The woman, who was in her 90s, had lived for several years at the Ecumen
Sunrise nursing home in Two Harbors, Minn., where the staff had grown accustomed
to her grimaces and wordless cries. She took a potent cocktail of three
psychotropic drugs: Ativan for anxiety and the antipsychotic Risperdal to calm
her, plus an antidepressant. In all the time she’d lived at Sunrise, she hadn’t
spoken. It wasn’t clear whether she could recognize her children when they came
to visit.
Belinda Day Saylor Eva Lanigan, right, director of nursing at the Ecumen nursing
home in Two Harbors, Minn., with a resident, Marjorie Labrie, 94.The Two Harbors
home happened to be where Ecumen, which operates 16 nonprofit Minnesota nursing
homes, was preparing an experiment to see if behavioral rather than
pharmacological approaches could help wean residents off antipsychotic
medications. They called it the Awakenings program.
“What’s people’s biggest fear? Being a ‘zombie’ in a nursing home,” said Laurel
Baxter, the Awakenings project manager.
Any visitor can see what she means. Even in quality nursing homes, some
residents sit impassively in wheelchairs or nod off in front of televisions,
apparently unable to interact with others or to summon much interest in their
lives. Nursing home reformers and regulators have long believed that this
disengagement results in part from the overuse of psychotropic medication to
quell the troublesome behaviors that can accompany dementia — yelling,
wandering, aggression, resisting care. For nearly 25 years, federal law has
required that psychotropic drugs (which critics call “chemical restraints”) be
used only when necessary to ensure the safety of a resident or those around her.
The drugs can cause serious side effects. Since 2008, the Food and Drug
Administration has required a so-called black box warnings on their packaging,
cautioning that they pose an increased mortality risk for elderly patients.
Nevertheless, a national survey reported that in 2004 about a quarter of nursing
home residents were receiving antipsychotic drugs. (Among the antipsychotic
drugs most commonly used in nursing homes are Risperdal, Seroquel and Zyprexa.)
Though they may be prescribed less frequently following the F.D.A.’s warnings,
these drugs are still overused in long-term care, said Dr. Mark Lachs, chief of
geriatrics at Weill Cornell Medical College. And once the pills are prescribed,
residents keep taking them. “They get perpetualized, like insulin,” he told me,
even though the behaviors they’re meant to soothe may wane anyway as dementia
progresses.
“If a place is understaffed, if it takes particularly unruly patients, you can
see how it happens,” Dr. Lachs added. “Behavioral interventions are far more
time-consuming than giving a pill.”
Nevertheless, Ecumen’s Awakenings project emphasizes nondrug responses.
“Medications have a place, but that shouldn’t be the first thing you try,” said
Eva Lanigan, director of nursing at the Two Harbors facility.
So the home trained its entire staff (housekeepers, cooks, dining room servers,
everyone) in a variety of tools to calm and reassure its 55 residents: exercise,
activities, music, massage, aromatherapy. It taught people the kind of
conversation known as “redirecting” — listening to elders and responding to them
without insisting on facts that those with dementia can’t absorb or won’t
recall.
“The hands-on, caring part is the most important,” Ms. Lanigan said. “Sometimes,
people just want a hug. You sit and hold their hand.”
At the same time, consulting with a geriatric psychiatrist and a pharmacist, the
home began gradually reducing the doses of antipsychotics and antidepressants
for patients whose families agreed. Among them: the woman with the mysterious
cries.
As Dr. Lachs pointed out, behavioral interventions are labor-intensive. Two
Harbors hired an additional nurse to oversee those efforts, and Ms. Lanigan was
available to answer staff questions around the clock. Ecumen estimates that
introducing the program to a 60-bed nursing home cost an additional $75,000 a
year for two full-time employees.
The results startled even the believers, however. Every resident on
antipsychotics (about 10) was able to stop taking them, and 30 to 50 percent of
those taking antidepressants also did well without them. When drugs still seemed
necessary, “we tried to reduce them to the lowest dose possible,” Ms. Lanigan
said.
Encouraged, Ecumen has introduced the Awakenings program to its 15 other nursing
homes, using a $3.8 million, three-year grant from the state of Minnesota. “I
believe we may learn that spending a little time now with a resident, preventing
the use of psychiatric medications and their side effects, you’ll save time and
money in the long run,” said Ms. Baxter, the project manager. “I’m optimistic.”
Of course, you can’t tell how well nondrug approaches work based on one
facility’s outcomes. “We know how to reduce behavior problems and mood issues in
controlled clinical trials,” said Kimberly Van Haitsma, a senior research
scientist at the Polisher Research Institute in Philadelphia. “The actual nuts
and bolts of how do you do this and keep it in place — over not weeks or months,
but years — is a question the field is struggling with.” Turnover among both
staff and residents is high in nursing homes, she pointed out.
But with reduced medications, the woman at the Two Harbors home did seem to
awaken. She was able to speak — haltingly and not always understandably, but
enough to communicate. And what she let Ms. Lanigan know, after years of being
virtually nonverbal, was that she was suffering physical pain, the cause of her
crying out.
It took doctors a while to find effective medications for her nerve condition,
but they were eventually able to make her more comfortable without further
fogging her mind. She stopped taking psychotropic drugs altogether.
None of this can halt dementia; it’s a terminal disease, and it took this
resident’s life last year. But in her final months, she smiled and played
balloon volleyball with other residents and could say she felt fine or was
hungry.
“She engaged more. Her family came to help her eat,” Ms. Lanigan said. “It was a
big change.”
SUN CITY, Ariz. — From behind the wheel of his minivan, Bill
Szentmiklosi scours the streets of Sun City in search of zoning violations like
unkempt yards and illegal storage sheds. Mostly, though, he is on the lookout
for that most egregious of all infractions: children.
With a clipboard of alleged violations to investigate, he peers over fences and
ambles into backyards of one of America’s pioneer retirement communities, a
haven set aside exclusively for adults, where children are allowed to visit but
not live.
Mr. Szentmiklosi, 60, a retired police officer who settled here four years ago,
has remade himself as the chief of Sun City’s age police, the unit charged with
ensuring that this age-restricted community of sexagenarians, septuagenarians
and even older people does not become a refuge for the pacifier-sucking,
ball-playing or pimple-faced.
One recent morning, as he slowly wheeled between ranch homes and palm trees, Mr.
Szentmiklosi kept a sharp eye on the driveways and yards, surveying for any
obvious signs of youth. It could be a stray ball, a misplaced pint-size
flip-flop. In sniffing out children, he said, he relies on his three decades as
an officer.
But it is when he strides up to a home, dressed in shorts, sandals and a polo
shirt, and knocks on the door that his detective work really begins. He tells
the suspected violator that a neighbor has complained and he asks gentle
questions to get to the bottom of things, all the while peering around for signs
of youthful activity. His work is helped by a simple reality: children are hard
to hide.
They leave tracks and make unique sounds. Newborns bellow, toddlers shriek and
teenagers play music that is not typical around Sun City.
Mr. Szentmiklosi and his fellow child-hunters have their work cut out for them.
The number of age violations in Sun City, a town of more than 40,000 residents
outside Phoenix, has been rising markedly over the years, from 33 in 2007 to 121
in 2008 to 331 last year, a reflection of a trend at many of the hundreds of
age-restricted communities nationwide.
This year’s figures are expected to be even higher, said Mr. Szentmiklosi, who
knows that despite his patrols Sun City is probably harboring more children that
have not yet been detected. The economic crisis is aggravating the problem, he
said, forcing families to take desperate measures to cut costs, even if it means
surreptitiously moving into Grandma and Grandpa’s retirement bungalow.
The vigorous search for violators of Sun City’s age rules is about more than
keeping loud, boisterous, graffiti-scrawling rug rats from spoiling residents’
golden years, although that is part of it. If Sun City does not police its
population, it could lose its special status and be forced to open the
floodgates to those years away from their first gray hair.
The end result would be the introduction of schools to Sun City, then higher
taxes and, finally, an end to the Sun City that has drawn retirees here for the
last half-century.
At 50, Sun City is not old by the standards of Sun City, where the average
resident is in his or her early 70s.
To remain a restricted retirement community, at least 80 percent of Sun City’s
housing units must have at least one occupant who is 55 or older, allowing for
younger spouses or adult children. But the rules are clear on one thing: no one,
absolutely no one, who is a teenager, an adolescent, a toddler, a newborn, any
form of child, may call Sun City home.
“Visits are O.K. as long as they’re limited,” said Mr. Szentmiklosi, who
describes himself as a doting grandfather and insists that he does not have an
anti-child bone in his body. “You can have children visit for 90 days per year.
That means if you have 10 grandchildren, each one can visit, but they can only
stay nine days each.”
Mr. Szentmiklosi, the compliance manager for the Sun City Homeowners
Association, said that although the city was scrupulous, it remained
compassionate. For instance, it allowed a young woman with an infant who was
renting a home without the association’s knowledge a year to move out.
But the association also plays hardball, issuing fines and threatening legal
action to pressure youthful violators to leave. One reason Sun City is so
vigorous is because of what happened on the other side of 111th Avenue, one of
the main roads traversing the neighborhood.
Although Del Webb, who developed Sun City in 1960, gets credit for inventing the
idea of a community of active retirees, the concept actually started years
before on an adjacent tract in what was called Youngtown. But the developers
there were not diligent in drawing up their legal paperwork. A challenge by the
family of a teenage boy led the state to strip Youngtown of its age restrictions
in 1998.
So on one side of the road, little people can be seen running around. On the
other side, many people remember the Great Depression, and not from reading
about it in a book.
“It was so much quieter before,” said Librado Martinez, 80, a retired machine
operator who lives on the Youngtown side of the line and has to put up with
children playing ball in the park in front of his house. “You heard no screams
before.”
That peace is what Sun City residents want to keep. They rose up last month to
block a charter school, which is not governed by the same rules as other public
schools, from moving in.
“They were concerned about children roaming the streets and terrorizing things,”
said Marsha Mandurraga, who works for the school’s founder.
To prevent future incursions, Sun City’s leaders are using their clout to urge
state legislators to change the law to keep Sun City school-free.
“I’ve raised kids,” said Chris Merlav, 61, breathing through an oxygen tank and
resting on the side of a Sun City pool designed for walking, not swimming.
“After a while you get to the point where you don’t want to be bothered
anymore.”
Mr. Merlav, who moved here from Rochester, had evidence at hand that he was not
anti-child. His 20-year-old stepdaughter, Danielle Anastasia, was lounging in
the pool with him. She understood the desire of Sun City residents to be with
people their own age. “It’s like me hanging with my college friends,” she said.
Some of Sun City’s more hard-line anti-child activists can sound as though they
somehow bypassed youth completely.
“There are people here who have never had children, don’t care for children and
don’t particularly want children around,” said Jan Ek, who runs Sun City’s seven
recreation centers, eight golf courses, two bowling centers and assorted other
entertainment venues, some of which sometimes open up for child visitors.
At Sun City’s museum, the resident historian, Bill Pearson, 62, played a
videotape used to lure retirees to the development in the 1960s.
The narrator said then what many residents still say now: “Of course we love
them and enjoy their visits, but you deserve a little rest after raising your
own.”
LAGUNA WOODS, Calif. — The ladies in the card room are playing bridge, and at
their age the game is no hobby. It is a way of life, a daily comfort and
challenge, the last communal campfire before all goes dark.
“We play for blood,” says Ruth Cummins, 92, before taking a sip of Red Bull at a
recent game.
“It’s what keeps us going,” adds Georgia Scott, 99. “It’s where our closest
friends are.”
In recent years scientists have become intensely interested in what could be
called a super memory club — the fewer than one in 200 of us who, like Ms. Scott
and Ms. Cummins, have lived past 90 without a trace of dementia. It is a group
that, for the first time, is large enough to provide a glimpse into the lucid
brain at the furthest reach of human life, and to help researchers tease apart
what, exactly, is essential in preserving mental sharpness to the end.
“These are the most successful agers on earth, and they’re only just beginning
to teach us what’s important, in their genes, in their routines, in their
lives,” said Dr. Claudia Kawas, a neurologist at the University of California,
Irvine. “We think, for example, that it’s very important to use your brain, to
keep challenging your mind, but all mental activities may not be equal. We’re
seeing some evidence that a social component may be crucial.”
Laguna Woods, a sprawling retirement community of 20,000 south of Los Angeles,
is at the center of the world’s largest decades-long study of health and mental
acuity in the elderly. Begun by University of Southern California researchers in
1981 and called the 90+ Study, it has included more than 14,000 people aged 65
and older, and more than 1,000 aged 90 or older.
Such studies can take years to bear fruit, and the results of this study are
starting to alter the way scientists understand the aging brain. The evidence
suggests that people who spend long stretches of their days, three hours and
more, engrossed in some mental activities like cards may be at reduced risk of
developing dementia. Researchers are trying to tease apart cause from effect:
Are they active because they are sharp, or sharp because they are active?
The researchers have also demonstrated that the percentage of people with
dementia after 90 does not plateau or taper off, as some experts had suspected.
It continues to increase, so that for the one in 600 people who make it to 95,
nearly 40 percent of the men and 60 percent of the women qualify for a diagnosis
of dementia.
At the same time, findings from this and other continuing studies of the very
old have provided hints that some genes may help people remain lucid even with
brains that show all the biological ravages of Alzheimer’s disease. In the 90+
Study here, now a joint project run by U.S.C. and the University of California,
Irvine, researchers regularly run genetic tests, test residents’ memory, track
their activities, take blood samples, and in some cases do postmortem analyses
of their brains. Researchers at Irvine maintain a brain bank of more than 100
specimens.
To move into the gated village of Laguna Woods, a tidy array of bungalows and
condominiums that blends easily into southern Orange County, people must meet
several requirements, one of which is that they do not need full-time care.
Their minds are sharp when they arrive, whether they are 65 or 95.
They begin a new life here. Make new friends. Perhaps connect with new romantic
partners. Try new activities, at one of the community’s fitness centers; or new
hobbies, in the more than 400 residents’ clubs. They are as busy as arriving
freshmen at a new campus, with one large difference: they are less interested in
the future, or in the past.
“We live for the day,” said Dr. Leon Manheimer, a longtime resident who is in
his 90s.
Yet it is precisely that ability to form new memories of the day, the present,
that usually goes first in dementia cases, studies in Laguna Woods and elsewhere
have found.
The very old who live among their peers know this intimately, and have developed
their own expertise, their own laboratory. They diagnose each other, based on
careful observation. And they have learned to distinguish among different kinds
of memory loss, which are manageable and which ominous.
A Seat at the Table
Here at Laguna Woods, many residents make such delicate calculations in one
place: the bridge table.
Contract bridge requires a strong memory. It involves four players, paired off,
and each player must read his or her partner’s strategy by closely following
what is played. Good players remember every card played and its significance for
the team. Forget a card, or fall behind, and it can cost the team — and the
social connection — dearly.
“When a partner starts to slip, you can’t trust them,” said Julie Davis, 89, a
regular player living in Laguna Woods. “That’s what it comes down to. It’s
terrible to say it that way, and worse to watch it happen. But other players get
very annoyed. You can’t help yourself.”
At the Friday afternoon bridge game, Ms. Cummins and Ms. Scott sit with two
other players, both women in their 90s. Gossip flows freely between hands, about
residents whose talk is bigger than their game, about a 100-year-old man who
collapsed and died that week in an exercise class.
But the women are all business during play.
“What was that you played, a spade was it?” a partner asks Ms. Cummins.
“Yes, a spade,” says Ms. Cummins, with some irritation. “It was a spade.”
Later, the partner stares uncertainly at the cards on the table. “Is that ——”
“We played that trick already,” Ms. Cummins says. “You’re a trick behind.”
Most regular players at Laguna Woods know of at least one player who,
embarrassed by lapses, bowed out of the regular game. “A friend of mine, a very
good player, when she thought she couldn’t keep up, she automatically dropped
out,” Ms. Cummins said. “That’s usually what happens.”
Yet it is part of the tragedy of dementia that, in many cases, the condition
quickly robs people of self-awareness. They will not voluntarily abandon the one
thing that, perhaps more than any other, defines their daily existence.
“And then it’s really tough,” Ms. Davis said. “I mean, what do you do? These are
your friends.”
Staying in the Game
So far, scientists here have found little evidence that diet or exercise affects
the risk of dementia in people over 90. But some researchers argue that mental
engagement — doing crossword puzzles, reading books — may delay the arrival of
symptoms. And social connections, including interaction with friends, may be
very important, some suspect. In isolation, a healthy human mind can go blank
and quickly become disoriented, psychologists have found.
“There is quite a bit of evidence now suggesting that the more people you have
contact with, in your own home or outside, the better you do” mentally and
physically, Dr. Kawas said. “Interacting with people regularly, even strangers,
uses easily as much brain power as doing puzzles, and it wouldn’t surprise me if
this is what it’s all about.”
And bridge, she added, provides both kinds of stimulation.
The unstated rule at Laguna Woods is to support a friend who is slipping, to act
as a kind of memory supplement. “We’re all afraid to lose memory; we’re all at
risk of that,” said one regular player in her 90s, who asked not to be named.
Woody Bowersock, 96, a former school principal, helped a teammate on a swim team
at Laguna Woods to race even as dementia stole the man’s ability to form almost
any new memory.
“You’d have to put him up on the platform just before the race, just walk him
over there,” Mr. Bowersock said. “But if the whistle didn’t blow right away,
he’d wander off. I tell you, I’d sometimes have to stand there with him until he
was in the water. Then he was fine. A very good swimmer. Freestyle.”
Bridge is a different kind of challenge, but some residents here swear that the
very good players can play by instinct even when their memory is dissolving.
“I know a man who’s 95, he is starting with dementia and plays bridge, and he
forgets hands,” said Marilyn Ruekberg, who lives in Laguna Woods. “I bring him
in as a partner anyway, and by the end we do exceedingly well. I don’t know how
he does it, but he has lots of experience in the game.”
Scientists suspect that some people with deep experience in a game like bridge
may be able to draw on reserves to buffer against memory lapses. But there is
not enough evidence one way or the other to know.
Ms. Ruekberg said she cared less about that than about her friend: “I just want
to give him something more during the day than his four walls.”
Drawing the Line
In studies of the very old, researchers in California, New York, Boston and
elsewhere have found clues to that good fortune. For instance, Dr. Kawas’s group
has found that some people who are lucid until the end of a very long life have
brains that appear riddled with Alzheimer’s disease. In a study released last
month, the researchers report that many of them carry a gene variant called
APOE2, which may help them maintain mental sharpness.
Dr. Nir Barzilai of the Albert Einstein College of Medicine has found that lucid
Ashkenazi Jewish centenarians are three times more likely to carry a gene called
CETP, which appears to increase the size and amount of so-called good
cholesterol particles, than peers who succumbed to dementia.
“We don’t know how this could be protective, but it’s very strongly correlated
with good cognitive function at this late age,” Dr. Barzilai said. “And at least
it gives us a target for future treatments.”
For those in the super-memory club, that future is too far off to be meaningful.
What matters most is continued independence. And that means that, at some point,
they have to let go of close friends.
“The first thing you always want to do is run and help them,” Ms. Davis said.
“But after a while you end up asking yourself: ‘What is my role here? Am I now
the caregiver?’ You have to decide how far you’ll go, when you have your own
life to live.”
In this world, as in high school, it is all but impossible to take back an
invitation to the party. Some players decide to break up their game, at least
for a time, only to reform it with another player. Or, they might suggest that a
player drop down a level, from a serious game to a more casual one. No player
can stand to hear that. Every day in card rooms around the world, some of them
will.
“You don’t play with them, period,” Ms. Cummins said. “You’re not cruel. You’re
just busy.”
The rhythm of bidding and taking tricks, the easy conversation between hands,
the daily game — after almost a century, even for the luckiest in the genetic
lottery, it finally ends.
“People stop playing,” said Norma Koskoff, another regular player here, “and
very often when they stop playing, they don’t live much longer.”
CAMDEN, Ala. — Hundreds of hospice providers across the country are facing
the catastrophic financial consequence of what would otherwise seem a positive
development: their patients are living longer than expected.
Over the last eight years, the refusal of patients to die according to actuarial
schedules has led the federal government to demand that hospices exceeding
reimbursement limits repay hundreds of millions of dollars to Medicare.
The charges are assessed retrospectively, so in most cases the money has long
since been spent on salaries, medicine and supplies. After absorbing huge
assessments for several years, often by borrowing at high rates, a number of
hospice providers are bracing for a new round that they fear may shut their
doors.
One is Hometown Hospice, which has been providing care here since 2003 to some
of the most destitute residents of Wilcox County, the poorest place in Alabama.
The locally owned, for-profit agency, which serves about 60 patients, mostly in
their homes, had to repay the government $900,000, or 27 percent of its
revenues, from its first two years of operation, said Tanya O. Walker-Butts, a
co-owner. Its profits were wiped out in the time it took to open the demand
letters, Ms. Walker-Butts said.
Hometown paid its first assessment with a bank loan. When the bank declined
credit for the second year, the hospice structured a five-year payment plan with
the Centers for Medicare and Medicaid Services, the federal agency that
administers the program, at 12.5 percent interest.
The next bill is expected any day.
“If they hit us with a number in the several hundred-thousand range, I just
don’t see how we can survive,” said Gaines C. McCorquodale, Hometown’s other
owner.
In the early days of the Medicare hospice benefit, which was designed for those
with less than six months to live, nearly all patients were cancer victims, who
tended to die relatively quickly and predictably once curative efforts were
abandoned.
But in the last five years, hospice use has skyrocketed among patients with less
predictable trajectories, like those with Alzheimer’s disease and dementia.
Those patients now form a majority of hospice consumers, and their average stays
are far longer — 86 days for Alzheimer’s patients, for instance, compared with
44 for those with lung cancer, according to the Medicare Payment Advisory
Commission.
The commission, which analyzes Medicare issues for Congress, recently projected
that 220 hospices — about one of every 13 providers — received 2005 repayment
demands totaling $166 million. The National Alliance for Hospice Access, a
providers’ group that is lobbying for a three-year moratorium on the
collections, places the numbers at 250 hospices and $200 million.
Because fewer than a tenth of all hospice providers have faced repayment,
Medicare officials suggest that management might have been an issue. But Lois C.
Armstrong, president of the hospice access alliance, said that if the cap on
Medicare reimbursements was not lifted, the availability of care would tighten
at a time when demand for hospice care was exploding and when new research
suggests it saves money for the runaway Medicare program.
Many elderly people here in the remotest reaches of the state’s Black Belt would
most likely live out their last days alone if not for Hometown Hospice nurses
like Meg Appel Youngblood.
One recent autumn morning, Ms. Youngblood forded the Alabama River by ferry and
set off on her rounds of the storied quilting enclave of Gees Bend, looking in
on old women who had grown too feeble to quilt or to care for themselves.
Inside a clapboard house, she checked the vital signs of Loretta L. Pettway, a
former farmhand whose stitchwork has been celebrated in postage stamps and
picture books, and found that her blood pressure was a bit high.
“Miss Loretta, have you had your medicine?” she asked, and Ms. Pettway, 65,
weary from chronic heart disease, shook her head no. “I didn’t think so,” Ms.
Youngblood said, as she started to inventory the 14 pill bottles Ms. Pettway had
stowed in a plastic bag.
Medicare’s coverage of hospice, which began in 1983, has become one of the
fastest growing components of the government’s fastest growing entitlement.
Spending nearly tripled from 2000 to 2005, to $8.2 billion, and nearly 40
percent of Medicare recipients now use the service.
To be eligible, patients must be certified by two doctors as having six months
or less to live, assuming their illness runs a normal course. They must agree
not to bill Medicare for curative procedures related to their diagnosis.
Medicare, which pays the vast majority of hospice bills, reimburses providers
$135 a day for a patient’s routine home care. The hospice is then responsible
for providing nurses, social workers, chaplains, doctors, drugs, supplies and
equipment, as well as bereavement support to the family.
Studies have reached various conclusions about whether hospice care actually
saves money, especially for long-term patients. But a new study by Duke
University researchers concluded that it saved Medicare an average of $2,300 per
beneficiary, calling hospice “a rare situation whereby something that improves
quality of life also appears to reduce costs.”
In 1998, Congress removed limits on the number of days that an individual could
receive Medicare hospice coverage, a move that encouraged physicians to refer
terminal patients.
But lawmakers did not remove a cap on the aggregate amount that hospice
providers could be reimbursed each year, a measure designed to contain the
program’s cost. A hospice’s total annual reimbursement cannot exceed the product
of the number of patients it serves and a per-patient allowance set by the
government each year ($21,410 in 2007).
For reasons that are not fully understood, problems with the cap have been most
prevalent at small, for-profit hospices in Southern and Western states like
Mississippi, Alabama and Oklahoma.
Those programs typically have had higher proportions of noncancer patients and,
thus, longer lengths of stay. But the Medicare advisory commission’s analysis
also determined that the average length of stay in the cap-busting programs was
significantly higher for all types of patients, including those with cancer.
Herb B. Kuhn, the deputy director of the Center for Medicare and Medicaid
Services, said that finding was attracting attention at the center, which is
eager to keep the hospice care benefit from morphing into a long-term care
entitlement. “Well over nine out of 10 hospices seem to be managing well,
including the ones in higher-wage areas, so it does raise an issue of
management,” Mr. Kuhn said. Mr. Kuhn said it remained a question whether hospice
care saved money, but called it “a wonderful benefit” that “probably needs
refinement” after nearly 25 years.
Among the matters meriting review, he said, is whether doctors have been
premature in certifying patients as terminal. Medicare has issued
disease-specific guidelines for the certifications, which must be made by both a
personal physician and the hospice medical director.
The medical director at Hometown Hospice, Dr. Sumpter D. Blackmon, said he
relied heavily on the judgment of the hospice’s nurses to determine whether
prospective patients were rather likely to live longer than six months. But of
the 56 patients on the books on Oct. 31, 17 had been there for at least that
period, including two for more than 500 days.
“Doing this for 40-something years,” said Dr. Blackmon, a longtime physician
here, “every time I think somebody is going to die tomorrow, damned if they
don’t live for a year and a half.”
A number of hospice providers said ethical and legal constraints would prevent
them from discharging patients who outlived their profit potential. But some
said they sometimes delayed admission for those patients with illnesses that
might result in longer stays.
Like other providers, Richard R. Slager, the chairman and chief executive of
VistaCare, which is based in Arizona and has programs in 14 states, said his
company now aimed its marketing at cancer patients.
“In communities where we have had cap issues, we have to really look hard for
shorter-length-of-stay patients to offset it,” Mr. Slager said. “It’s a
never-ending nightmare.”
After being hit with $200 million in cap charges over four years — the
equivalent of a year’s revenues — Mr. Slager said he chose to close or sell 16
of 58 hospices.
Some providers have survived only by aggressively recruiting new patients, using
this year’s Medicare reimbursements to pay off last year’s cap charges, while
stalling for Congressional relief. Ms. Youngblood, the Hometown Hospice nurse,
said that after she visited her charges — doling out their pills, and turning
the sweet potatoes in their ovens — she trolled for new patients at nursing
homes and senior centers.
At the small hospital here, she said, the nurses joke about her “marketing”
forays: “They’ll say, ‘Here comes Nurse Kevorkian. She has no shame.’ And I’ll
say, ‘Look, I have to have a paycheck, too.’”
