slum dwellers have pitched their makeshift tents on the nursing home’s ground, in effect shielding the elderly patients from the outside world with a tense maze of angry people, themselves hungry and thirsty.

“I’m pleading for everyone to understand that there’s a truce right now, the streets are free, so you can come through to help us,” said Emmanuel, 27, one of the rare officials not to have fled the squalor and mayhem.  He insisted that foreign aid workers wouldn’t be in danger if they tried to cross through the crowd to reach the elderly group.

Violent scuffles erupted Saturday in the adjacent soccer stadium when U.S. helicopters dropped boxes of military rations and Gatorade.  But none of this trickle of help had reached the nursing home residents, who said some refugees have robbed them of what little they had.

Dautriche, who was sitting on the ground because of her broken back, held out an empty blue plastic basin.  “My underwear and money were in there,” she said, sobbing.  “Children stole it right in front of me and I couldn’t move.”

The area was an eery corner of silence within the clamour of crying babies and toddlers running naked in the mud.  Guarding the little space was Phileas Jilien, 78, a blind man in a wheelchair who shouted at anybody approaching to turn back.

During moments of lucidity, Julien said he was better off than other pensioners because the medicine he was taking provided sustenance.  A moment later, he threw his arms out to hug a passer-by he mistook for his grandson.

Also trying to guard the centre was Jacqueline Thermiti, 71, who couldn’t stand because of pain but who brandished her walking stick when children approached.

“Of all the wars and revolutions and hurricanes, this quake is the worst thing God has ever sent us,” Thermiti said.

Initially, Thermiti and others believed their relatives would come feed them, because many live in the slums nearby.  “But I don’t even know if my children are alive,” she said.

Thermiti was suprisingly feisty for someone who hadn’t eaten since Tuesday.  She attributed that to experience with hunger during earlier hardships.

“But I was younger, and now there’s no water either,” she said.

She predicted that unlike other pensioners, she could still hold out for at least another day.

“Then if the foreigners don’t come (with aid),” she said, “it will be up to baby Jesus.”

http://www.cbsnews.com/stories/2010/01/17/world/main6107810.shtml

Ensure that you get quality care

To make to most of hospital-based medicine:

*Don’t allow a lack of familiarity to prevent you from getting your questions answered.  If it’s on your mind, it’s not a stupid question – so go ahead and ask.

*Regardless of who’s caring for you, have a friend or family member act as an advocate for you while you’re in the hospital.  An advocate speaks out on your behalf when necessary, ensuring that procedures and processes are done in a timely manner and asking important questions that might have been overlooked.

*Call your primary care doctor if you feel the need to talk to him or her while you’re in the hospital.  Simply because your regular physician isn’t heading up your care doesn’t mean her or she can’t participate in it.

*If you’re uncomfortable with the hospitalist that you’ve been assigned, ask to change.  Although policies differ from one institution to the next, no hospital wants unhappy patients.  More likely than not, you’ll be allowed to switch doctors.

*Get involved in the discharge process.  Make sure you fully understand what medications you’re supposed to take when you leave the hospital and any other special instructions the hospitalist gives you.

*Schedule an appointment with your primary care physician before you leave the hospital.  If nothing else, the visit will allow your doctor to familiarize himself or herself with what transpired while you were there.

Ulene, V. (2010, Feruary 1). Ensure that you get quality care. Los Angeles Times, Web.

Study: Doctors delay communicating end-of-life care issues with terminally ill patients

Delays mean patients might not be able to make informed choices early in their treatment.

Most doctors don’t talk about end-of-life issues with their cancer patients then those patients are feeling well, a new survey has found.  Nor do they talk about them until treatments have been exhausted.  Those delays mean patients might not be able to make truly informed choices early in their treatment.

The study, published online Jan. 11 in the journal Cancer, surveyed 4,188 physicians about how they would talk to a hypothetical cancer patient with four to six months to live.  A majority of of respondents (65%) said they would discuss prognosis, but only a minority said they would discuss do-not-resuscitate status (44%), hospice (26%) or preferred site of death (21%) at that time.  Rather, they would wait until symptoms were present or until there were no more treatments to offer. 

Current guidelines, from the National Comprehensive Cancer Network, a not-for-profit alliance of 21 of the world’s leading cancer centers, say that such conversations should be initiated whenever a patient has been given less than a year to live, if not a diagnosis.

Doctors gave various reasons for not following the guidelines.  Some didn’t want to dash patients’ hopes; some wanted to continue treating patients.  In addition, said lead author Dr. Nancy Keating of Harvard Medical School: “There’s at least some evidence to suggest that patients don’t want to hear about these things.”

Here’s a closer look at why end-of-life discussions are important.

If don’t sensitively and as part of ongoing medical care, discussing whether to resuscitate, when to seek hospice care and where patients want to spend the last days of their lives can actually empower patients, rather than making patients lose hope, say Keating and other palliative care experts.  Instead, the talks help patients gain some control over treatment and over the final stage of their lives.

“My own view about this is that the whole approach to dying is really an approach to living,” says Dr. Katherine Kahn, a UCLA physician and co-author of the new study.  “The more we can make these discussions about end of life part of a larger set of discussions with patients about how they approach medical care and how they approach life, the better we can honor their medical wishes when it comes time.”

To do this, patients and doctors need to accept the facts, says Dr. Michael Levy, an oncologist at Fox Chase Cancer Center in Philadelphia.  He chaired the panel that crafted the cancer network guidelines.

Only 15% of patients with Stage 4 cancer have viable chance at a cure, he says, and even in those patients, only 50% are cured.  “That means that 92.5% of patients with advanced disease will die of their cancer,” Levy says.  “So you’ve got to just talk about it.”

Patients may not fully understand the implications of additional chemotherapy or aggressive interventions.  Further chemotherapy can limit the number of days in which they feel well enough to enjoy the company of friends and loved ones.  And interventions such as cardiopulmonary resuscitation often don’t work as well as people expect.  Less than 10% of cancer patients who get CPR recover enough to leave the hospital, according to a 2007 review published in the American Journal of Hospital Palliative Care.

A study published Jan. 10 in the Journal of Clinical Oncology found that patients who watched a six minute video explaining lifesaving procedures, hospitalized care and palliative care made much different choices than those patients who didn’t watch the video.

Of 23 brain cancer patients who watched the video, 91% chose care designed primarily to keep them comfortable rather than basic hospital care or life-prolonging care.  The latter includes CPR and ventilation.  Of 27 subjects who heard a description of the different care levels but didn’t watch the video, 22% chose comfort care, 52% chose basic care and 26% of patients chose life-prolonging care.

Research has shown that informing patients about end-of-life care can reduce medical costs.  (See related story.?  Moreover, nurses and family members reported more physical distress and worse quality of death in the uninformed patients.

In addition to medical costs, the number of treatments and the amount of suffering go up when patients are not informed about palliative care choice, says Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.  “When I look at the unnecessary costs that accrue at the end of life, the first ones I see are the high human costs of suffering and the toll that that takes on patients’ – and families’ – well-being.”  He described one woman with advanced cancer who was sedated and intubated in the intensive care unit after a bowel obstruction.  “To her family, the worst thing they can imagine is their dear mother dying,” he says.  “To those of us who do this work, we know that in fact there are worse things than someone you love dying.  The most obvious thing that is worse is having someone you love die badly, to see them die suffering.  Often they’re sedated or having their hands physically tied down so they can’t remove [tubes].  Perhaps even worse than even that is realizing at some point that your loved one’s suffering is largely unnecessary.”

In order to have such conversations, doctors first must give up their own notions of what constitutes good care, Levy says.  Reflecting on his early years in cancer care, Levy acknowledges: “I honestly found it easier to give end-of-life care to someone else’s patient than my own.  Because [after] having entered that contract of ‘I’m going to control your disease, I’m going to get it,’ it really is hard to feel some sense of failure.”

By reframing the doctor’s job – or contract, as Levy calls it – palliative care becomes a useful and necessary part of care.  He says doctors’ jobs are to provide care for that patient rather than engage in battle with the cancer.

Keating says many doctors are more comfortable when patients say they want to do everything possible to fight their cancer.  Then the doctor can simply move on to the next treatment plan, which might have some effect.  “But what does ‘some effect’ mean?” she asks.  “It might slow the progression of your tumor temporarily, but it’s not going to cure you.  I think that’s where the lack of communication is the most important.”

In fact, the hypothetical patient from Keating’s survey was by definition already eligible for hospice care — “a significant package of services for patients and families,” Byock says.

Under Medicare, people 65 and older are entitled to hospice care.  “In not mentioning that to patients, the clinicians are limiting access to valuable services in a way that does not conform with best practice,” he says.

Adams, J. (2010, January 25). Study: doctors delay communicating end-of-life care issues with terminally ill patients. Los Angeles Times, Web.

http://www.latimes.com/features/health/la-he-closer25-2010jan25,0,5766082.story

Choices at the end of life

It’s a time that can be emotionally and financially draining.  Those who’ve studies the matter say that informed choice can make a difference.

Every year, billions of dollars are spent in the United States to treat terminally ill patients during their final year of life.  Tests, procedures and hospitalizations do little to prolong or improve the quality of that life, research suggests, and in fact may make the final days of terminal illness more emotionally upsetting for patients and their families.

The Centers for Medicare and Medicaid Services estimate that 5% of the beneficiaries who die each year take up 30% of the $446-billion annual Medicare budget.  About 80% of that money is spent during the final month, on mechanical ventilators, resuscitation and other aggressive life-sustaining care.  Often, the aggressive steps taken to save someone’s life are futile.  A 2009 study published in the New England Journal of Medicine found that just 18% of adults older than 65 who received cardiopulmonary resuscitation in the hospital survived the procedure long enough to be discharged.  In addition, researchers found the procedure in some cases prolonged patients’ suffering. 

“People may think that the more money spent on their healthcare, the better care and quality of life purchased.  At the end of life, it doesn’t work that way,” says Holly G. Prigerson, director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute at Harvard Medical School.  She was one of the authors on an end-of-life care study published last year in the Archives of Internal Medicine.  “In fact, we found the opposite to be true.  We found that most of the costs of end-of-life care pay for burdensome, non-curative care that offers no substantial survival advantage.”

That study showed that cancer patients who planned in advance with their doctors about end-of-life treatment had much lower healthcare costs in their final week of life than those who didn’t.  What’s more, the higher the cost of medical care, they found, the worse the patient’s quality of life was in the final week of life. 

“People may not realize what their healthcare dollar buys them at the end of life,” Prigerson says.  “We found that the costs of care increase dramatically as death approaches, so too does the patient’s emotional and physical suffering.”  The emotional disadvantages of receiving aggressive treatment at the very end stages of illness extend to the patient’s family.  People who die in hospice, for example, are less likely to get aggressive care, and their quality of life is better, Prigerson said.  There is no difference in the patient’s survival, and the bereaved family members fare better emotionally six months later, she said.

Overall, end-of-life discussions and the use of advance directives, which allow patients to state their treatment wishes and appoint someone to make medical decisions on their behalf, seem to lead to happier patients and lower medical costs, studies have shown.  In fact, the Archives study by Dana-Farber researchers found that patients who had engaged in end-of-life discussions incurred more than $1,000 less in medical costs in their final week of life than those who did not.

Informed Patients

Patients’ understanding of their illness and how it’s likely to progress plays a large role in the choices the make about treatment.

“Generally speaking, when patients are given their treatment options and the risks and benefits of each, they tend to choose, the research has shown, less intensive and less costly approaches to care,” says Rosemary Gibson, who led national initiatives to improve healthcare quality and safety at the Robert Wood Johnson Foundation for 16 years.  She’s the author of the forthcoming book “The Treatment Trap.”

Many people don’t realize, says Prigerson, that a person kept alive on a breathing machine can’t talk to doctors or loved ones.  Once people understand the details of some of the procedures used to keep someone alive at the end, she says, many choose another path. 

There is evidence that palliative care is generally less expensive.  That type of care emphasizes working collaboratively with terminally ill patients to ensure their physical and emotional comfort – not to cure them.

A 2008 study also published in the Archives if Internal Medicine examined the cost effects of palliative care programs at eight hospitals throughout the country and found savings of about $1,700 per patient for those discharged from the hospital alive, and nearly $5,000 per patient who died during hospitalization.  Reduced pharmacy, laboratory and ICU costs accounted for much of the savings.

“If you sit down with patients and families in the setting of serious illness, and talk to them about their goals of care, talk realistically about what modern medicine can achieve and what it can’t, and then match treatments to those goals, you save money,” says Dr. Sean Morrison, the study’s lead researcher and director of the National Palliative Care Research Center at the Mount Sinai School of Medicine in New York.

Most experts on end-of-life care insist that focusing so intently on end-of-life costs won’t fix what ails our healthcare system.  “We don’t want to save on the backs of the dying,” Morrison says.  “The larger issue is cost associated with people living with serious illness.”

Reforming care

Palliative care programs have proliferated throughout U.S. hospitals over the last decade.  As of 2005, 70% of large hospitals reported having such a program, up 96% from 2000.  Still, few patients are gaining access.

There are a number of reasons for this, Morrison says.  Most hospital-based palliative care programs are quite small and depend on primary physicians to make the referral.  For that to happen, many more doctors need training on how to treat people with serious illness and discuss end-of-life care.  There are several national initiatives underway to meet that training need, he says.

The healthcare reform bills now being debated in Congress include a number of demonstration projects aimed at reining in costs and improving the quality of healthcare received by terminally ill Medicare beneficiaries.  If successful, such programs might later become a permanent part of the Medicare benefit.

One project would allow hospice-eligible patients to continue to receive all Medicare covered services for which they were eligible prior to entering hospice.  Under current guidelines, once a recipient enters hospice care, Medicare no longer pays for services to treat the terminal illness that put them there.

Other measures contained in both the House and Senate bills, if passed, ultimately may improve efficiency of care, as well as foster better communication among physicians, hospitals, long-term service providers and patients, says Peter Notarstefano, director of home and community-based services for the American Assn. of Homes and Services for the Aging.

By placing a greater emphasis on coordination of care, patients at the end of their lives are more likely to die in comfort and with dignity, he says. 

“Congress is saying we have to break down the silos and the mind-set of this provider does and that provider does that,’ “ Notarstefano says.  “It’s losing the fee-for-service mentality and recognizing that we need to learn how to best treat people at the end of their life.”

Zamosky, L. (2010, January 22). Choices at the end of life. Los Angeles Times , Web.

http://www.latimes.com/features/health/la-he-end-of-life-costs25-2010jan25,0,6316828.story

Hospice care helps patients and loved ones.

More patients use the service for end-of-life care.  But what is it?

Over the last 25 years, the number of Americans turning to hospice for end-of-life care has climbed dramatically – from 25,000 in 1982 to 1.45 million in 2008, as more and more people choose to spend their final days in the comfort of home or a patient facility with a home-like environment rather than in a hospital pursuing aggressive treatments. 

During the last decade, Medicare reimbursements for hospice have also risen, allowing more hospices to open without relying on fundraising for survival, says Christy Whitney, chief executive of Hospice and Palliative Care of Western Colorado in Grand Junction.

The decision to stop curative treatment and enter hospice is never easy, and it comes at a stressful time.  Even once the decision is made, arranging for hospice care requires the acknowledgment of unpleasant realities, which doctors themselves may hesitate to discuss.  This reluctance can put the onus on patients and families to initiate difficult conversations about end of life care.

Here’s a guide to navigating the hospice system so that you and your loved ones can get the information you need to make informed decisions. 

What is hospice?  Hospice provides support for people entering the final stages of their lives, and their families; the word is a medieval term that describes a brief resting place on a long and difficult journey. 

According to the official philosophy statement of the National Hospice and Palliative Care Organization, “Hospice affirms life and neither hastens nor postpones death.”  Instead, it strives to enhance the quality of a person’s remaining life by providing medical care, pain management, and emotional and spiritual support.

When hospice first came to the U.S. from England in the 1970s, it was used mainly as a home care program for cancer patients.  It soon broadened its scope to include anyone facing a terminal diagnosis.  Today, cancer accounts for fewer than 40% of all hospice patients, says Donald Schumacher, president and chief executive of the National Hospice and Palliative Care Organization.

Hospice service is most commonly delivered in the home, but it can also be provided at a nursing home or in-patient hospice care facility.

Who is eligible?  Anyone with a terminal illness who has decided to stop seeking curative treatment.  The initiation of hospice care requires a referral from a doctor certifying that the person has been diagnosed with a disease or illness that, if it ran its normal course, would result in a prognosis of six months or less to live.  That doesn’t limit patients to six months of care, though.  “You can continue receiving hospice as long as you’re still terminally ill,” Schumacher says.  In 2008, the median number of days that patients received hospice care was 21.4 days, and the average was 69.5.

What does it cost?  About 84% of hospice care is paid for by Medicare, and most insurance companies cover it.  But hospice services are provided without regard to the ability to pay, and most have programs to help families pay if they lack coverage or means.  “No one is turned away,” says Mary Ellen Blakley, administrator for the hospice Partners of Southern California.

Make plans long before you are sick:  Whether you’re perfectly healthy or you’ve just been diagnosed with a serious condition but are still feeling fine, now is a good time to put your last wishes in writing.  “It’s hard to make good decisions when you’re in the midst of a tragedy or drama,” Schumacher says.

An advanced directive, a legal document that identifies your wishes regarding medical treatment at the end of life, gives doctors formal instructions on the care you want if faced with a terminal illness or injury, and can give peace of mind to loved ones who can know for certain they’re following your wishes, Whitney says.

Often family members have different ideas about “what Mother really wanted,” and that can put families in conflict.  “Don’t assume that anybody knows what you want.  Get it down in writing,” Schumacher says.

Each state’s advanced directive forms are different; you can download them free at Caringinfo.org.  Leave copies with family members and your doctor, not in a safe-deposit box where no one can get to it.

Perhaps the most effective thing you can do in advance is to designate a medical power of attorney, a person you assign the authority to make medical decisions for you if you become incapacitated, Whitney says.  Ideally, this is someone who understands your values and wishes and can explain these to family members who might feel torn about what to do.

When and how to have the discussion:  Family members and terminally ill patients often struggle to initiate discussions about death, and this can result in a conspiracy of silence that can delay hospice care, Whitney says.  “Very often the patient says to me, ‘I know my husband is dying, but please don’t tell him.’ “ 

Because doctors too may be reluctant to suggest hospice, it’s often up to the patient or family to ask.  If needed, hospice staff can call the doctor to help initiate the discussion.  Some loved ones fear that raising the idea of hospice care could make the patient think that they’re withdrawing support, but Schumacher, a clinical psychologist, says that’s rarely the case.  Discussing what is happening in frank terms can often come as a tremendous relief to the person who’s dying.

“They can be living under this pressure to stay alive for the wife and kids.  I’m surprised at how often they feel guilty, like they’ve let people down by getting ill, and giving them permission to be sick can lift this burden,” Schumacher says.

One way to begin the discussion is by taking an “expect the best but prepare for the worst” approach.  “You don’t want to push people into talking about it if they’re not ready,” Schumacher says.  “But you can say, ‘Listen – we’re going to fight with you, but let’s just talk about what we should do if you aren’t getting better, just in case.’ “

What to expect from hospice: Hospice care begins with a visit from a nurse, who meets with the patient and the family to put together a care plan that fits with the patient’s values and needs.  But it’s not just for the patient.  “Our basic philosophy is that the patient and the family are the unit of care,” Schumacher says.  “The family receives a lot of psychosocial and spiritual support throughout the process.”

Hospice provides visits from doctors, nurses, home health aides and volunteers, but these do not take the place of the primary caregiver, Blakley says.  Instead, hospice workers go in as an extra set of hands, helping to bathe the patient and assisting with bed changes and similar tasks.  A hospice volunteer might also visit to read to the patient or offer a listening ear for family members.  Workers help caregivers ensure that their loved ones are comfortable and deliver pain medications, nursing care and palliative measures as needed.

Most hospice care is delivered in the patient’s residence, where routine visits from hospice doctors, nurses and home health aides are designed to make the dying process and comfortable as possible for the patient and family.

Hospice doesn’t take hope away, Whitney says.  “There’s no rule that you have to die because you go into hospice.  We discharge 15% of our patients every year, because they get better.”  In fact, many people make improvements after they begin hospice, because they stop treatments that were making them feel lousy, she says. 

Preliminary evidence suggests that hospice may actually extend life.  A study published  in the Journal of Pain and Symptom Management in 2007 examined the outcomes of 4,493 patients with six different terminal illnesses – five cancers and congestive heart failure – and found that those who received hospice care had an average survival of 29 days longer than those who did not.

After a loved one has died: Support for the family continues for a year or more.  Men often remarry quickly to avoid grieving, but hospice helps surviving spouses and other loved ones manage better than that by offering individual grief counseling, information about coping strategies and support groups.

The hospice period gives people an opportunity to finish up their life business and let go of loved ones in a way they can feel good about, Schumacher says.  “When people have those final conversations, they can become very close.  It’s a very intimate process, and it’s unique to each person.”

Aschwanden, C. (2010, January 22). Hospice care helps patients and loved ones. Los Angeles Times, Web.

http://www.latimes.com/features/health/la-he-hospice25-2010jan25,0,6111030.story