The overuse of antipsychotic drugs “is one of the most common and longstanding, but preventable practices causing serious harm to nursing home residents today,” Toby Edelman of the Center for Medicare Advocacy told the Senate Aging Committee last week.

She said these drugs are often used off-label (that is: for purposes other than the ones for which the FDA approved them) and that overuse both costs Medicare hundreds of millions of dollars and harms patients.  

Last year, an investigation by the federal Department of Health & Human Services inspector general found that 14 percent of nursing home residents were prescribed anti-psychotics but 8 in 10 were off-label, and, thus, not for treatment of mental illness.

Still, this is not a simple issue. Sometimes, aides cannot provide basic hygiene for dementia patients without the use of these meds. Patients can be too violent or agitated for an aide to change their diaper or bathe them.

Edelman said the Center is not opposed to all uses of these medications but rather wants nursing facilities to try other solutions first.  

Alternatives to drugs can be time consuming and may require special skills. For example, a patient may react poorly to a specific aide—not because the aide is not competent but because there is something about her that triggers agitation. A nursing home can figure this out and make adjustments. But it takes time and training.

Similarly, many dementia patients resist being given a shower, so bed baths may reduce agitation and be more appropriate. Yet, this too requires taking the time to understand why the patient or resident is uncomfortable and finding a better solution.  

Alternative therapies, such as music and other non-pharmacologic solutions,  may also work, although we need more evidence-based research to know for sure.

Dr. Jonathan Evans, the incoming president of the American Medical Directors Assn., urges that caregivers learn ways to better understand why a patient’s behavior changes and to address the causes.  But, for too many facilities, it is easier to give a patient a pill.

This fall, the Consumer Consortium for Advancing Person Centered Care and the UCLA Luskin School of Public Affiairs, with the support of the U.S. Senate Committee on Aging, will hold a forum on non-drug interventions for people with dementia. The goal will be to develop consensus best practices for the use of non-drug alternatives.  (Full disclosure: I serve as an unpaid member of the leadership council of the consortium’s parent organization).

This initiative follows an Aging Committee hearing last fall on the issue.  The use of anti-psychotics is an important and complex issue. This is an opportunity for medical professionals, nursing facilities, researchers, and consumers to work together to find cutting-edge ways to care for dementia patients in the safest and most effective ways possible.

Senator Bob Corker (R-Tenn) warned today that long-term care financing is “a major train wreck” and “heading for a national crisis.” Corker, the senior Republican on the Senate Aging Committee, said he was very worried about the viability of private long-term care insurance and added , “there is no doubt there is a public sector role” in the future of financing long-term care supports and services.

At a time when the issue has fallen victim to partisan demagoguery (Exhibit A: the CLASS Act)  Corker’s remarks, at a Senate Aging Committee hearing on long-term care,  suggested an opening to build a consensus on future financing and delivery reforms. 

Interestingly, Corker was speaking on the same day a House committee proposed completely eliminating the federal  Social Service block grant program which, among other things, funds Meals on Wheels and other critical programs for the frail elderly living at home.

Corker was not the only participant in today’s hearing who was worried about private long-term care insurance.  John O’Brien, Director of Healthcare and Insurance at the federal Office of Personnel Management, proudly told the panel that enrollment in the federal LTC insurance program rose 20 percent this year, to about 270,000 employees. But he also expressed concern that only one carrier bid for the federal contract in 2011 and that so many insurers have left the business.

Senators are eligible to enroll in O’Brien’s program but both Corker and Democrat Mark Udall admitted they had not. Udall, like so many consumers, said he keeps putting it off. Corker flatly said he “may not” buy.

Still, former Congresional Budget Office director Doug Holtz-Eakin said that private insurance needs to be part of the solution. He suggested finding ways to encourage businesses to include coverage in their benefit packages, adding new tax subsidies, and perhaps making enrollment automatic (which was also an element of the CLASS Act).

Witnesses at today’s hearing shared a wide range of views about how to improve care delivery. My Urban Institute colleague Judy Feder presented research showing that patients with both chronic disease and personal care needs account for an outsized share of Medicare spending. Much of those costs–and average of $16,000 per year for those enrollees–were for hospital and post-hospitalization care at home or in nursing facilities.

The key to both better outcomes and cost savings, Judy argued, is to improve care coordination and primary care and reduce hospitalizations. She suggested those who receive both Medicare and Medicaid benefits (the dual eligibles), might be better off if all their care was provided by Medicare.

But  Loren Colman, Assistant Commissioner of the Minnesota Department of Human Service, argued that states, though Medicaid, ought to be given more flexibility to design care for this population. He argued, as I and others have, that the default option for Medicaid long-term care ought to be home care and not nursing facility care, as it is today.

States, he said, should not have to apply for complicated waivers to provide community care.

Bruce Chernof, President and CEO of the SCAN Foundation in Long Beach, CA, agreed. A goal, he said, should be to free the frail elderly from the “tyranny of bricks and mortar.”  But, he said, home and community programs need to be well-organized, cost-effective, and accountable to care recipients and their families.

While there was little consensus at today’s hearing, the discussion was productive and pointed the way towards what could be some creative solutions for both delivery and financing of long-term care services.

Why not make insurance for long-term care services and supports part of health care coverage?

It is a radical idea that turns the current model—which often treats long-term care insurance as an element of retirement planning—entirely on its head. 

The concept isn’t new. John Rother, who ran public policy for AARP for many years, talked about integrating long-term services and chronic care long ago. And real people with chronic disease see no difference between medical and personal care. But nobody could ever figure out how to make the insurance work.

Here’s the problem: As long as most medical insurance was based on a fee-for-service model, there was little incentive for carriers to provide benefits for personal care. Why would they add a costly extra benefit if it didn’t improve the bottom line?

But the rise of Medicare Advantage managed care plans, Medicaid managed care, and the growth of integrated health systems such as Kaiser Permanente may be changing that. In fact, a few states are effectively trying this experiment by expanding Medicaid managed care to seniors. The PACE progam is built on the same idea.

In all these managed care models, which are explicitly encouraged by the 2010 health reform law, insurers are at financial risk if their cost of care is too high. And they have the opportunity to make more money if they can provide quality care at lower cost.

A key goal is to keep people with chronic disease out of the hospital. And one cost-effective way to do that is to get elderly patients with chronic disease good quality personal assistance.

Here’s a simple example:  Medicare spends nearly 40 percent of its budget on patients with congestive heart failure (many of whom suffer from other diseases as well). And the average cost of hospitalizing a patient with severe heart failure is about $24,000-a-year.

We can keep heart failure patients stable and out of the hospital by making sure they watch their diet and properly take their medications, and by weighing them regularly (weight gain is a key indicator that CHF is out of control).

Now, imagine a system where, as part of Medicare Advantage insurance, a senior receives basic long-term care benefits that may include an aide who weighs them, cooks healthy meals, and helps administer meds.

Keeping a patient at home is a potential win/win. She is healthier and the insurer saves money.  While such a system might only provide basic coverage for personal care, consumers could supplement coverage much as they buy Medigap health insurance today.

I don’t know what such coverage would cost or what the benefits would be. But, as a reality check, I asked a senior executive at a large health insurer what he thought. His response: “The concept seems to make sense.”  

We have to try something new. Given its increasingly constrained resources and complex rules, traditional Medicaid–which finances more than 40 percent of all paid long-term care–isn’t the answer.

Similarly, private long-term care insurance, sold almost exclusively through life insurance companies, has been a dismal failure. The few who do buy tend to be the wealthy who are looking to preserve assets for their heirs.

But I’m not worried about them. A solution to the problem of financing long-term care should be about middle-class people who need resources to pay for quality assistance in frail old age or in the event they become disabled as younger adults. And for them, personal assistance, whether at home or in a nursing facility, is an integral part of their health care. Why not insure it that way?

Increasingly, surgeons are beginning to change the way they perform operations on elderly patients. They are coming to realize that almost everything is different about surgery on older people:  The patient’s goals, the likelihood of complications, and the entire process of treatment from pre-op through surgery itself to recovery.

As a result, doctors are learning that they not only need to adjust the way they perform surgery, but the health system needs to do all it can to be sure older patients are as healthy as possible before these procedures. Surgeons are also coming to understanding that while some procedures are absolutely appropriate for even very elderly patients, others are not.  

In one recent article, (behind a firewall) Johns Hopkins University professor Michael Zenilman said surgeons should not just aim for minimal complications and survival. Elderly patients, he wrote, may be more concerned with preserving their quality of life. Yes, even more than survival itself.  (Full disclosure: As regional director of surgery for Johns Hopkins Medicine, Zenilman manages surgeons at Suburban Hospital in Bethesda, MD, where I am a member of the board).

Over the past twenty years, surgeons have come to recognize that older patients are different than younger adults. But for much of that time, they misunderstood why. And they have been slow to adjust their practices to reflect those distinctions. Now, finally, that is beginning to change.

For many years, doctors thought the biggest difference between older patients and younger adults was simply that they were older. And as patients aged, their organs were less able to tolerate the shock of surgery. Like many simple explanations, it was wrong—or at least incomplete.

Zenilman, a practicing surgeon and author of a textbook on geriatric surgery, says key predictors of unsuccessful procudures are not age itself but factors such as a patient’s overall frailty and whether they suffer from dementia. And, importantly, outcomes also can be worse for those suffering from delirium (temporary confusion often caused by hospitalization), the effects of multiple medications, or cardiac and respiratory disease.  

In short, not every 90-year old is alike. Some will tolerate surgery well and others won’t.  New ways to measure frailty can help both doctors and patients recognize who is a good candidate for surgery.

And not every surgery is alike. It turns out, for example, that older patients do just as well with surgery for early stage pancreatic cancer as younger patients, according to Johns Hopkins research.

This means that surgeons need to learn how to carefully identify who is likely to have a good outcome and work with families, patients, and other medical practitioners to address those risk factors they can control.

For example, before surgery, doctors must make sure their patients are in the best possible physical condition. During surgery, they need to know the best techniques for operating on older patients. And after surgery, doctors should be aware of potential risks for delirium and bedsores.

Most important, families and physicians need to be clear about what a patient really wants from her treatment. Is her goal to maximize her lifespan, even if it means limiting her quality of life? Or is it maintaining independence and dignity, which may suggest less aggressive alternatives?

What Zenilman and other surgeons are learning is that knowing the answers to these questions is at least as important as their skill with a scalpel.