News Briefs – APRIL 2022
HOSPICE CUTS | ALZHEIMER’S AND CALCIUM | WORLD HAPPINESS
Financial Challenges for Hospice Care
The Medicare Payment Advisory Commission (MedPAC), which advises Congress, has recommended a 20% cut in the annual per-patient payment limit for hospice providers. If a hospice’s annual Medicare payments divided by the number of patients exceeds the cap amount, the hospice must repay the excess payments.
Currently the limit is set at $31,000. According to MedPAC, in 2018, 16% of hospices exceeded the limit. If the cut is approved by Congress, MedPAC estimates that 28% of hospices would exceed the allowed limit. Such a result would affect not only the hospices with higher margins, but also many rural hospices that might find it impossible to survive.
One of the causes of high per-patient payments that exceed the limit is patients who remain on hospice care for long periods of time. Some of these patients may not continue to meet the criteria for eligibility—and justifying continued care for some patients may become harder as their stays on hospice become longer. These cases then become targets for Unified Program Integrity Contractors (UPICs) that look for hospice reimbursements that can be challenged for not meeting the eligibility criteria. UPIC audits can lead to multimillion-dollar overpayments that can be challenged and may also trigger referrals to the Office of Inspector General or the Department of Justice for investigations of potential fraud.
Another challenge to the finances that support hospice, and ultimately the care of patients, relates to private equity businesses buying up hospices. For-profit hospices started to grow rapidly after 1990. Between the 1990s and 2011, for-profit hospices grew from just 5% of the market to 51%. That growth has continued to the present day. Now 70% of all hospices are for-profit, according to the National Hospice and Palliative Care Organization.
Critics of for-profit hospices raise concerns about the services they provide, the kinds of clinical training and pay staff receive, and the prioritization of questionable long-stay patients. These concerns are now exacerbated by the involvement of private equity firms, which buy up for-profit hospices and squeeze the model of care even further to extract as much profit in the short term as possible. A report from the Private Equity Stakeholder Project suggests that the way to mitigate the potential harm to patients and staff of these private equity hospices is to increase transparency and accountability, rather than cutting the revenues of hospices by cutting the per-patient limit or reducing the daily reimbursement rate.
Calcium in the Brain May Provide Answers to Alzheimer’s
For quite some time, scientists have believed that calcium within the neurons of the brain plays a role in the brain’s ability to adapt to its environment, known as “plasticity,” and its ability to hold on to memories. While most research around calcium and plasticity has focused on calcium’s movement through synapses, a recent study by researchers at Columbia University’s Zuckerman Institute focused on the role of calcium reserves within the hippocampus, which is the first area of the brain affected by Alzheimer’s disease, according to Dr. Franck Polleux, one of the principal researchers in the study.
In order for cells to achieve plasticity, calcium is moved into and out of the synapses on the surface of neurons. Another large storehouse of calcium exists within the endoplasmic reticulum (ER), a network of tubes within brain cells, which the study shows may also play a key role. Using mice, the researchers concentrated on how memories of a place are associated with a reward, color, smell, or other markers of a place, and the impact of removing the Pdzd8 gene, which controls the release of calcium from the ER. This allowed large amounts of calcium to be released from the ER, which significantly increased the size of a place the mouse remembered and the duration of that memory.
One of the other researchers, Dr. Justin O’Hare, said that each cell connected to a place memory receives tens of thousands of inputs carrying information about that place. He likened a single neuron to the complexity of a supercomputer, which is why, according to Dr. Polleux, the study at the Zuckerman Institute was extremely challenging. Nonetheless, it has furthered the understanding of how calcium plays a role in memory. Future research will explore what happens to place cells in a mouse model of Alzheimer’s disease when calcium levels are manipulated as the disease progresses. That research may lead to new therapies.
The World Happiness Report Highlights Benevolence
The 2022 World Happiness Report, released in March, marks the 10th year of this effort to examine happiness across the globe. Happiness has a big impact on people’s sense of well-being and their long-term health. The report ranked countries on the overall happiness of its citizens based on individual responses to a simple survey question about overall well-being that is further explained by measures such as GDP, life expectancy, corruption, and freedom. Perhaps the most striking message of this year’s report is that global benevolence has increased remarkably in 2021, up almost 25% from its level before the onset of the COVID-19 pandemic.
Benevolence is calculated by averaging three measures of prosocial behavior: donations, volunteering, and helping strangers. The report shows that all of these measures increased in 2021 in every region of the globe at rates not seen for any of the variables tracked before and during the pandemic. The report expressed the hope that this surge in benevolence will live on long after COVID-19.
When it came to ranking the happiness of individual countries, Finland held the top ranking for the fifth year in a row, followed closely by several other Northern European countries. The United States ranked 16th, just below Canada and just above the United Kingdom. The lowest of the 146 countries surveyed was Afghanistan.
The rankings of countries in the report are determined by asking individuals to evaluate their current life as a whole, using the mental image of a ladder. The lowest rung on the ladder, representing the worst possible life, is 0; the top rung, representing the best possible life, is 10. The Gallup organization conducted the surveys for the report by gathering around 1,000 responses from each country and weighting them to build a national average that is representative of the population makeup. The rankings were based on a three-year average to get better estimates.
The country rankings were further determined based on observed data across six variables: GDP per capita, social support, healthy life expectancy, freedom, generosity, and corruption. Some of this data also came from asking respondents whether they experienced particular emotions on the day before the day of the survey—emotions such as laughter, enjoyment, worry, sadness, and anger. These variables helped the authors of the report explain the variation of life evaluations across countries.
One cautionary finding in the report is that the measures of misery—stress, sadness, physical pain, anger, and worry—have been steadily rising, which has narrowed the gap between positive and negative emotions over the past 10 years. Two of the positive emotions tracked, enjoyment and laughter, have been declining in most regions of the world, while worry and sadness are rising, particularly in South Asia, Latin America, the Middle East/North Africa, and sub-Saharan Africa. In addition, average stress levels have risen in all regions of the world. However, the outpouring of kindness noted above provided the authors of the report hope and optimism for the future “in a world needing more of both.”
