Category: USA

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Doctors making house calls? An old idea whose new time has come

by Fran Johns

Could house calls make a comeback? It’s already happening. The University of California at San Francisco, for one success-story example, started the UCSF-Mt. Zion Housecalls Program in 1999 with a philanthropic gift. Its original goal was to teach medical students about home care, but with the exploding need for primary care for homebound elders it has evolved into filling that need throughout San Francisco — while still teaching the new generation about house calls.

In an article in the San Francisco Chronicle, staff writer Victoria Colliver details some of the many advantages that such programs have.

June Hagosian’s brain tumor has made it difficult for the 77-year-old San Francisco woman to leave her house in recent years, keeping her mostly confined to her bed.

For someone like Hagosian whose medical needs require frequent doctor visits, that would usually pose a problem. But because of a program run by UCSF, the doctor comes to her. She has had to leave her bright yellow home in the Richmond District to go to the hospital just three times in the past seven years.

“This program has been so wonderful,” Hagosian said during a recent home visit with her physician, Rebecca Conant, director of UCSF’s Housecalls Program. “I wish everyone could have it.”

Conant, who had just 15 patients when she took over the program in 2001, is one of five part-time UCSF physicians who spend all their clinical time outside the office, traveling from home to home visiting frail and elderly patients. Housecalls currently serves nearly 100 San Francisco residents and has an eight-month waiting list.The Housecalls physicians visit patients whose conditions make it so hard for them to go to the doctor’s office that they might otherwise put off seeking medical care. By then, they would be so sick they would need an ambulance and end up in a hospital emergency room. The program takes patients regardless of whether they have insurance or an ability to pay, which separates it from private practices that offer home visits as a convenience but at an added cost.

UCSF’s 10-year-old Housecalls Program is an old idea that has gained new traction. Both the House and Senate versions of the health reform bills contain proposals to examine whether home-based care improves the health of chronically ill patients and saves the government money by reducing hospitalizations and ER visits.”There’s no question there is both a medical need and substantial cost savings to the Medicare program,” said Constance Row, executive director of the American Academy of Home Care Physicians.

The Department of Veterans Affairs’ Home-Based Primary Care program, which has been operating for more than two decades, has showed a 24 percent reduction in costs for those patients, and some studies suggest savings as high as 40 percent, Row said.

UCSF’s Housecalls Programs operates on an annual budget of $300,000, almost all of which is devoted to physician salaries. That’s an average cost of $3,000 per patient, which does not include the cost of hospital care when needed. Medicare spends a national average of $46,412 per patient over the last two years of life, when patients typically have several chronic illnesses, according to researchers from the Dartmouth Institute for Health Policy and Clinical Practice.

But new technology – the ability to X-ray patients using portable machines, conduct blood tests and provide other services using mobile devices – allows doctors to offer a much higher level of care in the comfort of the patient’s home.

Conant, an associate clinical professor at UCSF, said she uses mobile devices to aid in her patient care, but she finds home visits offer other advantages like allowing her to see patients’ physical environments, meet their caregivers and better understand what kind of care they need.

“Not only does that improve medical care, but it’s based in reality,” she said.

The UCSF program is not the only home-based primary care program in the Bay Area. Kaiser Permanente, for example, serves some 370 members in San Francisco as part of its 13-year-old Community Care Program, which is handled by physicians, nurse practitioners and social workers.

Reinstituting and reinforcing in-home care, considering the significantly improved care for patients and the reduced cost to the taxpayer, would seem a no-brainer. But brains are losing out to politics a lot these days.

via UCSF program shows house calls’ time returning.

California/Education/General interest/Health/Lifestyle/Money/seniors/USA
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On learning at 30… or 40… or…

by Fran Johns

True/Slant contributor Gina Welch, on turning 30 just now, posted a fine list of 20 things she learned in her twenties, at the precise moment when I’d been musing about the passage of time myself. A somewhat more elderly muse, that is, since mine was prompted by the realization that day before yesterday marked the 85th anniversary of my parents’ marriage. In case that doesn’t sound elderly enough, my parents were both born in 1897, whew.

So in response to Gina’s wisdom here are six things I learned in my sixties (which are way past, at that.) It was terribly hard not to plagiarize, especially Gina’s Listen to your mother, even if it’s only to her long-departed voice in your head, or Wallow not, advice that improves exponentially with age.

1 – Get up early in the morning. It’s way more fun when you aren’t doing it because the baby’s crying, the school bus is waiting or the boss is calling… but just because the To-Do list actually contains stuff you want to do. Plus, days have fewer hours in them.

2 – Go back to school. Classmates a generation or two younger can be wise beyond your years. After a lifetime of writing for newspapers and magazines (you remember print journalism?) I joined the Class of ’00 at the University of San Francisco to pick up an MFA in short fiction. Who knew? If you run into anyone ready to publish my short story collection, let me know. A few of them have actually seen the light of publication, but I’m going to publish The Marshallville Stories in full if I live long enough… or perhaps if I learn enough in my 70s.

3 – Medicare is good. Imagine not having to freak out at every bodily suggestion that fatal expenses could be right around the corner. Imagine everybody having that unfreakable experience. How about we pass health reform?

4 – Listen to your daughter. She can probably teach you a LOT about changing mores, gender identities, adventure travel and how to see the world. Not to mention low fashion, hair styling, organic food and living well.

5 – Listen to your granddaughter. She can definitely teach you about computer programs, digital photography, what 18-year-old college art students are doing, and teenage music. You can close your ears when the teenage music part comes.

6 – Count your blessings. Seriously. If you’re still able to get up in the morning and remember how to count, this is good exercise. And if you count forwards and then repeat the same numbers backward you have exercised your brain, which is increasingly important. At a certain point in life it is tempting to reflect on the world when nobody locked their doors and you dashed onto airplanes just as they were pulling up the steps. And people apologized if they inadvertently used the D-word in front of your mother (there’s her voice again in my head…) So it’s okay to count nostalgic blessings, too; just don’t forget about par courses or contemporary chamber music or sunsets over the Pacific or that grandson who speaks Mandarin and Spanish at 17…

Thanks, Gina. Happy Birthday.

General interest/Health/seniors/USA/Women
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New Cancer Guidelines: One Good Message

by Fran Johns

News about changing guidelines for cervical and breast cancer screening have some women cheering, a lot of women fuming, and most women feeling confused. Or betrayed, or mistreated or worse.

There is one universal message in it all: every woman has to be her own advocate.

For most of us, that is no big deal. We’ve known for a long time that no two of us (and surely no four collections of breast tissue or no two histories of sexual activity) are alike, and most of us have gotten used to asking a lot of questions. It’s unfortunate that so many changes have been announced at almost the same time, and especially that the issue has become politicized.

New York Times health writer Denise Grady summed up the latest developments, and the issues that have caused confusion and anger in a November 20 article:

New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.

The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.

Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”

She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”

Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians’ group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.

Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.

It boils down to this: every woman will need to pay close attention to her own health care. That is bad news for the less educated, the less aggressive, and those with less access to care, and not particularly good news for many older women who grew up with “The doctor knows best” excuse for not paying attention.But it’s good news for those of us, particularly older women, who have questioned what sometimes seemed too-frequent testing and screening.

Asking questions just got more respectable.

Guidelines Push Back Age for Cervical Cancer Tests – NYTimes.com.

General interest/Health/Money/seniors/USA
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Facing Up to Dental Terrors

by Fran Johns

The only thing worse than toothache/jaw pain, to be cruelly specific, is toothache/jaw pain without insurance. Most of us are without such insurance. It has not even been on the radar of health reform advocates, which is just as well — if you add dental terrorism to abortion and public options we won’t see reform for another few decades.

Nevertheless, tooth reform, euphemistically referred to as full mouth restoration in some circles, is ahead for increasing numbers of Americans sooner or later. It comes down roughly to a choice between fixing the mouth or buying a yacht, but if your jaw aches, you forgo the yacht.

New York Times health writer Jane Brody traced the new path of dental repair journeys in a thoughtful article yesterday, explaining her own costly route from tooth decay to bridges to implants, and throwing out an estimate of approximately $3,500 to $4,000 per tooth for the now-preferred latter. Multiply this by at least three or four times if you have other issues, which most of us do once things start going south in the mouth, needing attention. That would be gum problems, repair to surrounding teeth or necessary attention to bone.

I write with authority. Some years ago, facing all of the above, I visited an assortment of dentists with an assortment of solutions that frequently had me in tears when contemplating the time, details (one would have had screws in my jawbone which I would tighten every few days for months as it rebuilt itself) and costs. Like Brody, I grew up before the days of fluoridated water and have had more repair work since childhood than the Bay Bridge. It was a mess in there.

Finally my husband, whose best wives have been born in 1933 but with bad teeth, said, “Just do it all. Don’t be going patch-patch-patch; do it all.” I proceeded to choose the most sympathetic and understandable (most of them were, except for the screws-in-the-jaw guy) dental professionals, assembled a team and went to work. Or rather, I scrinched my eyes shut while they went to work. Some 18 months and $40,000 later we were free at last.

(Out of this experience, during which I was doing a great deal of entertaining just to keep us happy and sane, came one of my finer unpublished books, Cooking for the Dentally Impaired: Recipes and Menu Suggestions for the Impaired and Unimpaired in Difficult Times. I think it’s a book whose time has come; my agent disagrees.)

Brody’s article is a must-read for anyone stewing over this issue. The following are abbreviated tips for anyone with teeth and plans to keep them:

1 – Consider early-decision. The sooner things like gum surgery, crowns, implants-v-bridges or bone issues are dealt with, the likelier all can be made well and kept that way.

2 – Get second opinions. You may even choose the screw-in-the-jaw route, but there are many different procedures and it is good to find one suited to your temperament and bank account.

3 – Ask questions. I asked so many that I was fired by one team; a polite letter said they did not believe they should take my case. It’s just as well. Those I wound up with answered my questions and seemed happy to do so.

4 – Ask for references. Brody suggests this, and I agree. Because I already knew several people who had been patients of the dentists with whom I eventually invested all that time and money, talking with them about their experiences helped keep me from any surprises.

5 – Talk finances. Several friends of mine have had major dental expenses that were far outside their budget, but worked out payment schedules with their dentists so that necessary work could be done sooner rather than later.

Meanwhile: floss.

California/General interest/Lifestyle/Money/Sports/USA
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Finances after 50: Have we learned anything from the Great Recession?

by Fran Johns

Too soon poor, too late smart? A story by WSJ staff reporter Glenn Ruffenach in the November 14/15 Wall Street Journal “Encore” section  asks if we’ve learned any lessons from the financial crisis. And just in case you’re feeling smug about having done so, a quiz inside may shine a sober light of reality. It also contains a lot of data you will find useful, interesting and possibly surprising.

Amid the tumult of the past year, financial advisers are telling us that the Great Recession has produced one invaluable benefit: an education.

We now know, for instance, that our nest eggs can lose almost half their value in a matter of months; that “diversifying” our holdings doesn’t necessarily safeguard those holdings; and that our homes—our one investment for later life that was supposed to be foolproof—can make us look like, well, fools.

How much have you taken away from the events of the past year? Try our quiz and find out.

OK, so it isn’t much of a silver lining. But even worse is that we’ve supposedly learned these lessons before—after each recession, sell-off and market bubble since the 1960s. And yet, we continue to make the same mistakes.

How much have you learned about retirement finances in the past year? And has it sunk in this time? Our quiz will offer you a chance to see if you know where you stand—and provide some guidance for the future.

You’ll have to pick up the Weekend Journal for the quiz, but here’s one freebie in advance:

Q – In retirement, Social Security will likely replace what percentage of your pre-retirement income: (a) 23%; (b) 33%; (c) 43%; (d) 53%.

A – Well, don’t guess high.

Or:

Q – The single best cure for a battered nest egg is: (a) invest more aggressively; (b) save more money; (c) Work longer; (d) Plan to withdraw less money from retirement savings

A – And just when that pile of books to read is so inviting… sorry. (c)

The quiz is full of useful data and interesting insight (fully 40% of men and 41% of women ages 40-50 are considered obese by the Centers for Disease Control & Prevention, for instance; you knew?) One overall message seems to be, in fact: If you have one, don’t quit your day job.

Education/General interest/Politics & Causes/USA
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Thinking about the Bush think tank

by Fran Johns

Why am I not encouraged by reports of the official launch of the George W. Bush Institute on the campus of Southern Methodist University? According to Dallas Morning News reporter Lori Stahl,

Former President George W. Bush will make his first scheduled Dallas appearance at SMU today when he and wife Laura unveil plans for the Bush Institute before an audience of 1,500 people at McFarlin Auditorium.

The Institute has been described by foundation officials as a scholarly forum that will conduct research and promote dialogue on four core principles identified by the Bushes.

These core principles, reports the San Francisco Chronicle, include education, global health, human freedom and economic growth. Hmm.

My father Earl Moreland, who grew up to be, among other things, president of Randolph-Macon College in Ashland, VA for 28 years, died in 1987 without voting for either of his fellow Texans. He was in the first class ever to enter what would become SMU, and one of my fond memories is of accompanying him to Dallas for his 60th reunion.  I believe it is safe to say he would not be proud to have a Bush think tank on the campus of his alma mater.

For my part, I am just stumbling over those “core principles,” and their connection to our former president. Education? Global health? Embodied by someone who condemned millions throughout Africa and beyond to sickness and death through his ill-advised policies? Economic growth? Hello? Times are surely tough today, ten months into Barack Obama’s presidency, but did he create this mess or inherit it?

Some of my favorite people voted for George W. Bush. All of them are, in my humble opinion, smarter than he is. One of them did graduate work at SMU years ago, but does not support placement of the Institute on campus.

During our trip to Dallas for his reunion (the school opened in 1915, you can do the math) my father remarked that he would come back for his 65th if there were anyone around to reune with. Turned out he never made that return visit. If he were here today I’m not sure he would be making plans for his 100th.

My father had a favorite response to all things he considered outrageous (often applied to his daughters) which sounded like “Poosharisha!” It was from his second language (which I sadly never learned), adopted during a 12-year period in Brazil at the Instituto Porto Alegre. Long after he died I learned it was a Portugese expression that  translates, roughly, “That is beyond anything within the natural order of the universe.”

Somewhere in the ethernet I hear my father contemplating the coming of the George W. Bush think tank, and clearly also hear his voice. Poosharisha.


George W. Bush to unveil Bush Institute programs today at SMU | News for Dallas, Texas | Dallas Morning News | Latest News.

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Housing, homelessness & other inequities

by Fran Johns

Today’s Sonoma County (CA) Press Democrat features a front page story about Joe Montana’s digs near Calistoga, available for $49 er–million. It is right above a photo of homeless vet Jack Saltzman reading in his hatchback, the juxtaposition of photos hard not to notice.

Others vets don’t have hatchbacks. Press Democrat feature writer Jeremy Hay reports that according to the Department of Veterans Affairs, approximately 400, or 12%, of Sonoma’s 35,000 vets are homeless, which fellow homeless vet Don Bridges says is “just the tip of it.” Some 131,000 of the nation’s 24 million veterans are homeless on any given day.

Hay details some of the measures being undertaken to alleviate the problem, including $3.2 billion recently pledged by the V.A. to be spent over the next five years toward getting veterans off the street and keeping them from falling into homelessness. But returning vets have been part of another world most of us only see in the extreme abstract and can’t possibly comprehend; fitting right back into mainstream America can be harder than anywhere they have served, where at least, another vet explains, “you’ve been part of your tribe.” More vets will return, and more will wind up on the streets.

None of this is the Montanas fault.

Another Press Democrat front page story, a New York Times article by Andrew Martin and Lowell Bergman, mentions a 91-year-old Florida woman who got a letter from Citibank last month advising her that her new credit card interest rate was 29.99 percent, up 10 points from the previous rate. Haven’t we been reading about Citibank lately?

These bits of information are being digested by those of us who elected Mr. Obama and now feel sad and frustrated because our expectations were, perhaps, too high. Some of us are wondering why he ever wanted the job in the first place.

We don’t have an answer to homelessness. We may not make an offer on the Montana estate — even though, with a Tuscan-style mansion, equestrian center, full-sized basketball court, gym, pool, etc, etc it is probably worth that matching 49er price — because with 20% down and a 30-year 6% fixed rate mortgage the monthly payments of $235,023 would be a stretch. And we are not planning any credit revolt, despite the fact that it is the responsible credit users who are being penalized by the likes of Citibank. What we are doing is just trying to comprehend the surreal nature of today’s news as covered on one front page.

And keep the faith.

California/General interest/Health/Lifestyle/Politics & Causes/USA/Women
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Abortion, health reform and me: who is making our choices?

by Fran Johns

Am I the only person around who is squirming — make that fuming a little — over the concessions made to the anti-choice guys before the House passed its health reform bill? Does no one else find it offensive to turn from reading on page one of today’s New York Times about this sad state of events to page 14 for a large photo of President Obama shaking hands with Cardinal Sean O’Malley? They were meeting at the funeral for Senator Ted Kennedy in August, where reportedly the good clergyman told the president that the Congress of Catholic Bishops really wanted to support health reform ——– oh, but only if everybody caved to their wishes that abortion remain unavailable.

It is not as if we weren’t forewarned. I posted a brief note in this space a few days ago (see Abortion Foes Winning Health Concessions, 11/4, below) and tried to resume a position of calm.

It is hard to remain calm. Somewhere the lines about separation of church and state have to fuzz themselves back into reality. I believe in the right of the U.S. Congress of Catholic Bishops to tell Catholics how to behave (despite the fact that of my many Catholic friends I know almost none who pay any attention in matters of personal choice.) I even believe in the right of the Pope to tell the Bishops to tell their parishioners how to behave. I even believe in the responsibility of all individuals, including my Presbyterian self, to behave according to their conscience and their faith. I just hate being governed by someone else’s faith.

This is not a small distinction. My own church, admittedly starting with a small group here in woo-woo San Francisco, passed a fairly strong national resolution denouncing our country’s torturing folks and seeking justice. As far as I know, no one threatened the president about withholding support for these occasionally immoral wars we keep fighting unless the instigators of torture-in-our-name were sent to jail. However strongly I would like to see the latter happen, I believe there are limits to what faith communities should do.

I had personal experience with back-alley abortion, in the dark days pre-Roe v Wade. It was not pleasant. Is there any way a celibate Catholic bishop could even remotely understand the horrors to which he is condemning poor, desperate pregnant women with the relentless push to make abortion totally unavailable? No. I wish there were.

We still have got to have health reform. But what prices we are paying.

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