Author Archives for Herb Weiss

Rethinking Rhode Island’s LTC Delivery System

Published in the Woonsocket Call on April 12, 2015

AARP Rhode Island releases a state-specific analysis, of the 2014 edition of “Raising Expectations: A State Scorecard on Long-Term Services and Supports (LTSS) for Older Adults, People with Physical Disabilities, and Family Caregivers” that just might give state officials cause for concern, a low rating on its long-term care delivery system, when compared to other states.

The 2011 Scorecard was the first multidimensional assessment of state performance of LTSS. Like this earlier version, the release of the 109 page 2014 report, referred to as the LTSS Scorecard, and its state-specific analysis (prepared by policy consultant Maureen Maigret), measuring how well the nation and each of the states is doing in providing long-term care services, does not bode well for the nation’s littlest state. It finds the Ocean State ranks 38th nationally on 26 performance indicators, with it achieving the lowest rank of all New England States.

“Our analysis provides a closer look at where Rhode Island is keeping pace and where we fall short,” said AARP State Director Kathleen Connell. “The report indicates that, as the state with the highest percentage of persons 85 and older, we face exceptional challenges. It is our hope that the General Assembly and state policymakers find the analysis to be a valuable tool,” she says.

Failing Grades

The 2014 LTTS Scorecard indicates that Rhode Island:

• Ranks 4th highest among states in nursing home residents per 1,000 persons age 65 and over

• Has a high percent of low-care nursing home residents and spends a far higher percent of its LTSS dollars than the national average on nursing home care as opposed to home and community-based services.

• Has some of the highest long-term care cost burdens in the country making private pay long-term services unaffordable for the vast majority of older households.
But, on a positive note, the state-specific analysis noted that Rhode Island’s best progress was made in the Legal and System Supports dimension largely due to the 2013 passage of the Temporary Caregiver Insurance program and Caregiver Assessment requirements for Medicaid Home and Community Based Services (HCBS).

In addition, to revisiting the 19 recommendations made following the release of AARP’s 2011 Scorecard, the more recent 2014 analysis recommends five new major policy initiates to improve the littlest state’s LTSS. Among the recommendations: funding of an Aging and Disability Resource Center; the developing an online benefits screening tool to allow access to income-assistance benefits and conducting outreach programs to increase participation; reviewing the Rhode Island’s Nurse Practice Act to allow nurse delegation of certain health maintenance and nursing tasks to direct care workers; requiring hospitals to provide education and instruction to family caregivers regarding nursing care needs when a patient is being discharged; and exploring emerging medical technologies to better serve home and community based clients.

The current analysis finds that only four recommendations out of the 2011 recommendations have been implemented, most notably those to promote coordination of primary, acute and long-term care and to strengthen family caregiver supports.

Meanwhile, only six recommendations were partially implemented, including the expansion of the home and community co-pay program and authority (but not implementation) under the 1115 Medicaid waiver renewal to provide expedited eligibility for Medicaid HCBS and for a limited increase in the monthly maintenance allowance for persons on Medicaid HCBS who transition out of nursing homes. Finally, nine recommendations, although still relevant, have not been implemented.

Response and Comments

Responding to the release of AARP’s 2014 Scorecard and state-wide analysis, Governor Gina Raimondo says, “we need to ensure that we have a strong system of nursing home care for those who truly need those services, but we must invest our Medicaid dollars more wisely to support better outcomes. We cannot continue to have the fourth highest costs for nursing home care (as a percent of median income of older households) and also rank near the bottom of all states in investments in home and community-based care.”

According to Raimondo, the state’s Working Group to Reinvent Medicaid is looking closely at AARP’s Scorecard and state-specific analysis and Rhode Island’s spending on nursing home and long-term care. Health & Human Services Secretary Elizabeth Roberts has directed her staff to look directly at the proposals recommended by AARP Rhode Island.

“I expect the Working Group will include specific proposals stemming from these findings in their April budget recommendations and their long-term strategic report they will complete in July,” says the Governor.

AARP Rhode Island Executive Director Connell, representing over 130,000 Rhode Island members, was not at all surprised by the findings of the recently released 2014 Scorecard. “Based on benchmarks set in the 2011 Scorecard, it was apparent that there was much work to do,” she says, recognizing that there are “limited quick fixes.”

“Some steps in the right direction will not lead to an immediate shift in the data. This is a big ship we’re trying to steer on a better course. We were encouraged, however, by ‘improving’ grades for lower home-care costs and the percentage of adults with disabilities ‘usually or always’ getting needed support rising from 64 percent to 73 percent,” adds Connell.

Connell says that the Rhode Island General Assembly is considering legislation to improve the delivery of care, which might just improve the state’s future AARP ‘report’ cards.” “In this session, there is an opportunity to improve long-term supports and services with passage of several bills, including one that would provide population-based funding for senior centers,” she says, stressing that it’s a “responsible investment that will help cities and towns provide better services.”

Connell adds, “The proposed CARE Act gives caregivers better instruction and guidance when patients are discharged and returned to their homes. This can be a cost saver because it can reduce the number of patients returned for treatment or care.”

The larger mission for state leaders is the so-called ‘re-balancing’ of costs from nursing care to home to community-based care. That’s where real savings can occur and home is where most people would prefer to be anyway.”

Finally, Virginia Burke, Executive Director of the Rhode Island Health Care Association, a nursing facility advocacy groups, supports the implementation of the policy initiatives recommended by AARP’s state-specific analysis. But, “The primary driver of our state’s nursing facility use is the extremely advanced age of our elders,” Burke says, noting that the need for nursing facility care is more than triple for those aged 85 and older than for seniors just a decade younger. Due to the state’s demographics you probably won’t see a change of use even if you put more funding into community based home services, she adds.

Governor Gina Raimondo and the General Assembly leadership will most certainly find it challenging to show more improvement by the time the next Scorecard ranks the states. Older Rhode Islanders deserve to have access to a seamless system, taking care of your specific needs. Creative thinking, cutting waste and beefing up programs to keeping people in their homes as long as can happen might just be the first steps to be taken. But, the state must not turn its back on nursing facility care, especially for those who need that level of service.

Herb Weiss, LRI ’12 is a Pawtucket writer who covers aging, health care and medical issues. He can be reached at hweissri@aol.com.

How to Keep Social Security off the GOP Chopping Block

Published in Woonsocket Call on April 6, 2015

One of the first political skirmishes to protect the nation’s Social Security program, 589 days before next year’s Presidential election, took place on March 24th in the U.S. Senate during budget debate. Leading the charge, Rhode Island Senator Sheldon Whitehouse called up Senator Wyden (D-OR)’s budget amendment, requesting a Senate point of order against legislation to cut benefits, raise the retirement age, or privatize Social Security.

During the debate, “Social Security benefits are a solemn promise that our seniors have earned over a lifetime of work,” said Whitehouse, a founding member of the Senate’s Defend Social Security Caucus. “Sadly, Republicans have made it their mission for decades to dismantle that promise, attempting to turn it over to Wall Street and cut benefits through misguided ideas like the so-called ‘chained-CPI’,” he charges, noting that the Democratic sponsored amendment protects Social Security from right-wing attacks and ensure that retirees can count on their earned retirement benefits.

Republican Senator Enzi from Wyoming raised a point of order, calling Wyden’s amendment non germane to the budget resolution being debated. With the Democrats rallying 51 Senators to vote yea, 60 votes were required to wave Enzi’s point of order.

Although his attempts to protect Social Security in the Senate budget failed, Richard Davidson, Whitehouse’s Rhode Island Press Secretary, tells this columnist that the Senator plans to continue his efforts to keep Social Security off the GOP budget chopping block and from being privatized by supporting legislation like the Keeping Our Social Security Promises Act, legislation that would raise the income cap on the payroll tax to ensure the program’s solvency.

Davidson also states that the Social Security trust funds are projected to be fully solvent though 2033, and there’s no immediate funding crisis. But, in the longer run, Whitehouse believes the program must be bolstered by applying the payroll tax, which currently only applies to income up to $118,500, to higher levels of income, he says.

Protecting SSDI

One month before the Senate Budget debate, the GOP-controlled Senate Budget Committee put a spotlight at a hearing on the impending insolvency of the nation’s Social Security Disability Trust Fund (SSDI). The federal government has predicted that SSDI fund reserves will run low by the end of 2016, at which point millions of disabled beneficiaries could see up to a twenty percent cut in benefits.

At the Senate hearing, entitled “The coming crisis: Social Security Disability Trust Fund Insolvency,” Democrats called for an easy quick fix to the problem, specifically the shifting of a small percentage of the Social Security payroll tax from the retirement trust fund to the disability trust fund. No big deal, they say, because these transfers have occurred 11 times in the past with bipartisan support without political bickering. But, from this hearing it seemed clear that GOP Senators, who control the Senate, now see things differently and are threatening to block the infusion of funds to SSDI.

Approximately 10.2 million Americans received SSDI benefits in 2013, including roughly 42,000 Rhode Islanders. In order to qualify, beneficiaries are required to have worked in a job covered by Social Security, and must have been unable to work for a year or more due to a disability.

A February 9 posting on the Plum Line blog, penned by Greg Sargent for the Washington Post web site, takes a look a look at this SSDI entitlement debate.
In his opinion blog, Sargent says that GOP lawmakers claim that a “restricting a fund transfer is all about forcing a necessary discussion on how to improve Social Security’s long term finances, rather than merely “kicking the can down the road.” On the other hand, the Washington Post blogger believes Democrats see the Republicans as “exaggerating the sense of crisis to realize one of two political goals. Either they want to force immediate, and unnecessary, cuts – or they want to hold the disability fund hostage, in order to have another run at cuts to the broader program [Social Security].”

Gathering the Troops

At a March 23rd panel discussion hosted by the Providence-based Headquarters of Community Action Partnership , Whitehouse and Congressman Jim Langevin with Rhode Island Senator Donna Nesselbush, a disability attorney, along with SSDI recipients, disability groups, and the Social Security Administration, came to discuss the solvency of SSDI and its impact on the Ocean State. The lawmakers called for shifting Social Security payroll taxes to financially shore up the ailing SSDI program. Both lawmakers also supported a long-term solution, fully funding the federal retirement and disability programs by lifting the cap on the amount of income that is subject to the payroll taxes that fund the program.

“Right now, a millionaire hedge-fund manager pays the same amount of taxes into the Social Security system as someone who makes $118,500,” said Whitehouse. He called for “wealthiest Americans to pay a fair share into the program, so that it’s not funded disproportionately on the backs of middle-class workers.”

Congressman Langevin stressed “SSDI is not only a critical safety-net for disabled workers, their children and spouses, it is also a promise we make to everyone who pays into the Social Security trust fund that they won’t be impoverished if they are left with a debilitating condition or disability.”
Although Whitehouse’s efforts to protect the nation’s Social Security and Disability programs were derailed in the Senate Budget debate because of a GOP procedural call, it’s only the first of many political skirmishes to come. The upcoming 2016 Presidential elections will firmly put this entitlement issue on the nation’s radar screen, hopefully to address once and for all.

But, here’s my message to Whitehouse: Even if you lose a skirmish, or battle, you can always win the war. Keep pushing.

Herb Weiss, LRI ’12, is a Pawtucket-based writer covering aging, health care and medical issues. He can be reached at hweissri@aol.com.

Putting the Brakes on Testosterone Prescriptions

Published in Pawtucket Times on March 30, 2015

Sophisticated mass marketing pitching testosterone to combat age-related complaints combined with lax medical guidelines for testosterone prescribing can be hazardous to your physical health, even leading to strokes and death, warns an editorial in this month’s Journal of the American Geriatrics Society.
The March 2015 editorial coauthored by Dr. Thomas Perls, MD, MPH, Geriatrics Section, Department of Medicine, Boston Medical Center in Boston, and Dr. David Handelsman, MBBS, Ph.D., ANZAC Research Institute, in New South Wales, Australia, expressed concern over commercial-driven sales of testosterone, effectively increasing from “$324 million in 2002 to a whopping $2 billion in 2012, and the number of testosterone doses prescribed climbing from “100 million in 2007 to half a billion in 2012.”

Pitting Patients Against Patients

The editorial authors see the “40 fold” increase of testosterone sales as the result of “disease mongering,” the practice of widening the diagnostic boundaries of an illness and aggressively promoting the disease and its treatment in order to expand the markets for the drug. Glitzy medical terms, like “low T” and “andropause,” showcased in direct-to-consumer product advertising pit aging baby boomers against their physicians, who demand the prescriptions, say the authors.

“Clearly, previous attempts to warn doctors and the public of this disease mongering that is potentially medically harmful and costly have not been effective, says co-author Dr. Perls.

The epidemic of testosterone prescribing over the last decade has been primarily the proposing of testosterone as a tonic for sexual dysfunction and/or reduced energy in middle-aged men, neither of which are genuine testosterone deficiency states,” observes Dr. Handelsman.

According to the National Institutes on Aging (NIA), the nation’s media has increasingly reported about “male menopause,” a condition supposedly caused by diminishing testosterone levels in aging men. “There is very little scientific evidence that this condition, also called andropause or viropause, exists. The likelihood that an aging man will experience a major shutdown of testosterone production similar to a woman’s menopause is very remote.”

The authors agree with the NIA’s assessment, but go further. They point out in their editorial that for many men, testosterone does not decline with age among men retaining excellent general health, and if it does, the decline is often due to common underlying problems such as obesity and poor fitness. Those who hawk testosterone have developed advertising that focus on common complaints among older men such as decreased energy, feeling sad, sleep problems, decreased physical performance or increased fat.

But, many times a testosterone level won’t even be obtained and the patient is told that, simply based on these common symptoms alone or with minor reductions in serum testosterone, they have “late onset hypogonadism” or that their erectile dysfunction may be improved with testosterone treatment, say the authors. But the authors also point out the true hypogonadism is the cause in fewer than 10% of men with erectile dysfunction.

FDA Enters Debate

The U.S. Food and Drug Administration’s (FDA) recent dual commission findings concluded that testosterone treatment (marketed as ‘low T’) is not indicated for age-associated decline. The benefits of this “deceptive practice” remain unproven with the risks far outweighing the perceived benefits,” says the agency. Pharmaceutical companies are now required to include warning information about the possibility of an increased risk of heart attacks and stroke on all testosterone product labels.

Health Canada, Canada’s FDA, recently echoed the FDA’s committee findings that age-related hypogonadism has not been proven to be a disease-justifying treatment with testosterone. Both agencies warn of an increased risk of blood clots in the legs and lungs and the possibility of increased risk for heart attack associated with testosterone use.

In a statement, James McDonald, the chief administration officer for the Board of Medical Licensure and Discipline, says: “There is a concern in healthcare regarding direct-to-consumer prescribing of medication. At times, the prescription is not evidence-based, and can lead to misuse. There is concern with Testosterone, a schedule 3 controlled substance,that can be used as a performance-enhancing drug. The Rhode Island Board of Medical Licensure (BMLD) investigates complaints regarding all types of misuse of prescription medications as well as complaints regarding over-prescribing.”

Drs. Handelsman and Perls also warn about another drug commonly hawked for anti-aging, growth hormone. The FDA requires that doctors perform a test to demonstrate that the body does not produce enough growth hormone. “Those who market and sell HGH for these common symptoms nearly never perform the test because if they did a properly performed test, it would almost never be positive because the diseases that cause growth hormone deficiency in adults, such as pituitary gland tumors, are very rare,” said Perls. Growth hormone is well known for its side effects, including joint swelling and pain and diabetes. Ironically, opposite of anti-aging claims, growth hormone accelerates aging, increases cancer risk and shortens life span in animal studies.

In the editorial, Perls and Handelsman call upon professional medical societies and governmental agencies to take definitive steps to stop disease mongering of growth hormone and testosterone for conjured-up deficiencies.
“These steps include the banning of ‘educational’ and product advertising of testosterone for these contrived indications,” said Perls. “Furthermore, the FDA and Health Canada should require a physician’s demonstration of a disease process proven to benefit from testosterone administration in order to fill a lawful prescription for testosterone.”

Tightening Up Prescription Guidelines

The issue of prescribing testosterone is firmly on the medical profession’s radar screen with the FDA’s recent committee’s findings and Perls and Handelsman’s pointed editorial calling for the medical profession to seriously tighten up the lax consensus guidelines in order to stop the medically inappropriate prescribing of testosterone.
Rather than pushing testosterone, wouldn’t it be a “mitzvah – a good deed- if the nation’s pharmaceutical companies ran public service commercials stressing the importance of losing weight, exercising and eating nutritious meals as a way to effectively combat age-related problems, like low libido. But, this won’t happen because it is not a revenue generator or good for the company’s bottom line.

Herb Weiss, LRI ’12 is a Pawtucket-based writer covering aging, health care and medical issues. He can be reached at hweissri@aol.com.