No News Is Bad News

~ Chris Langston ~ Leave a comment

Once again it is time for my annual update on the number of physicians in geriatrics fellowship programs[1].  While this number might seem to be the eldercare workforce equivalent of looking for your wallet under the street light rather than out in the dark where you lost it, as I’ve argued in past years, the trend over time is actually a good measure of interest in the field of aging and reasonably reflective of the fortunes of other geriatric specializations in healthcare (e.g., nursing, social work, etc.), as well as being a very cheap and easy measure[2].

And, as usual, there just isn’t much good news to report.   As the 13 years of data show, the overall trend is downward or flat in all three specializations in geriatrics: internal medicine, family medicine, and psychiatry.  This year’s tiny uptick in internal medicine-based geriatric fellows is more than offset by the decline in family medicine and psychiatry.  The fill rate for positions is still just around 50% meaning that there are as many funded slots empty as there are filled and the rates of “foreign medical graduates” in fellowship slots remains astoundingly high, indicating that US medical school training is still not setting physicians onto the path into the discipline.  (And Pediatric Cardiology, our comparison group, seems to be back on its growth track. . .)

Somehow, I am reminded of an interaction I had about 10 years ago with an esteemed leader of one of the most prestigious academic medical centers in the country.  This leader visited me at my prior employer, chaperoned by his geriatrics division chief, who was also a long-time grantee of the foundation with grant support to produce future geriatrics faculty.  After an oddly lackadaisical pitch for funds for some purpose I don’t really recall, this esteemed eminence decided to offer some free advice – “You know what geriatrics needs?  A big research award to attract the best and brightest faculty and draw attention to the field, that’s what will make the discipline strong.”  As he said this I could see his geriatrics person, blanch as the foundation had been part of a funding consortium for just such an award since the mid ‘90s (The Paul B. Beeson Award[3]) and their esteemed institution was the nation’s biggest winner of such junior faculty support.

So, I allowed myself to gently snark back, that perhaps this theory of influence on the career choices of physicians was not complete.  And I mentioned the then hot idea of medical students learning to “follow the ROAD” – into residencies in Radiology, Orthopedics, Anesthesiology, and Dermatology.  These disciplines are famously lucrative and offer excellent quality of life, with scheduled, predictable work and few distraught people calling late at night.  But I was quite surprised that he effortlessly snarked right back that research in these disciplines had created interventions and services that people found valuable, thus earning the pay that they received.  Given that this is not exactly the way that reimbursement for physician specialty services is determined, I didn’t agree, and our mutual friend rapidly changed the subject.

But I am still struck that this department chair didn’t really disagree that pay was correlated with career choice, but only amended that pay was determined by something near and dear to his eminent heart – the research base that creates powerful and impactful interventions.[4]  Does geriatrics have powerful and effective interventions?  This is a question I’ve asked myself many times.  Is it true that more training in elder care makes health professionals more proficient and able to help their patients get better outcomes?  From time to time I’ve doubted, but I think the evidence is quite clear to the open mind.  Geriatrically expert care is better.  Through large scale research (e.g., the ACOVE program[5]) and my personal experiences, I’ve learned that older people frequently get care that fails them.  They can be over treated in ways reduce function and make them sicker.  They can be undertreated in ways that ignore solvable problems.  And they can be mistreated in ways that leave them frightened and suffering.

Unfortunately, this perception is not shared by the public nor by generalist physicians.  The public doesn’t want to be old and doesn’t want to admit that their health issues (and treatments) are a problem until it is too late.  The health professions don’t want to admit the sins against common sense that they make all too often in care of older adults – too many drugs, too little assessment of symptoms written off to “aging” and too much testing and treatment that isn’t going to matter anyway.

So, let’s turn it around – rather than moan about how people aren’t drawn into geriatrics because Medicare’s reimbursement is low (making the income low) – let’s look at who is serving complex older adults in non-fee-for-service roles and if geriatricians are taking/getting these jobs that would seem to be the best use of their skills.

As we all know by now 5% of the population drives 50% of healthcare spending.  The poster child for this spend is the homeless man who uses the ED in lieu of housing, food, and when it is very cold.  However, half of those 5% of people are over 65 and have much quieter and less public problems yet still wind up in the ED and hospital enough to make it into the group of elite “high utilizers.”  And with the shift from “volume to value” there is a case for effective management and prevention for this population.

And this is a “hot” part of healthcare.  The knowledge of the concentration of costs in a small population (many of whom are older Medicare beneficiaries) and capitation/sub-capitation has created a role for specialist provider organizations such as Iora and CareMore, which may be part of Medicare Advantage plans or partner with one.  These organizations design their processes and staffing for complex older adult patients with substantial health problems and social needs.  Similarly, working with fee-for-service beneficiaries, Medicare’s Accountable Care Organizations (AKA Medicare Shared Savings Programs) seek to hit quality and outcome targets while simultaneously reducing total healthcare costs.  While these organizations are defined by the population attributed to a network of primary care physicians, they are required to have medical directors to work within the system to design processes, educate their colleagues, and improve care.

These specialized delivery roles and specialized health system roles are something I’ve long wished would develop.  They create the hope that expertise in geriatrics could be profitable rather than a financial looser.  They get geriatrics out of the trap created by Medicare’s set prices for cognitive services.  Moreover, if geriatric expertise is valuable, it should be “bid up” in price given the limited labor supply, perhaps eventually drawing more physicians into the field (and fellowships).

So, are geriatricians being employed in these specialized care systems?  First, I looked at the executive leadership of Iora and CareMore including the corporate level medical directors.  None of the leaders in these organizations have done geriatrics fellowships.  In the case of CareMore that was the limit of the information I could find, while clinical sites are listed (in California, Nevada, and Arizona) the drill down to physician specialty of those staffing sites is not easily available.  In the case of Iora, the corporate website does link down to teams at sites around the country.  I looked at the specialty of 10 physicians working at 6 Iora sites (including the original Dartmouth site, but not sites specializing in other population segments e.g., women’s health).  Of those 10 physicians, 1 was a geriatrician.  (It was Marty Levine, MD – the first fellowship trained geriatrician hired by Group Health Cooperative back in 2001 with a boost from JAHF.  Hey Marty, are you still with Iora?)

With this disappointing result in hand, I reviewed the leadership of the 15 Medicare ACOs in the New York City, Westchester, and Long Island region.  In addition to the usual urban advantage in physician workforce, one of the special advantages of health systems in this region is the large number of geriatric fellowship programs and the (relatively) large number of geriatricians trained here.  If I ran a health system and my business strategy was to earn a share of the savings on reduced spending on my Medicare beneficiaries, I think I would very much want someone with a strong foundation in care coordination, multidisciplinary care, and aging.  Unfortunately, looking at the leadership of the 15 ACOs listed on the very helpful CMS website, I see no geriatricians as medical directors.  There are five general internists, two anesthesiologists, two gastroenterologists, a family physician, an emergency physician, a spattering of other IM specialties, and a pediatrician.  No sign of a bidding war for geriatricians.

Just to be sure that I wasn’t having a spelling problem or that Google was broken or something, I looked up the leadership of PACE programs around the country.  I got bored after looking at 6 pace programs, 4 of which had geriatricians serving as medical directors (along with 1 pediatrician!).  A small sample, but perfectly adequate to prove that I can find geriatricians when they are there.  Unfortunately, while PACE programs are a good use of geriatricians, PACE nationally has failed to grow and cares for a very small number of albeit very frail older adults (fewer than 60,000).

I wonder what a wider analysis might find?  What about Special Needs Plans (D-SNPs) which have nearly 2 million older adult enrollees.  What about Independence at Home programs?  Medical Directors of integrated “Duals” plans?  Leadership at CMS?  (Not to be mean, but both Don Berwick [former CMS head] and Patrick Conway [former CMS Chief Medical Officer, among other hats] were pediatricians.)  Are there other factors at work?  Is the ethos of the field such that geriatricians just don’t venture out of academic institutions?  Does the one-year geriatrics fellowship not provide the cool tools for modern “population health?”  This seems like an issue that warrants serious analysis to understand and correct.  Geriatricians don’t seem to be employed where their clinical skills would seem to be most valuable (outside of PACE programs) nor do geriatricians seem to be employed in systems leadership jobs where they could have an indirect ,but vital, impact on care.

What’s going on here?

 

[1] Geriatrics is a physician specialty in internal and family medicine as well as in psychiatry.  Specializing in geriatrics in one of these fields gives a physician a year of focused clinical training across a range of settings, mentored by senior physicians in the discipline.

 

[2] The numbers come from the annual “education” report in JAMA, the Journal of the American Medical Association, and is a very high-quality review of the numbers of physicians in different training programs, both at the residency level and the specialty (fellowship) level of training.  See https://jamanetwork.com/journals/jama/fullarticle/2666480

 

[3] The Paul B. Beeson Award is just now winding down as a partnership supplementing more usual career development awards from the National Institute on Aging.  https://www.afar.org/research/funding/beeson/

 

[4] Cynically you could ask if the interventions in these fields were really powerful and impactful on health or that their attraction was really a form of “gizmo idolatry” from which Americans professional and lay seem to suffer – equating big machines and flashing lights to the quality of care.

[5]See the paper archive at: https://www.rand.org/health/projects/acove.html

 

The Next Shoes Drop: What the Attacks on the ACA Foretell for Medicare and Social Security

~ Chris Langston ~ Leave a comment

I wrote this piece back in the spring when ACA repeal and replace was looming. I feared that that win or lose on healthcare, the new administration and congress would be moving on to tax “reform” and necessarily cutting the largest and most important social programs in the federal budget – social security and Medicare.  However, because the ACA efforts kept mutating and I couldn’t find an audience for a look beyond the issues of the day, I held the piece.  Now the tax plan is out and the next shoe(s) have dropped – the initial proposal calls for cutting over $400 Billion from Medicare (and a Trillion from Medicaid) in the usual 10 year budget window.  Because even with very optimistic assumptions about growth in the economy (and the planned cuts) this tax bill still increases the deficit by $1.5 Trillion, I strongly suspect that it will be the staged provocation for further cuts to social programs (like social security) in the future.  So I still hope that we can learn from the effort to repeal the ACA and glean some valuable insights into how congress and the administration will be treating Social Security and Medicare and the people who depend upon them.

 

***************************************************

While the flames of congressional and administration efforts to repeal and replace “Obamacare” seem to be reigniting from their smoldering embers, I hope there is some capacity to appreciate the gift that the administration and congressional leadership have given us.   Now that we have seen the various house and senate bills, we know not only their specific ideas regarding health insurance, but also something about their principles.  While application of these principles to Medicaid and the individual market (what is usually meant by Obamacare) is bad enough, these same principles will, without a doubt, define the approach to the other two really big parts of the federal budget and national safety net:  Social Security and Medicare.

Driven by a political need to cut taxes and a small government ideology, congressional leaders will be back soon, especially if the current health policy revenant can be held off till the witching hour at the end of the month.  Regardless of the outcome of this current policy battle, we can expect more of the same – and instead of Medicaid and the exchange markets, Medicare and Social Security could easily be the victims next time.  We need to attend the warning we have inadvertently been given because we will soon face second and third “dropped shoes” with enormous potential for mischief and misery.

For all of the Affordable Care Act’s complexity, length, struggles, and controversy it actually expressed a pretty simple idea, everyone should have health insurance. It also reflected some basic principles:

  • The better off should help the less-well off – it had tax surcharges on income above $250,000 to fund expansion of Medicaid to low income people between 100% and 138% of poverty;
  • A competitive market is a good thing – it created the state or federal individual market “exchanges” on which people can buy insurance with sliding scale subsidies from private plans;
  • But fair markets need regulations that protect buyers and sellers – and so the ACA required standardized “essential benefits” from insurers (e.g., no exclusions for pre-existing conditions) and used penalties to require people buy insurance to force even healthy people into the market (e.g., the individual mandate);
  • Budget discipline – hard to believe, but with the taxes on insurance companies, medical devices, high incomes, and a variety of other “revenue enhancers,” the ACA actually reduced the budget deficit and extended the fiscal life of Medicare versus prior projections.

Deducing the New Principles

We have now seen how the republican leadership wants to address the “problems” of Obamacare. A commonly voiced concern was that deductibles and premiums are too high/rising too fast for the 11.4 million people on the individual market exchanges (state or federal).  The congressional leaders address the problem not by lowering deductibles and premiums but by changing the way that people are subsidized so that some people will have lower premiums and some will have radically higher.  They also recreate ways through which insurance plans can once again offer plans with wildly varying covered services, resurrecting the risk of discovering too late that whatever your need is, it isn’t covered. From this we can deduce a retreat from “fairness” meaning a level playing field, to a world of unbridled markets.

In the 32 states that chose to expand eligibility for Medicaid from only the terribly poor to the just plain poor, relatively few people who gained coverage in the program complained of problems[i].  Under the ACA 11.9 million people previously ineligible for Medicaid but making up to 138% of the federal poverty limit (e.g., the working poor with an income of $24,600 for a family of 4) got Medicaid.  With the various taxes in the ACA not only were federal budget deficits reduced, but 90% of the cost of care for these new Medicaid beneficiaries was paid for by the federal government rather than the usual 50-50 state-federal split.  Not only were people newly entering Medicaid seemingly satisfied with the program, which for the most part, doesn’t have co-pays and deductibles, but they also reported that it was pretty easy to find health care services that accepted the insurance.

However, despite the lack of consumer complaints and the fact that states got to choose to participate in the expansion (or not), the proposals called for a reversal of the expansion. Over a few years there would have been a reduction of the federal match leading back to a 50-50 and states would be forced to drop out.  In fact, any reduction in the 90% match will trigger obligatory opt-out in 7 states right away.  And, in several proposals, even the federal payments for individuals currently covered at the 90% federal match rate would be whittled away through administrative gotchas.  I can only conclude that the real opposition to expansion derives from the taxes on high incomes that were used to finance it.  To add insult to injury, some administration spokespeople have suggested that the working poor who are they main beneficiaries of the expansion should just find better jobs that provide healthcare coverage[ii].  From these choices we can conclude that the republican leadership are more concerned about tax cuts than they are coverage for the vulnerable. (And we can see that respect for state choices only goes so far.)

Then, out of the blue, the congressional proposals also included some fundamental changes to the long-standing Medicaid program that existed before Obamacare was even a dream in the mind of Tom Daschle. Under these plans, the federal share of Medicaid payments would no longer be a roughly 50-50 split of actual costs, rather the federal share will become an annual ‘block’ payment or a per person annual capitated payment.  This puts a priority on predictability for the federal budget and expresses a touching faith in the ability of state governments to do more with less.  However, its real expression of principle can be seen in the ticking time bomb hidden in the policy.  Under the rhetoric of devolution and local control, the future federal block or cap payments would only increase with general versus the much higher rate of health care inflation.  This subtle difference will lead to big cuts in spending over just a 10 year period.  Given that Medicaid already only pays doctors and hospitals a fraction of what Medicare or commercial insurance does, I don’t see how this can be done without just wrecking the program or requiring the states to pick up the slack.

There didn’t seem to be any state leaders who felt this is a really good idea even in the red-red states that choose not to expand Medicaid. The Obama administration was actually quite generous in allowing states to make modifications to the Medicaid program through waivers and demonstrations (e.g., Mike Pence’s mandatory premium payments from individuals[iii]) and there is no reason to believe the Trump administration wouldn’t be even more trusting.  No matter what flexibility they might get to reshape the programs, state leaders knew that these block or capitation proposals would have made the program unsustainable.  There is only so low you can make your payments to physicians and hospitals before they will have to say, “No, thank you.” Again, the only reasonable conclusion for the gratuitous inclusion of these policy changes is that driven by a need to cut taxes republican leaders were willing to try to shift the costs of what is already a barebones program onto the states, heedless of a predictable mix of bad fiscal impact for the states and bad healthcare outcomes for the poor.

Application to Social Security and Medicare

So we know that the top priorities are cutting taxes for the wealthy, cutting benefits to those perceived as ‘unworthy,’ and that there is not the slightest commitment to promises of “better healthcare” made by the President or congressional leaders. What conclusions can we draw from these principles that might apply to two other major federal programs that are the other cores of the social safety net:  Medicare and Social Security?  While the “repeal and replace” argument has been about healthcare coverage for approximately 20 million people, if we were to see the same principles and proposals applied to Social Security and Medicare, we risk even more serious damage to the lives of three times as many people.

Social security is the national income support program for retirement and disability financed by a flat payroll tax of 12.4% split between employers and workers. Payout is determined by age at retirement as well as one’s contributions in social security taxes.  Social security currently makes payments to some 66.5 million people in America,[iv] 46.1 million older adults and 20 million people with disabilities or who are survivors of deceased relatives.  Its overall average monthly payment is $1,256 which represents over 75% of the total discretionary income of retired persons who were in the lower 40% of life-time income and 50% of the income of the middle fifth[v].  For a younger disabled person or the surviving child or spouse of a deceased worker, social security can be even more important.  Virtually everyone is or will be a social security beneficiary in some way.

Medicare is the only “universal” health coverage program in the US. Started in 1965 at a time when few older adults had health insurance because they were considered such bad risks by insurance companies, Medicare (combined with Social Security) has been a stunning success in reducing poverty among older Americans.  The program covers 55 Million people, 46 million 65+ and 9 million younger disabled people (Added in 1972).  Medicare coverage is earned for older adults by virtue of an individual (or spouse) working for 10 years or more and paying the dedicated Medicare payroll tax of 2.9% (split between the worker and employer).  In addition, people 65+ pay a monthly premium of $134 (deducted from Social Security) and a wide variety of deductibles and copays.  (Thanks to Obamacare, premiums are now substantially higher for high income participants.[vi])  And again it is a fair program, in that except for a very few unlucky people, you will have your chance to benefit from the program when the time comes.

Like Medicaid, these programs have been under attack for years from multiple sides aiming to undermine their legitimacy and trying to fracture the new deal/great society consensus. First, like Medicaid, they are attacked on the basis that they are “expensive” entitlements taking up more and more of the federal budget.  Second, paradoxically, it is argued that they are doomed – that they will go ‘bankrupt’ any day now and therefore just can’t counted upon anyway.  And last, they are poo-pooed as inefficient “government programs” which should be handed over to the private market or just become the individual responsibility of people to plan for in their lives.  These attacks are disingenuous at best and driven by a desire to cut taxes and reduce the size of government.

Others have responded to these attacks in detail, but in brief I will say that yes they are expensive because the things they buy – health care and minimal income security for people with serious disabilities or in retirement – are expensive.[vii]  However, unlike Medicaid, they are only “entitlements” in the sense that you are entitled to them because you have earned them, not in the sly sense we are encouraged to assume.  After all, who wants to be an ‘entitled’ person?  In 2017, almost everyone alive who gets these benefits (or will) earned them by paying their dedicated payroll taxes or being married to someone who did.

But they are NOT on the verge of “bankruptcy.” In the case of social security, income from the dedicated social security taxes plus the release of savings put aside in advance for the aging of the baby boom generation, will cover 70% of the forecast social security payout forever.  Obviously this leaves a gap after the savings run out in 2035, but not such an insurmountable one that the answer must be to cancel the program – a fix would be fairly easy especially if undertaken as soon as possible[viii]. While Medicare is in somewhat worse shape than social security in that it is already paying out more than it takes in through taxes (or is held in the trust fund) and therefore is drawing on “general revenues,” it is in no way “bankrupt.” Oddly, the ACA actually made Medicare more sustainable by premium increases for high income beneficiaries and some other cost reductions and revenue enhancements that would have been reversed in some of the repeal proposals.  (BTW – A big part of the fiscal future of Medicare is also pinned on reducing the actual utilization of services and real cost of care by increasing efficiency, coordination, and value – not just shifting responsibility from one payment source to another.)

And as for the notion of privatization of these social programs – can I just laugh? Even in the boom years, George W. Bush couldn’t make the math work to continue to send social security checks to current beneficiaries while redirecting the dedicated payroll tax into personal 401k ish plans.  Post-great recession and its stunning demonstration of market risk, fuggedaboutit.  And as for Medicare – it is almost 35% “privatized” now.  In Medicare Advantage, constituting 35% of the beneficiaries, the premium dollars are handed over to private insurance companies (e.g., United Health Care, Aetna) who take the risks of the cost of care and have the incentives to improve health so as to avoid costly healthcare crises.  And yet, the promised efficiencies have pretty much failed to materialize.

The Paul Ryan idea of converting Medicare into a defined contribution system (like 401ks) where people can use a fixed premium “voucher” to shop for a health plan greatly exaggerates the effectiveness of “market magic” and is moreover a transparent ploy to reduce benefits by the same buried time bomb hidden in Medicaid block/per capita grants – the premium payments would certainly not be increased at the relevant rate of inflation. This is not really about choice or even value, but rather about cost shifting onto individuals regardless of ability to pay.

In the face of income stagnation for the majority of Americans for more than 20 years and more extreme income disparities than any time since before the great depression, I think suggesting that we should give up our universal, intergenerational social insurance system for health and retirement and shift to a “every barrel on its own bottom” approach where you get only what you sock away for yourself, is ludicrous.

In fact most of these “problems” with social security and Medicare are driven by the good news of the aging of the US population. Despite recent reversals, people are living longer, which is good for them and their families.  The costs have been foreseeable for many year and at least among politicians who were not entirely feckless, actually planned for (e.g., the famed 1983 O’Neill-Reagan agreement to increase social security tax rates, in ADVANCE of the retirement of the baby-boom generation, and put the excess away for the future need[ix].)

If we heed the lessons from the ACA repeal and replace efforts we can see a strange bedfellows coalition of budget hawks, libertarians, and small government ideologues are perfectly willing to do “something” even if it has to be done in secret, the math doesn’t add up, and the hypocrisy stinks to high heaven. President Trump made silly promises about the repeal and replacement of Obamacare “it will be great!” and swore no one would lose Medicaid.  And yet he seems unconcerned that congress is making him a liar and he is certainly no constraint on their actions.  By the way, he also promised that no one would touch Medicare or Social Security.

We must not allow zealots to continue their efforts to delegitimize these fundamentally fair and successful programs to provide basic health and income supports to people who have earned them and rely upon them. The aging community has done its best to oppose the cuts to Medicaid and attacks on the exchanges and individual market – I hope we can hold on for another week and a half when the window for action through reconciliation ends.  But whether or not we succeed in protecting “Obamacare,” we must not ignore the threat to Medicare and Social Security. Failing to protect them now will not benefit other vulnerable groups – it certainly isn’t on the table to take existing social security or Medicare payroll taxes and use them to support other social programs.  And if these cornerstones of a just and civil society are destroyed now, how would we ever find the consensus and vision to restore them?

 

[i] http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2643347

[ii] http://fortune.com/2017/06/26/kellyanne-conway-medicaid-find-job/

[iii] http://www.kff.org/medicaid/issue-brief/an-early-look-at-medicaid-expansion-waiver-implementation-in-michigan-and-indiana/

[iv] https://www.ssa.gov/policy/docs/quickfacts/stat_snapshot/#table3

[v] https://cdn.bipartisanpolicy.org/wp-content/uploads/2016/06/BPC-Retirement-Security-Report.pdf

[vi] https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html

[vii] For all the horror about healthcare premium costs and deductibles on the exchanges, the premiums needed to buy Medicare equivalent coverage for people over 65 who most depend on healthcare to maintain quality of life, would knock your socks off.  Despite the fact that Medicare has 20% co-insurance with no stop-loss, a monthly premium deducted from social security, and annual deductibles (and only got a drug benefit in 2006), covering people over 65 is so expensive that in 1965 before Medicare, about half of older adults had no health insurance.

[viii] It is one of my greatest frustrations with the Obama administration that with this gap looming and the voices for privatization muted by the discrediting of the George Bush administration and its legacy of financial crisis, they still failed to even propose sensible fixes to social security – some mix of pushing up the cap on the taxability of income, increases in social security tax rates, reductions in payment growth due to inflation, win-win incentives for people who can to stay in the workforce, or other “solves.”

[ix] https://www.usnews.com/opinion/articles/2009/04/02/bipartisan-reagan-oneill-social-security-deal-in-1983-showed-it-can-be-done

 

In Evaluation, The Perfect is the Enemy of the Good

~ Chris Langston ~ Leave a comment

There are so many ways that the perfect is the enemy of the good that no one can possibly count them.  This is also a problem in many situations in program evaluation – counting things perfectly gets in the way of counting them well enough.

quote-the-enemy-of-a-good-plan-is-the-dream-of-a-perfect-plan-carl-von-clausewitz-45-57-07I came to this realization when I recently read an evaluation report written by some long-time friends and colleagues of mine summing up the “Centers of Excellence” program of The John A. Hartford Foundation.  The program was designed to help build up the number of physician faculty specializing in geriatrics (the care of older adults) so as to improve research, teaching, and care all across the health system for a part of the population that is not well served by today’s health care.  The theory was that some academic centers had excellent resources for training future faculty (e.g., senior faculty mentors, access to technical training, and a strong pipeline of fellows[i]) and, if given extra resources, could grow faculty for the field and seed other institutions.

At its high water mark, the program funded more than 20 academic health centers around the US with $300,000 in annual, lightly restricted/general support – $150,000 of Foundation money and $150,000 in institutional match. Over time, the amounts, centers, and mechanisms varied a bit, but the CoEs lasted more or less intact for 30 years (’88-’16) during which time the Foundation contributed $57.7 million.  The Foundation’s purpose in commissioning a final evaluation was largely to celebrate the program, salute its many accomplishments, and give a “roughly right” picture of the careers of the alumni of the program.  The evaluators are strong professionals, experienced in their fields, and with great track records and largely succeeded in meeting their charge.  Nevertheless, thanks to an accumulation of decisions taken many years before they arrived on the scene and an overdose of hope, they wound up needing to make lemonade out of lemons.  I think there are some lessons to be learned.

Evaluating a program like this poses many, many technical challenges.  It is neither desirable nor practical to randomly assign academic centers to receive the grant support or not (although I know some observers thought we were doing that anyway J).  Nor within centers could fellows and junior faculty be randomly assigned to receive support from the CoE pot of money.  One also faces what is called “censoring” in trying to look at outcomes at any one point in time (e.g., today) – that is the period of observation is cut off (censored) with wildly different lengths.  In other words, the earliest participants in the program could have been followed for 28 years and even possibly finished their working careers by 2017, but many of the scholars who entered the program in its final years had only begun theirs.

These technical issues have technical solutions with a range of credibility.  And for the purposes of the Foundation – simply to document what happened in the careers of participants – some of the issues and solutions are irrelevant, especially at the end of a program where, for the original funder, there is no longer an opportunity to directly apply its lessons.  Nonetheless, the fundamental problem with the evaluation that was performed was its overreach.  Not overreach in an effort to draw conclusions the data could never support, such as inferences of about causality or generalizability of the results, but simply in its hope of reaching all of the alumni – a victory of hope over experience.

The evaluation had the appropriately limited and conservative goal of simply describing the activities and progress of the 1,164 scholars who had participated in the program over its lifetime.  To meet this goal, the foundation, its consultants, and national program office set out to survey every one of the alumni.  At the start, the work was handicapped by a common, but frustrating, part of human life – the inability to see the future.  Back when the program started in 1988 nobody at the Foundation was thinking of long-term evaluation (at that point, the Foundation didn’t think much about any kind of summative evaluations and reports at all).  There was little thought given to maintaining contact information for scholar alumni, and no funding provided for the expensive and difficult work to keep an eye on members of a longitudinal cohort through moves, name changes, and death.  So the eventual survey of career achievements and request for a current academic curriculum vita could only even be sent to the most recent 878 of the 1,164 total scholars due to lack of contact information (creating a 24.6% loss to follow-up at the get go).

And it only got worse: of the 878 people sent invitations to complete an online survey and to submit their CVs, 336 and 282 responded, respectively.  Response rates of 38% and 32% are actually quite decent for “cold” voluntary surveys and I’m sure that achieving them took a great deal of time, effort, and paper cuts.  While other, more recent Foundation scholar’s programs outside of medicine (e.g., nursing and social work) with far more emphasis on collective identity and interpersonal ties, *had* achieved much higher response rates in similar voluntary surveys, the CoE scholars program was substantially different.  As a general support grant, the local center directors decided how money would be spent and branding of the program was highly variable (some scholars probably never were told their support came from the Foundation or were unaware of the National Program Office).  I would argue the fact that the response rates were going to be in this range (or below) was already known/knowable from prior efforts and similar long-term follow-up efforts of the Foundation in the past[ii].

So, despite the good faith effort to reach everyone, the very approach deeply undermines even the descriptive interpretation of the results.  For example, on a key issue of keeping scholars in the field of aging/geriatrics, the estimate offered was that 97% (N=327) of respondents said “yes” to continuing in some role of influence (e.g., research, teaching, or policy).  Given the context of being asked for a CV and the almost certain relationship of being lost to follow-up to academic success (even in the subset when there was an email available), this estimate is obviously wrong.  It has to be somewhere between 28.1% (327/1164) and 97% but there is just no way to know exactly where.

A second metric is the so-called “leverage” generated by the program.  In JAHF parlance this term had come to mean the grant revenue earned by funded scholars that could be thought of as the ROI for the program grant funds “invested.”  In this case, simply counting grants reported on the 282 CVs collected, the total was calculated to be $1.1 BILLION[iii].  Now there is nothing wrong with this number – it is a big fat fun number and on a $57.7 million investment, it is just terrific.  But it is clearly a very low estimate of reality.  Showing great restraint, and knowing when to quit when they were ahead, the authors do not make the obvious ~3 x calculation to try to estimate the full “leverage” that would have been documented if all of the participants had reported.  But the real figure *is* clearly much higher than $1.1 billion, we just don’t know how much.

However, the evaluation does make the analogous calculation when considering how many trainees the scholars influenced.  Observing that the total number of trainees touched by the group responding to the online survey in 2014-2015 was 16,123 (ranging from medical students in classes to mentees at the junior faculty level), they created a “’rough estimate’” assuming that the non-responding alumni would have similar training influence.  Thus the calculated that the full cohort would have reached 55,000 people with their geriatrics expertise in that year.  I am sure that the assumption of proportionality between the responders and non-responders is more reasonable in the case of teaching than it was in the case of winning grants. But it is still going to be systematically off, leaving us with an estimate of somewhere between 16,000 and 55,000 in that year[iv].

This evaluation, because it was dependent upon a strong response rate, where it was unreasonable to hope for one, both understates and overstates the results of the CoE program in ways for which it is impossible to appropriately adjust.

Dilbert Correlation is Not Causation

So what would have been better than this predictable disappointment?

I argued strongly when I was still involved, that instead of a futile effort to reach all the participants, that the evaluation should focus its limited staff time and scarce resources on a truly representative sampling of the population of interest.

Margin of ErrorIf the effort that was used to collect ~30% response rate from the 1,164 people had been used to collect responses from a planned, representative sample of 300 people, the estimates would be impacted by sampling error, but not the same uninterpretable bias due to respondent self-selection.  With 300 respondents the margin of error would be +/- 4.5% for percentage estimates around 80%.  Margin of error at the 95% confidence level for percentages is calculated using the formula  * +/- 1.96.  So if we were to find that 80% of the respondents were still in the field of geriatrics our sample error would be  and we would have 95% confidence that the true proportion was between 75.5% and 84.5%.  In fact, even if we had a sample of only 100 the margin of error at the 95% confidence level would still be less than +/-1 10%.  (+/- 7.8%, to be precise)[v],[vi].

With the number of people to be reached cut down to a manageable size, one could spend a lot more of time badgering people to complete their surveys and/or offer $$ incentives to participate, or any number of strategies.  I also feel pretty sure, that in these days of Google, social media, PubMed, and with the benefit of national licensing boards and membership associations, that 40-45 of 50 randomly selected people from the initial group with no contact info could be run to earth (“Hi! Are you the John Smith who did a fellowship in geriatrics at Harvard’s Beth Israel in 1989?”).  In fairness, I must admit that you won’t get 100% of a planned sample either, but if you can crank it up to 90% of the random sample participating, response bias has a much smaller room for mischief.

Sampling strategies also give some special opportunities.  For fun, one could stratify the sampling by era, gender, etc. to be sure that you had some room for comparisons.  And for extra credit – you could even oversample some rare populations (e.g., racial minority members, bench scientists, second career trainees) and make use of the extra precision of measurement without bollixing up the overall estimates by weighting the responses.  Even without the bells and whistles a good random sample of 100-300 beats an ad hoc group of 300 created by unknowable, but surely biased processes of self-selection.  It may sound small and embarrassing to settle for such a limitation at the outset, but it is just fine for government (or even Foundation) work.

Finally, if I were sponsoring this kind of work in the future, I would consider reducing the sample even further, to change the commission to the evaluation team to add some kind of comparisons that could make the results more meaningful.  If we can get estimates at +/- 10% for a measure like “having a continuing role in academic geriatrics” with only 100 respondents, could we use our freed up resources to look at the overall continuation rate in academic medicine?  I don’t always feel that causality is an answerable or even important question in Foundation work, but given that there are only a few hundred fellows certified in geriatrics each year, it wouldn’t be hard to get information to create a cohort of fellows who didn’t get the CoE “leg-up” so as to give some kind of reference comparison.

I think I know why these sampling strategies are not as popular as they should be.  I think people are embarrassed by the admission at the design stage that even beneficiaries of a program like this one, won’t respond to follow up.  (I personally know board members who concluded a-market-for-the-lemons-11-728that because the response rate was low, that the program couldn’t have been good, even for follow-ups done many years later.)  Sampling is a mildly technical concept that adds a layer of mystery that “survey” doesn’t have.  I also suspect that accepting the certainty of sampling error is an upfront loss, and there is a natural human tendency to try to avoid such a certain loss, even the logically expected outcome of an uncertain option is even worse.  We all tend to hope that “this time it will be different” and make the perfect the enemy of the good enough.

So don’t do it.  Hope is not a plan – give it up.  Embrace limitations and make them work for you.  Put your faith in random sampling – it works.

 

__________________________________________

[i] In academic geriatric medicine, people finish college (~4 years), medical school (~4 years), residency in internal or family medicine (~3 years), a clinical/research fellowship (in geriatrics the time shrank from 2 to 1 year during the CoE program), and then somewhere along the way or as a junior faculty person may get further research or educational training in an MPH or some similar program.  The recruitment pipeline was a constant problem – one of the main frustrations of trying to build the field of geriatrics was getting good people to start down the pathway and finish all 12+ years of it.
[ii] For example, the survey of alumni of fellows trained in geriatrics between 1990 and 1998, reported 15 years earlier by Medina-Walpole, Barker, and Katz, et al. in 2002 already had a 63% response rate and voluntary surveys of medical students who did a summer research experience in geriatrics, had several times shown even lower response rates.
[iii] And for the sake of simplicity, I am just ignoring the unequal observation periods of early versus later scholars.  If we could estimate a good “dollars per year” figure for the whole group from our observations, we could get an even nicer number and even project it forwards to the end of each person’s career, if we wished to assume a constant earning rate and funding environment.
[iv] And this “rough estimate” also doesn’t consider the element of time.  Why is the reach in 2014-2015 more important than all the prior years?
[v] And these calculations don’t even take advantage of the fact, that for descriptive purposes, the sample estimate is only intended to describe the 1,164 participants in the program, not generalize to the entire universe of people who might have participated in the program.  When generalizing to a finite population, using a substantial fraction of the population (e.g., 30% = 300 out of 1,164), you actually get a smaller margin of error – e.g., +/- 3.9%.
[vi] Similar processes can be used to estimate sampling error around estimate such as dollars collected and trainees influenced, although there is also an unclear bias created by the different duration of observation for participants depending upon year of entry that would need to be accounted for as well.
Continue reading →

Writing about Philanthropy – What is this ‘Sustainability’ thing?

~ Chris Langston ~ Leave a comment

‎As I wrote last week, writing usefully about philanthropy is hard. But a recent controversy has inspired me.  Late last year various news outlets carried the story that a generous donor, The Suder Foundation, creator of the First Scholars program of scholarships and support for “first generation” college students was suing some of its grantee institutions for failure to live up to the grant-based agreement to continue the program after the external funding ended.  Commentators talked about the perfidy of the grantee institutions or the naiveté and bad math of the grantor (failing to endow the programs).

This controversy highlights the broader issue of “sustainability” in philanthropy and non-profit activities. Sustainability seems to me to be one of those overused, “magic” words – people know it’s a good thing, but don’t think much further to try to understand exactly what kind of thing it is. At the end of the day, for a philanthropic funder, a program activity is sustainable when there is someone else who at some point will be willing to pay for it to go on. That “sustainability” funding may be from earned revenue, from dipping into an undifferentiated stream of individual donations, or somewhere else, but someone has to pay. There is no free lunch. And it is always harder than it sounds.

Sustainability is also not purely a program property, but a product of the program (costs and benefits), residing in an organization, in the context of its environment (funders, stakeholders, government).[1] Particularly as venture capital has increasingly become the metaphor for philanthropy, (I almost wrote “philanthropic investments,” which shows that I, too, have been sipping the Kool-Aid), the VC notion of being “taken out” gains currency. The idea is that “investment” money is always moving on and some other investor taking over, the way VC firms succeed each other at different stages of a start-up’s development. This occasionally may end in the Holy Grail of a successful IPO. Unfortunately, one of the potential over-extensions of the VC metaphor is that in the non-profit/philanthropic situation, an excellent program that delivers great impact can easily exist WITHOUT a viable new funding source to continue on. And while an IPO is like winning a lottery in the real start-up sector, there isn’t even a real analogy for an IPO for us.

In the case of the Suder Foundation’s grants and the Universities’ response (or lack of response), part of the problem seems to be this overextension of the financial metaphor.

http://firstscholars.org/our-approach/university-role/

The initial phase of external funding for the First Scholars program is described as the seed phase, where the Suder Foundation would pay for the start-up costs. According to news reports and its website, the First Scholars program was substantially more effective in keeping first generation college students enrolled than preexisting efforts.   While this success is described as “ROI” there is no actual short-term financial return to use to sustain the program. Metaphoric returns on investment are not spendable on real programs.

 

The second phase of the First Scholars is described as “University Self-Funding” but had no specified mechanism for raising new funding. (There was some discussion of Suder support for University “fundraising”, but having been in those shoes, I can testify how very hard it is to get one funder to replace another – it feels ignominious and uninspiring to most potential replacements. I’ve done it several times, but also faced intense board criticism for it.) So, to the extent that there was a plan, I deduce that the grantor and grantees expected to redirect existing scholarship and student support funding into a locally controlled version of the First Scholars program.[2] This is actually not an unreasonable plan. Finding new and more productive ways to spending existing resources is easy to support in concept, but doesn’t do justice to the complexity of such changes.

An example from my experience.

In 1999 at the John A. Hartford Foundation, I was staff lead for the IMPACT trial, an eight-site randomized clinical trial of depression treatment that still remains the largest such study in the US. Given our interest at the foundation we wanted the evidence from the trial to change national ‎practice and policy (still working on that), but we also wanted the participating sites to maintain the program, if the evidence showed that it produced superior outcomes for patients. Like Suder we paid directly for the services in the trial phase and we wanted the grantees to keep them going.

For four years as I traipsed around on my annual site visits, I would always ask the grantee team and whatever institutional leaders they could round-up: “If the model works, will you keep it?” And at least what I heard was “yes.” I distinctly recall a senior service leader at a large Midwest health system who always was very clear about the institution’s commitment to both evidence-based practice (meaning we would have to wait for results) and to high-quality care (meaning that if the results were good, they would keep the program in place.)

Well, when the trial phase came to the end and had not just good results but GREAT results – twice as effective as care as usual – this senior leader had retired and gone on a medical mission to‎ Africa. I was in the very same position as the Suder Foundation is relative to the University of Alabama where the entire development and leadership staff has turned over and nobody remembered any commitment to “sustain” the program.  Needless to say whatever minimal internal discretionary funds might have been under the control of this stakeholder, they were not forthcoming.

Does this make the institution evil or me naïve? (I certainly was less experienced, but I already knew sustainability was an issue.)  I would say “neither.”  Sustaining a program under these conditions or those of the Suder Foundation grants, requires recognizing a few realities.

  1. Academic/health institutions expect to get grant money. They are good at doing grant-funded projects, faculty and staff can “sell” time to new projects in a very flexible way, unlike in most companies where existing staff are dedicated to on-going functions. Senior administrators sign-off on many, many such grants each year, rarely with serious consideration of what they are agreeing to.
  2. However, on-going functions, such as standard health care practices or standing scholarship funds are controlled by other stakeholders, separate from the grant-seeking/grant-management leaders. This is part of what gives institutions flexibility –they insulate core activities as much as possible from the vagaries of grant funding.

It is not unreasonable, despite commentary to the contrary, to expect an institution to change the way it spends its own money depending upon the results of a grant funded project, it is just very complicated. Despite being within one institution, you essentially face the same problem of using evidence to encourage a program adoption without a grant when you want to achieve such “sustainability.” And, if at the end of the day, there simply aren’t enough shiftable resources to maintain the program, it won’t be sustained. A good business analysis and plan at the outset might be helpful, but should philanthropic dollars only go to those activities where someone else will be willing to pay down the road?

 

Notes:

[1] The early days of philanthropy are sometimes thought be a golden era where better solutions to social problems were relatively easily taken up by government (e.g., painted road dividing lines and the 911 emergency system, both started as philanthropic efforts but are now sustained by tax dollars). However, I’m sure it never was easy then and it does still happen now on occasion. See http://www.jhartfound.org/blog/philanthropy-1-0-still-building-better-mousetraps/.

 

[2] This was then to lead to the Third Phase, a National Network of operating “franchised” sites that would do program research, quality assurance, etc. – but again without the actual dollar flow of a franchise operation – another financial metaphor overextension.

A Meta Realization

~ Chris Langston ~ Leave a comment

Writing usefully about philanthropy is very hard. Since I left my former Writing is Hardposition, many times I’ve sat down to apply what I learned in my eighteen years in the field to current goings on and each time I’ve been stymied. ‎ Writing from the outside (especially while job hunting) really drives home the power differential in a visceral way. Saying meaningful things about the work of powerful and mysterious foundations is scary.

This is especially true because it’s hard to get enough information to have an informed view. Few funders make grant proposals easily available, much less the internal documents that would explain the strategies, issues, and broader context as seen by the funder. If I wanted to critique or praise a particular grant, I would have a very hard time in doing it in a knowledgeable and productive way, even after only five months out of the business.

I understand better now why we had such a hard time getting our grantee community at The John A. Hartford Foundation to engage with us when we started our blog, Health AGEnda. What could they say that wouldn’t be obsequious or potentially dangerous?

No wonder that majority of what is written falls into a few hackneyed categories:

  • The “Wow that’s a BIG . . . grant” story.
  • And its extension, the “Wow that new funder has lots of money and is going revolutionize everything.”
  • The knee-jerk “I hate this grant” (because ignores my issue), which at least has the virtue of showing courage, if not usually much insight.
  • And finally, the look back in sadness/anger, when results have failed to materialize.

Despite a few bright lights from the rigorously empirical and well-informed, such as the Center for Effective Philanthropy and Grantmakers for Effective Organizations, most of what’s written about grants and grantmaking just doesn’t get at the key questions about how grantmakers and grantseekers can do better together to solve our urgent social problems.  But if we are going to cut back on long-after-the-fact stories of missing results, we have to be able to talk about specific projects and grantmaking process.

In the next few weeks, I’m going screw up my courage to the sticking point and try to take on some issues in philanthropy, such as sustainability, strategy, and partnership.

Stay tuned.

Policy Change = Stories + Champions + Coalition

~ Chris Langston ~ 2 Comments

There’s a simple formula I learned for making major federal policy change: Change = Moving Stories + Legislative Champions + Relentless Advocacy Coalition. There are many things one might add, like procedural opportunities created by must-pass legislation or the opening of political windows early in a presidential term. Like all such formulae, it is an over simplification, but still useful as rough guide to strategy.

Retooling CoverThese were then the guiding principles my colleagues and I followed in our attempts to drive the implementation of the policy ideas set out in the Institute of Medicine’s 2008 study, Retooling for an Aging America: Building the Health Care Workforce.  While many funders were impressed with the majesty of the IOM, when I was first approached about paying for a study in 2006 while I was at the Atlantic Philanthropies, I opposed the idea arguing that we did not have the organizational infrastructure in place in the aging sector to take advantage of the opportunity and it would be squandered.

When it became clear that the study was going forward with or without Atlantic, I agreed to participate in funding the IOM’s work, but began furiously putting together the coalition that would be necessary to press for implementation of the report, with the particular help of Nancy Lundebjerg, then the COO of the American Geriatrics Society. When I returned to The John A. Hartford Foundation in 2007, I was able to continue the coalition building work with my former colleagues at Atlantic and The Meridian Institute  to set up what eventually became, the Eldercare Workforce Alliance.

It was quite a challenge to put together an effective coalition in advance of knowing what would be in the report, but I knew that if we waited for it to come out before starting to organize, we would lose time we could not afford, especially with the 2008 election year coming up. Many stakeholders in the health care industry, health professions, union, and consumer and family groups came to the table. Some did not – I was always disappointed that we could not engage the large primary care physician organizations: the American College of Physicians and the American Academy of Family Practice. Nor could we hold on to SEIU, the American Medical Association, or the National Association of Social Workers, which all spun out for their own idiosyncratic reasons. But with twenty odd organizations in the mix, including the American Geriatrics Society, AARP, American Nurses Association, and Leading AGE, it was enough to get started.

Our timing was reasonably good – the report was issued in April 2008 and EWA was funded before the end of the year. The legislation introduced by Wisconsin’s Senator Kohl, based on the report, was incorporated into the senate’s health reform bill developed in 2009 (AKA the ACA) which was eventually finalized through the reconciliation process in 2010. Of course, getting appropriations to go with authorizations, regulatory implementation through executive agencies, and continued attention has been an ongoing struggle. Nonetheless, I remember being wowed by some of the moving stories from health care professionals, paraprofessionals, and family caregivers that EWA has brought to DC to document the many barriers that keep the quality of actual care well below what is already possible.

EWA Report PICWhile EWA has done great work, the job is not done. Many recommendations have been ignored or miss implemented. This report, commissioned in 2015 describes the process and the progress of The Eldercare Workforce Alliance and its efforts to create an effective workforce to care for older Americans. It is work of which I am tremendously proud and for which I continue to have high hopes.  Older Americans deserve a workforce competent in their care.

REPRINT 2010 – Challenges of a Long-Distance Caregiver

~ Chris Langston ~ Leave a comment

My parents and my aunt represent two ends of the aging spectrum.  My parents fall into the category of “healthy,” independently living older Americans.  That is, while they have fairly serious multiple chronic illnesses and increasing impairment (arthritis, blindness, hypertension), they are moving through their seventies still coping pretty successfully.  My aunt, on the other hand, represented an increasingly uncommon demographic: an early death in her sixties from an untreatable acute illness.

My Uncle Hubert Langston is something else.  All his life he has been something else–a wild child, a hell-raiser, and a black sheep.  Now at 68 he is the proverbial train wreck.  He has hepatitis C, Parkinson’s disease, and diabetes, he is deaf, and he has end-stage renal disease requiring dialysis two or three times a week.  I’m sure there is more, but I think that’s quite enough.

Uncle Hubie lives in a house he bought a few years ago with his wife, about 90 miles South of Las Vegas, right on the Arizona border.  He is retired, living on social security. His wife, who also has serious health problems, still works in a clerical job in the gaming industry. Their adopted son Billy was a soldier deployed in Iraq when this was happening.

In the summer of 2008, my uncle had been in a steady routine for several months. He took the bus to his dialysis appointments, made dinner for his wife, Aunt Christie, and watched TV – which I suspect may be improved without the sound, anyway.  But this stability was shattered when he came home from dialysis one day ranting and raving and then ran out of the house, seemingly out of his mind,.  My Aunt was obliged to call the police out of fear for his safety, and they took him to the local hospital.

There he was physically restrained (probably necessary), put on the tranquilizer Haldol (vitamin H as it is known in the business), but not dialyzed.  He was diagnosed as having overnight-onset Alzheimer’s disease: a largely imaginary condition.  No one on his medical team seems to have considered the well-known difficulty in maintaining electrolytic balance while on dialysis or its possible cognitive side effects.

This precipitated a fairly typical family crisis – Aunt Christy feeling overwhelmed and guilty, my Dad in California feeling guilty and overwhelmed, leading to my Dad asking me to “go out to Nevada and help out.”  Despite being a first-born parent pleaser, I know my own limits of knowledge and patience.  I declined and adamantly insisted that we hire a locally knowledgeable geriatric care manager.  It took some ranting and raving of my own and forwarding of various links, but we found someone who seems to have been helpful.

In the process, I explored the Nevada Aging and Disability Resource Center website.  A more pitiful collection of outdated links, dead ends, and unavailable services would be hard to imagine.  There was literally nothing helpful I could find.  Google was much more useful, leading to a professional nurse care manager we hired from a firm operating in Southern Nevada.  [Since these events, the website has been redesigned and looks much more useful.]

In the meantime, having diagnosed my uncle as having Alzheimer’s disease and deciding there was nothing more that could be done for him (the infamous Medicare improvement standard), the hospital gave the inevitable Thursday afternoon warning of a Friday discharge.  The plan took my aunt totally off guard: “But they haven’t done anything for him!” she wailed.  They proposed discharge to a far-off skilled nursing facility with the rare combination of dialysis and psych capacity.  However, my aunt was inconsolable; even in the short term she feared the placement would either split them apart and/or cause her to lose her job.  The nurse care manager got busy working on a better placement and asked the hospital for more time.

Meanwhile, while Uncle Hubie was clearly still in an acutely altered mental state, it seemed very unlikely to me that he had Alzheimer’s, which has a gradual onset.  It seemed more likely to me that he was delirious as a side effect of the dialysis or even underlying kidney failure and the hospital and attending physician had just started making stuff up.  By turning to resources at the Medicare Rights Center, I learned more about patient rights and hospital discharge than I had previously been motivated to master.

It turns out that on paper, the Medicare discharge appeals process is very good.  Like most of Medicare it is designed by very sincere government employees who are trying their very best to look out for the interests of the beneficiaries.  So I called my Aunt and told her how to appeal the discharge.  She asked me to do it for her.  So I dutifully called Nevada’s Quality Improvement Organization responsible for managing discharge appeals for CMS.

Unfortunately, implementation of policy is often not so good.  Their telephone number wasn’t answering, their answering machine was full, and their server kicked the e-mail back to me.

Turns out it didn’t matter anyway, Uncle Hubie wasn’t hospitalized in Nevada!  He was just over the border in Arizona.

My newly acquired caregiving assertiveness was for naught.  In a few days, he was transferred to the skilled nursing facility and after a month to another one closer to home.  The care teams in both places were sure he was there for good and got my aunt working on Medicaid applications right away.  However, without there ever being any brilliant diagnosis or breakthrough treatment, Uncle Hubie gradually got better.  His delirium cleared and some light physical therapy (i.e., walking) helped him recover strength lost while being immobilized and inactive.  He did have some wild times when minor but stubborn infections and changes to his medications seem to have caused his delirium to return. But, with the monitoring of the geriatric nurse care manager and support from Aunt Christy, he finally returned to a normal mental state and came home–after more than two months.

A happy ending, yes, but the relatively good outcome seems much more an accident (even a miracle) rather than a predictable process you would want to count upon.  And I shudder to think of the expense in uncovered services and co-pays, much less what Medicare paid.  My Dad (Hubie’s brother) covered the care manager who helped paste together systemic dysfunction and put a band-aid on the incompetence of others.  Is this the system we should have?  What should I have done?  What should I do now?

Post Script

Several years had already passed after these events when I first wrote about them.  In the years since, my Uncle Hubie chose to stop his dialysis treatments (as do many)  and passed away.  Even with the most appropriate care there are many limits to how well people with serious illness can be served and supported.  These limits and the inevitability of death, should not be an excuse for less than competent care while people still live.

Short of Geriatricians? Been there, done that, got the t-shirt (and little else)

~ Chris Langston ~ Leave a comment

Recently I was interviewed for a Kaiser Health News/NPR story on overcoming ageism in medicine and promoting geriatrics by exposing students to older adults during medical school. The story was syndicated, I got a quote, and my former employer got a media hit – and all was right with the world.

KHNNPR HeadlineEfforts to introduce relatively healthy older adults to medical students can “reduce the sense of futility and show [the students] that there are real people with real lives who can benefit from quality health care,” said Chris Langston, program director at the John A. Hartford Foundation, which focuses on aging and health. Langston has been analyzing the trend for the past several years.

But . . .

The reporter Susan Jaffe is excellent and was really excited about the session she had seen at Case Western Reserve School of Medical where a panel of older adults over 90 had talked to the medical students about their lives, their health, and their needs. The title of the article and its tone strongly suggests that this is a new kind of program and that it will work “to sell medical students on the joys of geriatrics. As I was talking with Ms. Jaffe and telling her about this kind of program and what had been done before, I felt a wave of déjà vu and previously disconnected thoughts crystalized and my heart fell as I realized that we can be quite sure it won’t.

The reporter wanted to tell the story she wanted to tell, and left most of our conversation and most of the information I provided her out of the story. But the disappointing truth is that programs like this one aren’t new, have been tried extensively, and don’t seem to have had much impact.

Between 1999 and 2005 my former employer made 40 grants of $100,000 each to medical schools in the US to increase exposure to geriatrics in the curriculum and many used this kind of low-cost training experience.  Many went even further and created outstanding senior mentor programs where medical students would be paired with older adults living nearby and would meet regularly for a year or even four years with a series of planned exercises (e.g., history taking & medication review). These programs humanized older people to the students so that they weren’t just GOMERs in hospital beds and helped teach a variety of key interpersonal and pragmatic skills, typically provided by “doctoring courses.”

The Donald W. Reynolds Foundation program in geriatrics education started shortly after our AAMC program and was broader but undergraduate medical education was still its sweet spot. It provided $3M! each to 40 schools over the years 2001 and 2008 ($2M of foundation cash, but $3M for geriatrics when you count the very strict $1M local match requirements).  And, of course, for the academically minded future physician, the John A. Hartford Foundation was growing its summer medical student geriatrics program through the American Federation for Aging Research, supporting a couple hundred students each year in a clinical and research experience.

Understanding the impact of education on competence, career choice, and patient outcomes is really hard. The delays are substantial and measures of competence are weak.  The Case Western experience isn’t expected to make all attendees into geriatricians, nor were the interventions sponsored by The John A. Hartford Foundation or the Donald W. Reynolds Foundation. But it is hard to believe that if the experiences were effective in showing students the value of geriatric care and its personal and professional rewards, that we wouldn’t see some blip in enrollment in specialized fellowships when students finally finish medical school and residency and make further choices.

But when you look at the annual chart of graduating resident physicians choosing to specialize in geriatrics you don’t see any uptick in the 6th or 7th year following the start of these efforts. Looking at the chart, any effects would start in 2005 when 4th year students who had gotten some exposure would be deciding on fellowship.  The effects should have strengthened over the next few years as students who were earlier in training got more and more exposure and could shift their residency choices as a precursor to their career choice. However, as the graph below shows, the lines in these periods are definitely flat or falling.

2014 Fellows Numbers Blog

It might be nice to think that new programs like the one reported in the media could turn the tide, but we’ve been there, done that, and all we have is the t-shirt, not the workforce we wanted.