Tag: Chronic conditions

Good incremental primary care delivers better health, longer life
If you’ve ever questioned why having a good primary care doctor is so critical, Atul Gawande explains in no uncertain terms in the January 23, 2017 New Yorker. In a nutshell, well-trained primary care doctors understand the whole range of issues affecting a patient’s health; and, they take an incremental approach to treatment that often delivers better health and longer life.

Gawande tells us about spending time with a primary care doctor and patient with a serious chronic condition at the Graham Headache Center in Massachusetts. Rather than prescribing a battery of tests to help treat the patient’s migraine condition, the doctor has the patient explain his 40-year history of suffering from debilitating headaches and listens. The patient describes trying a battery of treatments to no avail, with his migraines only becoming more severe and more frequent.

Gawande then shares with us that, after four years of slow and steady progress, the patient’s migraines have largely subsided. What was the treatment? The patient kept a diary of each migraine attack and met with his doctor every three months to adjust treatment based on the diary entries. That simple. But, the patient’s improvement was barely perceptible to the patient during the first three years. It took four years for the migraines to stop recurring at a frequent pace and devastating intensity.

Gawande also describes a patient whose face is entirely swollen seeking treatment at a clinic in Jamaica Plain, Massachusetts. Again, rather than delivering the battery of tests to rule out conditions that are unlikely, the doctor takes advantage of her understanding of the patient’s full condition and the trust she has built with her patient. She takes “the long view.”

“They focus on the course of a person’s health over time—even through a life. All understanding is provisional and subject to continual adjustment. For Rose, taking the long view meant thinking not just about her patient’s bouts of facial swelling, or her headaches, or her depression, but about all of it—along with her living situation, her family history, her nutrition, her stress levels, and how they interrelated—and what that picture meant a doctor could do to improve her patient’s long-term health and well-being throughout her life.”

This approach led the patient’s medical team to determine she was allergic to naproxen, which she took to relieve migraine pain, and that it was causing the swelling.

The big problem, according to Gawande, is that we do not value incremental care. Primary care doctors tend not to have the resources at their fingertips to diagnose and treat patients that are available to specialists. And, their annual income is on average half of that of specialists. So, it can be hard to find a good primary care doctor. But, especially if you suffer from one or more chronic conditions, a good primary care doctor can improve your health and extend your life immeasurably.

Gawande notes that many Medicare Advantage plans charge high copays for primary care visits, deterring people from getting primary care. With traditional Medicare and supplemental coverage, you have no out-of-pocket costs. And, no matter which Medicare option you choose, Medicare covers the full cost of many preventive care services.

Here’s more from Just Care:
February 1, 2017
“Activated” people less likely to develop chronic disease
A new Commonwealth Fund study reveals that people who are better able to take care of themselves and navigate the health care system, “activated” people, are less likely to develop chronic disease. These study findings complement other recent study findings showing that having a purpose promotes better health and that having friends and not being socially isolated also fosters better health and longer life risk.

The Commonwealth Fund study found that people without good self-management skills were more at risk for chronic conditions, including depression and high blood pressure, after three years than people with good skills. They are also more likely to be hospitalized and to use emergency departments.

There are ways to help people gain confidence and take charge of their health so that they can age in place, have better health outcomes and need less health care. Just Care is piloting a new telebuddy program that will empower older adults and their designated caregivers through sharing simple health care advice during regular phone conversations. If you are interested in learning more about this program or participating in it, please email [email protected].

Here’s more from Just Care:
November 30, 2016
Be positive about aging and be healthier in old age
Some say you are what you do. Others say you are what you think. In fact, Becca Levy, PhD, Yale University, who has studied people’s views about growing older, finds that people who think more negatively about aging are significantly more likely to experience mental and physical decline as they age than people who are more positive about aging. In short, be positive about aging and be healthier in old age.

In their article, Memory Shaped by Age Stereotypes over Time, Levy’s team reports finding that people who are more negative about old age experienced a 30 percent larger loss of memory over 38 years than people who are less negative about old age.

A separate study found that older people who blame old age rather than a particular disability for their difficulties performing activities like walking or getting dressed are also more likely to have serious chronic conditions, such as heart disease, hearing loss and arthritis, than people who see the value of aging. To underscore the importance of seeing being old in a positive light, one study found that people who see old age as sickness–their chronic conditions stemming from being old–are more than doubly likely to die earlier than people who do not.

Interestingly, societal views about aging have also been found to play a role in the mental health of older adults. One study found that older adults in China have far better memories than older adults in the U.S. Researchers Becca Levy and Ellen Langer see a link between these findings and the fact that the Chinese have a more positive view of aging than Americans.

What can you do to increase your likelihood of enjoying old age? Look to older adults who are doing great things for inspiration. Watch the video below of this 86-year old gymnast performing on the parallel bars. Talk about a source of inspiration!

Here’s more from Just Care:
- Get a dog, improve your health
- Seven tips for healthy aging
- How young is your heart?
- The value of a primary care doctor and how to ensure you have a good primary care doctor
- Eat more plants and reduce your risk of Alzheimer’s
https://www.youtube.com/watch?v=aZjljqReu1I
November 10, 2016
The Obesity Paradox: What does it mean for you?
Obesity has long been a high-risk health threat in the United States; more than one in three adults are obese. However, the implications of obesity for older adults are more complicated than the well-known narrative of weight gain causing chronic conditions. The obesity paradox suggests that higher average weight can mean a longer life expectancy. It’s important for older adults and their caregivers to understand how to address weight gain in the context of a healthy, individualistic lifestyle.

Defining Obesity: Obesity is excess accumulation of fat in the body. Lifestyle choices like diet and exercise can contribute to weight gain The preexistence of medical conditions or the experience of immobilizing injuries also can contribute to weight gain.

Measuring obesity: Younger adults often rely on the Body Mass Index to measure weight composition. But many studies show the inaccuracy of the BMI system when applied to older adults. Measuring the waistline may be a better alternative when it comes to older adults; that measure can be compared to height and weight for a more accurate analysis of weight distribution.

What is the Obesity Paradox? Several studies have revealed a counter-intuitive concept that associates a higher average weight with a longer life expectancy. In other words, the optimal weight for survival increases with age. The reasons for these findings are varied, but they emphasize that body composition is more complicated than we might think. (That said, experts see many health risks for older adults with a high body mass index–30 kg/m² or higher.)

What does it mean for you? Caregivers and family members of obese or overweight older adults should understand that increased body size does not necessarily pose a threat to health, or risk complicating existing chronic conditions, and has actually been associated with longer life expectancies.

The reasons behind the obesity paradox are not universally understood. In no way does it mean that healthy adults should try to gain a lot of weight. However, it does mean that heavier adults might be at lower health risk than they think.

All adults and their caregivers should be familiar with specific medical risks of obesity, and understand that the idea that a fatter body signifies poor health is too simple. Older adults should seek help from a doctor or family nurse practitioner, who can evaluate their loved one’s specific conditions and prescribe measures that best fit the situation.

Here’s more from Just Care:
October 11, 2016
Value-based insurance design coming to Medicare
In January 2017, the Centers for Medicare and Medicaid Services, CMS, will launch a new initiative for some older adults and people with disabilities enrolled in Medicare Advantage plans. People in some states with certain chronic conditions will be able to choose a Medicare Advantage plan–a commercial insurance plan that contracts with the government to offer Medicare benefits–that has “value-based insurance design,” with the goal of providing them better care at lower cost. How good the care will be is still a big question mark.

Just to say it, the vast majority of people with Medicare are enrolled in traditional Medicare because it gives them easy access to care and predictable costs almost anywhere in the country. Medicare Advantage plans appear less costly, but they generally come with very little choice of doctors and hospitals and high out-of-pocket costs, particularly for people with costly and complex conditions. While there is a limit of $6850 on out-of-pocket costs in 2016, on top of that you usually must pay the full cost of your care, or a large chunk of the cost, if you use doctors or hospitals outside the health plan’s network. And, your copays and deductibles may not be included in the out-of-pocket limit.

Medicare Advantage health plans are supposed to provide the same benefits as traditional Medicare, but they often have a narrower view than traditional Medicare of when those benefits are reasonable and necessary, further limiting people’s access to care. The Medicare Advantage Value-Based Insurance Design Model (VBID), launching in 2017 is intended to benefit people with diabetes, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), past stroke, hypertension, coronary artery disease, mood disorders, rheumatoid arthritis (starting in 2018) and dementia (starting in 2018).

How does VBID work? The goal is to make out-of-pocket costs for people with these chronic conditions low enough to encourage them to take advantage of Medicare Advantage plan “high-value clinical services” that help manage and improve their care. CMS is encouraging plans to help members with these chronic conditions. Health plans have the flexibility to lower their members’ out-of-pocket costs if they use particular doctors, services or disease management programs; health plans can also offer extra benefits to meet their needs.

Historically, Medicare Advantage plans have tried to avoid enrolling members with costly and complex conditions in order to maximize their profits, so presumably CMS is giving them a financial incentive to participate in this pilot. That said, CMS says that another goal of this pilot is to reduce Medicare spending.

Medicare Advantage plans in seven states–Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee–may be able to test the VBID model. CMS will announce in September which plans will be offering VBID. In January, 2018, CMS will expand the model to three more states–Alabama, Michigan, and Texas.

Here’s more from Just Care:
August 23, 2016
Death rate up in U.S., though fewer dying of cancer
New CDC data show that the death rate is up in the U.S in 2015 to almost 2.6 million. The number of deaths (age-adjusted) rose from 723.2 deaths in 2014 to 729.5 per 100,000 last year. With the exception of the death rate for cancer, which has fallen slightly, death rates for most other chronic conditions are rising. Still, there are many more births—4 million births in the U.S. in 2014, up 1 percent from 2013—than deaths.

Here’s some age-adjusted data:
- More older adults are dying from falls, up from 58.7 to 59.8 deaths per 100,000
- More people are dying from suicides, stroke, emphysema, drug overdoses and Alzheimer’s disease
  - Stroke: Up from 36.4 to 37.4 deaths per 100,000
  - Suicides: Up from 12.7 to 13.1 deaths per 100,000
  - Emphysema and chronic bronchitis: Up from 40.1 to 41.3 deaths per 100,000
  - Drug overdose: Up from 14.1 to 15.2 deaths per 100,000
  - Alzheimer’s disease: Up from 25.4 to 29.2 deaths per 100,000
- Rates of death linked to heart disease, diabetes and kidney disease have not changed
  - Heart disease: Only slightly up from 166.7 to 167.1 deaths per 100,000
  - Diabetes: Only slightly up from 20.9 to 21.1 deaths per 100,000
  - Kidney disease: Very slightly up from 13.2 to 13.3 deaths per 100,000
- Fewer people are dying from cancer, down from 160.9 to 157.9 deaths per 100,000
Here’s more from Just Care:
June 9, 2016
Kidney disease prevalent; many unaware
Kidney disease is prevalent in the U.S, posing huge health risks at enormous cost, according to a recent report by Rajesh Balkrishnan. In 2013, Medicare spent $81 billion dollars treating people with kidney failure (End-Stage Renal Disease) and chronic kidney disease. Fourteen percent of Americans, some 26 million adults, suffer from chronic kidney disease–loss of kidney function–and most are unaware.

People with diabetes and high blood pressure are most likely to get kidney disease. People with chronic kidney disease need a range of costly services. Twenty percent of Medicare spending on people over 65 is for treatment of chronic kidney disease.

Drugs alone typically cost $3,675 a patient under Medicare Part D or 46 percent more than other people with Medicare, whose average Part D costs are $2, 509. People with kidney failure average $6,673 in Part D drug costs, 2.6 times what other people with Medicare spend. And dialysis patients average $7,142 in drug costs.

People with Medicare eligible for a low-income program that helps pay the drug coinsurance or copays only spend one or two percent of total costs out of pocket. But, people who must pay the full share of out-of-pocket costs end up with large bills amounting to about 30 percent of total costs.

Medicare now covers a diabetes prevention program.

Here’s more from Just Care:
April 10, 2016
Are women getting the health care they need?
We know that women’s bodies are different from men’s. But, health care research often fails to consider sex differences in study design and analysis. Or, the research overlooks sex differences and generalizes findings to include women when men are the primary research participants. Not surprisingly, women may not be getting the health care they need, particularly when it comes to certain diseases.

For example, a 2007 article published in the Journal of the Royal Society of Medicine on gender bias in research reported that a lot more money is directed towards studying coronary artery disease in men than in women. But the older women who are at risk have higher morbidity and mortality rates than men.

To help ensure women are getting appropriate care, among other things, more research dollars need to go to studying coronary heart disease in women. Four hundred thousand women die each year of heart disease, almost one death each minute. In fact, more women die of heart disease each year than of all cancers combined. Yet, not even one in four participants in heart-related studies are women according to the Women’s Heart Alliance.

Recently, a Women’s Heart Alliance poll of primary care doctors and cardiologists found that they did not see heart disease in women as their top concern, even though it is the number one killer of women as well as men. And, half of all doctors surveyed disagreed with the fact that women’s hearts are physiologically different from men’s. The signs of heart attack can also be different.

Here’s some additional cause for concern for women:
- Lung cancer is a major killer of women, greater than breast, uterine and ovarian cancers combined. Yet, women are often not as well represented as men in the research and gender differences are often not studied and reported.
- Women are twice as likely to suffer from depression as men. And, women have been shown to metabolize drugs in a different manner from men. Yet, depression research often does not take gender differences into account.
- Two out of three people with Alzheimer’s disease are women, but differences in physiology between men and women have not been studied to help understand the disease.
To make matters worse, twice as many women as men over 65 live in poverty.

Here are some ways to make sure your mom and the mom’s you love are safe and healthy.
February 17, 2016
Can Parkinson’s disease be treated?
Parkinson’s disease is a type of movement disorder affecting about 1 million people who are typically 60 and older. Parkinson’s causes people to have difficulty keeping their bodies still. It is a chronic condition, staying with people over time, generally with worsening symptoms. Some people become severely disabled, but it is not possible to predict the course of the disease for a particular person. There are four signs of Parkinson’s disease:
1. Tremor
2. Trembling in the hands, arms, legs, jaw or face
3. Stiffness in the legs or trunk
4. Balance problems
Over time, people with Parkinson’s may have trouble walking or talking or otherwise performing daily activities such as bathing, dressing or eating. Chewing and swallowing and even speaking can be a problem as well. Sometimes, people with Parkinson’s also experience depression or mood swings,

Doctors generally diagnose Parkinson’s based on a neurological exam and medical history, Blood and lab tests cannot diagnose Parkinson’s.

While there is no cure for Parkinson’s, several medications can relieve the symptoms, including tremors. People whose symptoms are not relieved can have Deep Brain Stimulation, recently approved by the Food and Drug Administration.
February 10, 2016
Should we treat aging as a disease?

Experts disagree as to whether aging is simply a natural process or we should treat it as a disease. If aging is seen as a diseases, we should be looking for ways to treat it. Not surprisingly, the pharmaceutical industry supports treating aging as a disease.

To be sure, there’s a difference between your biological age and aging. All of us age. We grow older and older over the years. But we don’t all age at the same rate. Put differently, aging happens more rapidly to some of us than others, and we all age in different ways.

People’s physical conditions vary based on age, much like their cognitive abilities. Some of us lose bone mass faster, others are better able to retain memory as the years pass and most of us turn grey in our 50s, while some do not. But does that make aging a disease like other chronic conditions?

Some say aging is a disease. They believe that if aging is seen as a disease, scientists may be more likely to research ways to treat aging. And, some experts believe that at least certain aspects of aging may be treatable, just as we treat heart disease or high blood pressure.

Indeed, a diabetes drug, metformin could extend the life of rodents. If it could extend human life, should it be considered an anti-aging drug? What do you think?

January 6, 2016