Wednesday, February 28, 2024

Who will care for me when I am old and gray?

Every day, 12,000 Americans turn 65. In 2022, 58 million were over 65 – 17% of the population – and estimates are that by 2040, seniors will make up 22% of the population.

While most people over 65 are healthy, as we age illnesses and frailty become increasingly common, and growing numbers need at least some care in their daily lives. How do they get that care?

Unlike many other western countries, the US has no organized program to help seniors who are unable to live and function independently. In many cases, particularly for those over 80, the choices come down to placement in a nursing home or a lot of help at home to allow them to avoid that dreaded option.

Many elders and their families are surprised to learn that Medicare does not pay for anything but short-term rehabilitation, either for nursing home stays or home health care. If you have a hip replaced, Medicare will cover a week or so at a rehab facility and a few weeks of home PT and visiting nurses, but if you are simply too frail and sick to live independently, you are on your own.

Long-term care insurance is available, but it is very expensive and frequently does not cover the full cost of nursing homes or extensive home care.

To get the care needed at home, home health aides are available but this “system” is full of problems. Such care is generally provided through agencies that hire and vet the aides. They charge the patient a lot and pay the aides very little. Most home health aides get minimum wage for very demanding work, resulting in a huge turn-over. Why lift and clean an elder when you can earn the same hourly wage at McDonalds?

In the end, it often falls to family members to provide needed care, difficult at best when families are scattered around the country and often trying to hold down a job while assisting their parent(s).

Medicaid will pay for nursing home care, but to be eligible, the recipient must spend down most of their assets and become impoverished. They cannot give away assets to their family – this is carefully scrutinized. Moreover, Medicaid rates are generally so low that you will not find many “upscale” homes willing to take you.

What can you do? Don’t get old. Seriously, one important factor is to stay as fit as you can to avoid the need for help. While exercise increases longevity, its more important benefit is to keep you independent longer.

If you can afford it, investigate long-term care insurance. Be very careful in reading the policy and assessing the likelihood that the policy will cover your needs.

While you are healthy, begin to make your home more “aging-friendly.” Get grab bars in the shower, railings on all stairs, better handles on doors and cabinets and put shelves lower.

Write to your state and federal legislators and ask them to start working on a plan, either at the state or national level, to improve the care we offer our frail elders. Part of any such plan must include better pay for home health aides to encourage people to make this a career.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, February 18, 2024

The heart risk factor no one knows about

Most readers of these columns, I assume, are aware of the relation between elevated cholesterol and coronary heart disease, and of the benefit of reducing high cholesterol with diet and medication. The statins have saved many lives, and newer agents have come to market for those who cannot take statins.

I do hope you are not among the third of Americans who do not know their cholesterol.

What I would like to discuss here is another heart risk factor, which has been prominently discussed recently in the cardiology community but has not received much attention more widely. This is lipoprotein(a), commonly referred to as Lp(a) and verbalized as “L p little a.”

Lp(a) is an LDL (low density lipoprotein) molecule with an apo(a) protein attached. It can be trapped in the arterial wall, causing atherosclerosis (“hardening of the arteries”) and it increases clotting.

We know a lot about Lp(a). It is genetically-determined; there is very little effect of diet on levels. This means that you don’t need to measure it on a regular basis – if it is high, it will stay high, and if it is low, it will stay low.

It is a major factor in causing coronary disease, independent of standard cholesterol values.

As of now, there are no medications available to lower it, but new medicines are on the horizon.

If we cannot treat it, you may ask, why measure it?

First, if it is elevated, your doctor can put you on cholesterol-lowering medication even if your standard cholesterol levels are normal and would not be treated. No one risk factor works alone, and even if we cannot yet lower a high Lp(a), we can still reduce your risk of heart attack by treating other risk factors.

Second, there is recent evidence that low-dose daily aspirin, which is now considered not appropriate for the general population, will cut in half the heart attack and stroke risk in people with Lp(a) over 50.

So, at your next visit, ask your doctor if they have ever measured your Lp(a), and request they do so if it has never been done.

Knowledge is power.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, February 11, 2024

Private Equity in Health Care

Those of you in the metro Boston news market have been regaled with the saga of the failing Stewart Health Care System, owner of nine hospitals in eastern Massachusetts. One eye-catching story described the $40 million yacht purchased by Stewart’s CEO, Dr. Ralph de la Torre, while Stewart hospitals were having equipment repossessed because of failure to pay their bills.

While a 190-foot yacht catches attention, it is only a symptom of a deeper problem.

Private equity (PE) firms’ business model is to buy companies as cheaply as possible, pull as much cash as they can from the company and then either resell it or declare bankruptcy. To be able to sell the business, they have to jack up profits by cutting costs and/or raising prices.

Private equity investment in healthcare is a recent phenomenon but one which is rapidly growing. These firms focus on specialties where lucrative procedures can be done and/or where patients have little choice. Many emergency medicine groups, pathologists and anesthesiologists now work for entities controlled by private equity. These groups were responsible for most of the “surprise” out-of-network bills that made headlines in the last few years. Knowing that patients rarely if ever have the option to select a physician in these fields, they would pull out of insurance contracts and then bill whatever they wanted.

Quality is secondary to the acquiring PE firm; profits come first. They can increase revenue by raising fees and/or encouraging their employed physicians to do as many well-paid procedures (such as catheterizations and endoscopies) as can be justified, even if not all are truly needed. They can cut costs by skimping on equipment and supplies that are not “revenue-producing,” even if they improve quality care. They can also substitute less-qualified, lower-paid personnel, such as aides in place of nurses.

Steward offers a textbook example. Cerberus Capital bought the troubled Massachusetts-based Caritas Christi hospital system, promising to turn it around. Soon after, they sold the land and buildings of its own hospitals to a real estate trust, pulling out $1.2 billion and saddling the hospitals with hundreds of millions in annual rent. That transaction allowed Cerberus to quadruple its investment and to pay its investors a $100 million dividend. They bought hospitals around the country, including Texas, Florida and Ohio. Many of these have since been closed, doubtless after the PE investors had pulled as much money out as possible.

So, Stewart’s CEO has a very expensive yacht and communities around the country are dreading the closure of what is often their only nearby hospital.

Tell your state legislators that private equity has no place in health care, certainly not without very strict guidelines and oversight.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, February 3, 2024

Do you want to live to be 100?

In 1521 Ponce de Leon arrived in Florida in search of the mythical fountain of youth; those who drank from it or bathed in it were said to be returned to their youth. Some 500 years later, the New York Times ran a lengthy article on a longevity guru whose disciples wear T-shirts emblazoned Don’t Die and who buy supposedly rejuvenating vitamins and supplements from him by the bushel.

What is real in our search for longevity? I assume that most of you, like me, are interested in healthy longevity – I would rather be well and active into my 90’s than live into my 100’s in a frail dependent state.

The maximum lifespan of any species, including our own, seems to be fixed. The longest documented human lifespan was 122 years, and the next oldest were 119. About 120 would seem to be as much as we can hope for.

In the famous Blue Zones, 5 scattered sites in Italy, Japan, Greece, Costa Rica and California, many people live healthy and active well into their 90’s, and much of what we know about healthy longevity came first from studying these populations, backed up by many other studies.

While heredity clearly plays a role – the best single predictor of a long life is having long-lived parents - only some 30% of your chance for a long healthy life comes from choosing the right parents. Much is under our control.

Diet is a critical factor. If longevity is very important to you, prepare to be hungry. There is incontrovertible evidence in mice and considerable data in humans that calorie restriction lengthens lifespan.

What you eat is important. Contributing to a long and healthy life is eating a plant-based diet, heavy in fruits and vegetables with little or no red meat. Get your protein from fish and nuts, and use olive oil in place of butter. This type of diet leads to less heart disease and less cancer.

Move. Regular exercise both leads to less premature death and better quality of life. While any amount of exercise is much better than none, more is better. Even walking 30 minutes a day will pay dividends, but exercising more and longer is even better. Do not forget strength. Aerobic exercise will do the most to extend life, but strength training prevents falls and injuries and strengthens the bones.

Don’t smoke. If you do, quitting now will do more to improve your health than anything else you can do.

Minimize your alcohol intake. There is soft evidence that moderate drinking may reduce heart disease, but it increases a variety of other disorders. One drink a day is probably a wash, but more is clearly bad.

Get enough sleep. Sleep is when we rejuvenate, and try for at least 8 hours a night.

Socialize. Spending time with friends and family and participating in group activities is very common in the Blue Zones and has been shown to be associated with less depression and better physical health.

See your doctor once in a while. Many chronic diseases that shorten life, including hypertension, high cholesterol and diabetes, have simple treatments that prevent premature death and worse diseases. A few preventive measures such as colonoscopy and immunizations have good data supporting their use.

Pills? Not many. As I wrote a while back, there is now data supporting the use of a daily multivitamin to stave off dementia. Softer evidence favors the amino acid taurine and the diabetes pill metformin; both are in early stages of testing and I do not take either. Most other supplements enrich their sellers but do not help you.

There are no quick fixes to let you live longer and better, but there are many things you can do.

Prescription for Bankruptcy. Buy the book on Amazon