Aging

‘Covid Hit Us Over the Head With a Two-by-Four’: Addressing Ageism With Urgency

Earlier this year, the World Health Organization announced a global campaign to combat ageism — discrimination against older adults that is pervasive and harmful but often unrecognized.

“We must change the narrative around age and ageing” and “adopt strategies to counter” ageist attitudes and behaviors, WHO concluded in a major report accompanying the campaign.

Several strategies WHO endorsed — educating people about ageism, fostering intergenerational contacts, and changing policies and laws to promote age equity — are being tried in the United States. But a greater sense of urgency is needed in light of the coronavirus pandemic’s shocking death toll, including more than 500,000 older Americans, experts suggest.

“Covid hit us over the head with a two-by-four, [showing that] you can’t keep doing the same thing over and over again and expect different results” for seniors, Jess Maurer, executive director of the Maine Council on Aging, said in an October webinar on ageism in health care sponsored by KHN and the John A. Hartford Foundation. “You have to address the root cause — and the root cause here is ageism.”

Some experts believe there’s a unique opportunity to confront this concern because of what the country has been through. Here are some examples of what’s being done, particularly in health care settings.

Distinguishing old age from disease. In October, a group of experts from the U.S., Canada, India, Portugal, Switzerland and the United Kingdom called for old age to be removed as one of the causes and symptoms of disease in the 11th revision of the International Classification of Diseases, a global resource used to standardize health data worldwide.

Aging is a normal process, and equating old age with disease “is potentially detrimental,” the experts wrote in The Lancet. Doing so could result in inadequate clinical evaluation and care and an increase in “societal marginalisation and discrimination” against older adults, they warn.

Identifying ageist beliefs and language. Groundbreaking research published in 2015 by the FrameWorks Institute, an organization that studies social issues, showed that many people associate aging with deterioration, dependency and decline — a stereotype that almost surely contributed to policies that harmed older adults during the pandemic. By contrast, experts understand that older adults vary widely in their abilities and that a significant number are healthy, independent and capable of contributing to society.

Using this and subsequent research, the Reframing Aging Initiative, an effort to advance cultural change, has been working to shift how people think and talk about aging, training organizations across the country. Instead of expressing fatalism about aging (“a silver tsunami that will swamp society”), it emphasizes ingenuity, as in “we can solve any problem if we resolve to do so,” said Patricia D’Antonio, project director and vice president of policy and professional affairs at the Gerontological Society of America. Also, the initiative promotes justice as a value, as in “we should treat older adults as equals.”

Since it began, the American Medical Association, the American Psychological Association and the Associated Press have adopted bias-free language around aging, and communities in Colorado, New Hampshire, Massachusetts, Connecticut, New York and Texas have signed on as partners.

Tackling ageism at the grassroots level. In Colorado, Changing the Narrative, a strategic awareness campaign, has hosted more than 300 workshops educating the public about ageist language, beliefs and practices in the past three years. Now, it’s launching a campaign calling attention to ageism in health care, including a 15-minute video set to debut in November.

“Our goal is to teach people about the connections between ageism and poor health outcomes and to mobilize both older people and [health] professionals to advocate for better medical care,” said Janine Vanderburg, director of Changing the Narrative.

Faced with the pandemic’s horrific impact, the Maine Council on Aging earlier this year launched the Power in Aging Project, which is sponsoring a series of community conversations around ageism and asking organizations to take an “anti-ageism pledge.”

The goal is to educate people about their own “age bias” — largely unconscious assumptions about aging — and help them understand “how age bias impacts everything around them,” said Maurer. For those interested in assessing their own age bias, a test from Harvard University’s Project Implicit is often recommended. (Sign in and choose the “age IAT” on the next page.)

Changing education for health professionals. Two years ago, Harvard Medical School began integrating education in geriatrics and palliative care throughout its curriculum, recognizing that it hadn’t been doing enough to prepare future physicians to care for seniors. Despite the rapid growth of the older population, only 55% of U.S. medical schools required education in geriatrics in 2020, according to the latest data from the Association of American Medical Colleges.

Dr. Andrea Schwartz, an assistant professor of medicine, directs Harvard’s effort, which teaches students about everything from the sites where older adults receive care (nursing homes, assisted living, home-based programs, community-based settings) to how to manage common geriatric syndromes such as falls and delirium. Also, students learn how to talk with older patients about what’s most important to them and what they most want from their care.

Schwartz also chaired a committee of the academic programs in geriatrics that recently published updated minimum competencies in geriatrics that any medical school graduate should have.

Altering professional requirements. Dr. Sharon Inouye, also a professor of medicine at Harvard, suggests additional approaches that could push better care for older adults forward. When a physician seeks board certification in a specialty or doctors, nurses or pharmacists renew their licenses, they should be required to demonstrate training or competency in “the basics of geriatrics,” she said. And far more clinical trials should include a representative range of older adults to build a better evidence base for their care.

Inouye, a geriatrician, was particularly horrified during the pandemic when doctors and nurses failed to recognize that seniors with covid-19 were presenting in hospital emergency rooms with “atypical” symptoms such as loss of appetite and delirium. Such “atypical” presentations are common in older adults, but instead of receiving covid tests or treatment, these older adults were sent back to nursing homes or community settings where they helped spread infections, she said.

Bringing in geriatrics expertise. If there’s a silver lining to the pandemic, it’s that medical professionals and health system leaders observed firsthand the problems that ensued and realized that older adults needed special consideration.

“Everything that we as geriatricians have been trying to tell our colleagues suddenly came into sharp focus,” said Dr. Rosanne Leipzig, a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York City.

Now, more Mount Sinai surgeons are asking geriatricians to help them manage older surgical patients, and orthopedic specialists are discussing establishing a similar program. “I think the value of geriatrics has gone up as institutions see how we care for complicated older adults and how that care improves outcomes,” Leipzig said.

Building age-friendly health systems. “I believe we are at an inflection point,” said Terry Fulmer, president of the John A. Hartford Foundation, which is supporting the development of age-friendly health systems with the American Hospital Association, the Catholic Health Association of the United States and the Institute for Healthcare Improvement. (The John A. Hartford Foundation is a funder of KHN.)

More than 2,500 health systems, hospitals, medical clinics and other health care providers have joined this movement, which sets four priorities (“the 4Ms”) in caring for older adults: attending to their mobility, medications, mentation (cognition and mental health) and what matters most to them — the foundation for person-centered care.

Creating a standardized framework for improving care for seniors has helped health care providers and systems know how to proceed, even amid the enormous uncertainty of the past couple of years. “We thought [the pandemic] would slow us down, but what we found in most cases was the opposite — people could cling to the 4Ms to have a sense of mastery and accomplishment during a time of such chaos,” Fulmer said.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Few Acute Care Hospitals Escaped Readmissions Penalties

Preventable rehospitalization of the nation’s older adults has proved a persistent health and financial challenge for the U.S., costing Medicare hundreds of millions of dollars each year.

Various analyses have found many readmissions within a month of discharge might have been avoided through better care and more attention paid to the patients after they left the hospital. The federal government’s campaign to reduce the frequency of so-called boomerang patients by applying financial disincentives has entered its 10th year with Medicare’s decision to lower payments to 2,499 hospitals throughout the current fiscal year, which began last month and runs through September 2022.

The Hospital Readmissions Reductions Program (HRRP), created as part of the Affordable Care Act, punishes general acute-care hospitals when more Medicare patients return for a new admission within 30 days of discharge than the government decides is appropriate. The average penalty this fiscal year is 0.64%, with 39 hospitals losing the maximum of 3% of reimbursements.

Over the lifetime of the program, 2,920 hospitals have been penalized at least once. That’s 93% of the 3,139 general acute hospitals subject to HRRP evaluation, and 55% of all hospitals. Moreover, 1,288 have been punished in all 10 years. Only 219 eligible hospitals have avoided any payment reductions since the program’s start in 2013, though more than 2,000 hospitals are automatically exempt from penalties because they have specialized functions: those that focus on children, psychiatric patients, veterans, rehabilitation and long-term care or those that serve as the only hospital in an area.

Hospital readmissions have become less frequent since before the ACA was enacted, and most experts attribute that partly to the financial threat of the penalties, though other factors likely contributed to the improvements. Less debatable is that the penalties have saved the government billions of dollars since their inception. The Centers for Medicare & Medicaid Services estimates that because of the HRRP, Medicare will keep an extra $521 million this fiscal year. You can look up individual hospital penalties using KHN’s interactive tool.

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Democrats’ Plans to Expand Medicare Benefits Put Pinch on Advantage Plans’ Funding

“Did you think we wouldn’t notice?” an older woman says, speaking into the camera. “You thought you could sneak this through?” an older man later adds. Others warn that Washington is “messing with” their Medicare Advantage health coverage and trying to raise their premiums.

But the television ad, paid for by Better Medicare Alliance, a research and advocacy group for Medicare Advantage plans, doesn’t spell out what cuts congressional lawmakers might be trying to slip past unsuspecting seniors.

Concerned that viewers could be confused and alarmed about coverage changes, we asked the Better Medicare Alliance for specifics about the sneaky moves the organization aims to alert people to. It’s not just one ad. The organization has launched a $3 million TV, radio and online advertising campaign, according to advertising tracker AdImpact.

In response, the group offered this emailed comment from its president and CEO, Mary Beth Donahue.

“Better Medicare Alliance is airing messages encouraging Congress to guard against cuts to seniors’ Medicare Advantage coverage, whether through benchmark policies in the reconciliation bill or other avenues.”

While still light on specifics, Donahue’s comment offered an important detail not mentioned in the ad. The group is concerned about coverage cutbacks through “benchmark policies in the reconciliation bill.”

Now we were getting somewhere. In the Democrats’ climate and social-spending bill being hammered out in Congress, one key health care proposal would add dental, hearing and vision coverage to the traditional Medicare program.

The provision, championed by Sen. Bernie Sanders (I-Vt.), is estimated to cost $350 billion over 10 years. As Democrats have labored to winnow their $3.5 trillion social-spending bill to make it palatable to moderates in the party, it’s unclear whether the Medicare benefits expansion will make it into the final version.

Assuming it does, here’s where benchmark calculations, and presumably the Better Medicare Alliance’s concerns, come into play.

Traditional Medicare vs. Medicare Advantage

First, some background. Most Medicare beneficiaries are in the so-called traditional Medicare program, in which members generally pay 20% of the cost of medical services after meeting a deductible. A separate plan covers prescription drugs. Enrollees can visit any doctor, hospital or other medical provider participating in the program, the vast majority of whom do nationwide. Many beneficiaries buy supplemental Medigap policies that cover their cost-sharing obligations and fill in other financial gaps.

However, a growing number of Medicare beneficiaries — more than 26 million, or 42% of Medicare enrollees — are in Medicare Advantage plans. Cost sharing is generally lower in these private-sector managed-care plans than in traditional Medicare, but the networks of doctors and hospitals are smaller, too. Many Medicare Advantage plans offer supplemental benefits such as dental, vision and hearing coverage, although the level of coverage varies widely.

“Traditional Medicare is a lousy program, and that’s why Medicare Advantage has really taken off over the last five or 10 years,” said Joseph Antos, a senior fellow at the American Enterprise Institute. “Medicare Advantage looks like the coverage you used to have [before joining Medicare] and there [isn’t] confusing cost sharing that most people don’t understand. Whereas with traditional Medicare, there are different deductibles and holes in coverage.”

The Benchmark

The federal Medicare program pays Medicare Advantage plans a set amount per member. Medicare Advantage health plans submit bids annually to federal officials that reflect how much they estimate it will cost to provide a package of benefits covering hospitalization (Medicare Part A) and outpatient services (Medicare Part B) to enrollees. Those bids are compared against a “benchmark,” which is based on the average spending per beneficiary in the traditional Medicare program, with geographic adjustments.

Plans that bid below the benchmark, as most do, receive a rebate they can use to reduce beneficiary cost sharing, subsidize premiums or pay for supplemental benefits like dental, vision and hearing.

The Benchmark Controversy

Groups like the Better Medicare Alliance say they support providing dental, hearing and vision coverage to all Medicare beneficiaries. But they’re worried that congressional leaders won’t factor the cost of new traditional Medicare benefits into the benchmark, resulting in lower rebates from the program, which could threaten other supplemental benefits that Medicare Advantage members enjoy, such as meals and transportation services, gym memberships and in-home care.

It’s not evident that lawmakers are considering excluding the benefit from the benchmark, however.

“I feel like this is the industry flexing its muscles and sending loud signals, but it’s not clear that Congress has any intention to modify payments as part of this legislation,” said Tricia Neuman, executive director of the program on Medicare policy at KFF.

Still, excluding the new benefits from the Medicare benchmark has generated interest as one way to pay for the pricey new benefits. According to one analysis, excluding the cost of the new benefits from the benchmark would reduce the fiscal cost by an estimated 41%, compared with a scenario that included the cost in the benchmark.

“This is because federal payments to [Medicare Advantage] plans would rise only modestly if the benchmarks excluded the new benefits, whereas they would rise substantially if the benchmarks included them,” according to the analysis by Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy.

Since rebates would fall, Medicare Advantage plans would have less to spend on supplemental benefits. But dental, vision and hearing would no longer be considered supplemental and would need to be incorporated into plans’ estimate of regular Medicare coverage costs, Fiedler noted.

That shift would mean that the rebate dollars that plans currently devote to dental, vision and hearing could be used for other supplemental benefits, which could shield those other benefits from substantial reductions, Fiedler said.

An analysis commissioned by AHIP, an industry group, estimated that incorporating a dental, vision and hearing benefit without adjusting the benchmark would have a substantial impact, resulting in a 48% decline in the national average rebate amount, or $58 per member per month.

No Sympathy

Critics of the Medicare Advantage program have long argued that the government is too generous in paying the private plans. When the Medicare program began incorporating private plans in the 1970s, part of the rationale was that the private plans could provide care more efficiently and save the program money. That hasn’t happened. In a June report to Congress, the Medicare Payment Advisory Commission estimated that the government pays 4% more for beneficiaries enrolled in Medicare Advantage than for those in traditional Medicare.

MedPAC recommended a 2% reduction in capitated payments to Medicare Advantage plans.

In addition, in a September report, the Office of Inspector General for the Department of Health and Human Services found that 20 of 162 Medicare Advantage companies used patient chart reviews and health risk assessments to boost their payments disproportionately compared with their enrollment size.

Losing Their Competitive Advantage

A big selling point for Medicare Advantage plans has been that they provide coverage for valuable benefits that the traditional Medicare program does not. In 2021, 94% of Medicare Advantage enrollees in individual plans are in plans with some level of dental coverage, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

But “some” coverage doesn’t necessarily mean comprehensive coverage. In a separate analysis, KFF found that Medicare beneficiaries faced high out-of-pocket costs for dental and hearing services, no matter what type of plan they had. In 2018, average out-of-pocket spending on dental care for traditional Medicare enrollees was $992. Medicare Advantage members spent modestly less out-of-pocket: $766.

In 2010, when the Affordable Care Act reduced Medicare Advantage plan payments to bring them in line with traditional Medicare, some in the industry predicted plans would pull out and benefits would be cut. That didn’t happen.

“The truth is Medicare Advantage has grown rapidly since then and extra benefits have proliferated,” Neuman said. So, if the payment methodology changes because of the addition of dental, hearing and vision benefits, “it’s hard to say what would really happen.”

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