Tag Archives: Kaiser

America’s other drug problem: Copious prescriptions for hospitalized elderly

Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

“This is actually a little bit alarming,” Bailey said.

He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal’s breathing.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

“This is America’s other drug problem — polypharmacy,” said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. “And the problem is huge.”

The medical center, where Bailey also works, is intended specifically for treating older people. One of its goals is to ensure that elderly patients are not harmed by drugs meant to heal them.

That work falls largely to Bailey, a clinical pharmacist specializing in geriatric care.

Some drugs can cause confusion, falling, excessive bleeding, low blood pressure and respiratory complications in older patients, according to research and experts.

Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.

Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable “adverse drug events” occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).

And even if a drug doesn’t cause an adverse reaction, that doesn’t mean the patient necessarily needs it. A study of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.

“There are a lot of souvenirs from being in the hospital: medicines they may not need,” said David Reuben, chief of the geriatrics division at UCLA School of Medicine.

Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.

University of California, San Francisco researcher and physician Ken Covinsky, said many doctors who prescribe drugs in hospitals don’t consider how long those medications might be needed. “There’s a tendency in medicine every time we start a medicine to never stop it,” Covinsky said.

When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don’t have a family member or a caregiver to help, the consequences can be disastrous.

One 2013 study found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.

UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital’s geriatric unit to improve care and reduce readmissions among older patients.

Speaking from his hospital bed at UCLA’s Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.

Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.

“I’m very confused about it, to tell you the truth,” he said after talking to Bailey. “It’s complicated. And if the pills are not right, you are in trouble.”

Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.

Over a six-month stretch after Bailey started working in UCLA’s Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.

Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.

“As you know, our elderly are already at risk for an accumulation of drugs in their body,” he told the group. “If you put a drug that has a really long half-life, it is going to last even longer in our elderly.”

The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey’s services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.

Bailey said he tries to answer several questions in order to determine what’s best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?

One of his go-to references is known as the Beers list — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.

When he’s not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients’ medication lists are accurate and up to date. He also monitors patients’ new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.

“Medications only work if you take them,” Bailey said dryly. “If they sit on the shelf, they don’t work.”

That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.

Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.

Bailey said he’s constantly weighing the risks versus the benefits of medications for elderly patients like Cal.

“It is figuring out what they need,” he said, “versus what they can survive without.”

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from The SCAN Foundation, and its coverage of late life and geriatric care is supported by The John A. Hartford Foundation. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Should big insurance become like Walmart to lower health costs?

Retail titan Walmart uses its market dominance to inflict “ruthless,” “brutal” and “relentless” pressure on prices charged by suppliers, business writers frequently report.

What if huge health insurance companies could push down prices charged by hospitals and doctors in the same way?

The idea is getting new attention as already painful health costs accelerate and major medical insurers seek to merge into three enormous firms.

Now that hospitals have themselves combined, in many cases, into companies that dominate their communities, insurance executives argue the only way to fight bigness is bigness.

No. 2 health insurer Anthem’s proposed marriage to No. 6 Cigna would let the combined company “manage the cost drivers that negatively impact affordability for consumers,” Anthem CEO Joseph Swedish told Congress last year. The bigger company could “negotiate better reimbursement rates” with medical providers, says Anthem spokeswoman Jill Becher.

In metro areas with only a few big insurers, hospital and doctor bills tend to be lower than what economists would otherwise expect. If only one or two insurers are bidding to include providers in their networks, hospitals and doctors must submit to the offered deal or risk getting shut out of a huge piece of business.

“There’s some literature out there that does show that when you have relatively concentrated insurance markets, they tend to keep actual hospital costs down,” said Yevgeniy Feyman, a researcher at Harvard’s T.H. Chan School of Public Health and a fellow with the Manhattan Institute.

The American Hospital Association as well as the American Medical Association, trade groups for hospitals and doctors respectively, have long worried that insurance mergers do just that. Now that Anthem is trying to buy Cigna, and No. 3 health insurer Aetna wants to buy No. 5 Humana, they’re even more concerned.

Both deals “have the very real potential to reduce competition substantially” and “diminish the insurers’ willingness to be innovative partners with providers and consumers,” AHA lawyer Melinda Reid Hatton wrote to antitrust authorities after the combos were announced.

But hospitals have built their own market power through numerous mergers, giving them broad ability to raise prices paid by employers, taxpayers and consumers beyond what a competitive market would allow, economists argue.

Hospitals “are much more concentrated than insurance markets,” said Glenn Melnick, a health care economist at the University of Southern California who has researched the matter. “They face a lot less competition than the [health] plans do.”

Why not give hospital giants somebody their own size to negotiate with?

For one thing, insurers might just pocket higher profits from low provider prices instead of passing the savings to consumers and employers.

“I don’t find any evidence that reduction in provider payment leads to reduction in insurance premiums, and I don’t know of any study that does,” said Leemore Dafny, an expert in insurance markets and an economist at Harvard Business School.

Feyman suggests requiring insurers in concentrated areas to spend 90 percent of their revenue on medical care. That might reduce their ability to boost profits with premium increases while preserving their ability to hold down hospital and doctor costs, he said.

But he sees such a measure as only a “worst-case scenario” for the most monopolized insurance markets, not a recipe to allow the Anthem and Aetna deals to go through.

Antitrust regulators are siding with the hospitals and doctors.

Late last month the Justice Department sued to block both insurance mergers, arguing that competition is important to keep premiums down and that the deals “would leave much of the multitrillion-dollar health insurance industry in the hands of three mammoth insurance companies.”

They also rejected the Walmart argument, which is related to what economists call “monopsony.”

Monopsony is the opposite of monopoly: Instead of using market dominance to raise prices for consumers, huge buyers force down prices from suppliers. Walmart is often described as holding monopsony-like power.

But critics of the insurance deals say monopsony can go too far. If the buyer pushes prices too low, suppliers stop producing, making needed goods and services unavailable.

“As a result of the merger, Anthem likely would reduce the rates that … providers earn by providing medical care to their patients,” the Justice Department argued. “This reduction in reimbursement rates likely would lead to a reduction in consumers’ access to medical care.”

Accepting Walmart logic for health care might bolster arguments for an even bigger, more powerful buyer of medical services: the government.

A “single-payer,” government health system, of the type advocated by Democratic presidential candidate Bernie Sanders, would be the ultimate monopsony: one buyer, negotiating or dictating prices for everybody.

Neither the hospitals nor the insurance companies want that.

This report was published by Kaiser Health News and ran on NPR. KHN is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Public wants more government action against opioid abuse

Two-thirds of Americans believe the federal and state governments should do more to combat the nation’s heroin and prescription drug epidemic, according to new results from the Kaiser Health Tracking Poll.

Only a third in the Kaiser poll said heroin abuse is an “extremely serious” health problem in the United States and even fewer — only about a quarter — said abuse of strong prescription painkillers is an “extremely serious” health problem. This is despite 44 percent of Americans reporting that they personally know someone who has been addicted to prescription painkillers.

Still, two-thirds of Americans acknowledge prescription pain relief abuse as either “extremely serious” or “very serious.”

The Kaiser poll showed Americans feel the effort to address the growing abuse of opioids is not aggressive enough at any level — not by federal and state governments and not by doctors and users. However, more Americans fault the users than government: About 70 percent said drug users aren’t doing enough to deal with addiction and 60 percent said federal efforts are too small.

In the survey, about 80 percent said the following steps would be at least somewhat effective:

• Increasing pain management training for doctors and students.

• Increasing access to addiction treatment programs.

• Increasing public awareness programs.

• Increasing research about pain and pain management.

• Monitoring how doctors prescribe prescription painkillers.

The poll, conducted in mid-April, also revealed most people don’t know the Affordable Care Act mandates that insurance plans provide mental health benefits and substance abuse treatment under the same copays, deductibles and coverage limits they apply to other medical services.

“This survey is just the latest in a long line of evidence that this out-of-control epidemic is affecting every one of us — no matter our background, no matter where we live,” said U.S. Sen. Rob Portman, R-Ohio. “I agree that the federal government must do more and be a better partner with state and local officials who are on the front lines every day.”

Get Yourself Tested campaign under way

The fourth annual GYT: Get Yourself Tested campaign is under way with the April observance of National STD Awareness Month.

The GYT campaign involves initiatives on air, online and on the ground at college campuses and in more than 5,000 health centers across the nation.

The primary forces behind GYT are MTV and the Kaiser Family Foundation and their focus is on addressing high rates of STDs among people aged 25 and under.

The campaign has the support of a range of organizations, including the U.S. Centers for Disease Control and Prevention and Planned Parenthood Federation of America.

“MTV has made a sustained commitment to challenging the stigma that prevents countless young people from getting tested for STDs and HIV,” said Jason Rzepka, VP for MTV’s public affairs. “We’re proud that GYT has helped drive notable increases in STD testing, but there’s no finish line in this race, and we will continue to do all we can to help our audience make responsible decisions about their sexual health.”

According to the CDC, people age 15-24 represent nearly half of all new STDs occurring in the United States but represent just 25 percent of the population.

Rates of chlamydia, a preventable and treatable STD, are particularly high. Chlamydia often has no symptoms, and when left undiagnosed and untreated can cause serious health consequences, including infertility in women.  As a result, CDC recommends annual screening for all sexually active women aged 25 and younger.

“We’re proud to be a part of GYT because of the positive difference it has made on the lives of so many young Americans,” said Gail Bolan, director of the CDC’s Division of STD Prevention. “The facts are clear – STDs are common, and the life-long impact of an untreated STD is real. But, these don’t have to be accepted parts of life. GYT provides the tools young people need to be proactive about their health.”

For information about GYT and getting tested, go to the campaign website.

Download a PDF of the current issue of Wisconsin Gazette and join our Facebook community.