Adults with extreme obesity have increased risks of dying at a younger age from cancer and many other causes including heart disease, stroke, diabetes, and kidney and liver diseases, according to a new study.
The study, led by researchers from the National Cancer Institute (NCI), part of the National Institutes of Health, found that people with class III (or extreme) obesity had a dramatic reduction in life expectancy compared with people of normal weight. The findings appeared July 8, 2014, in PLOS Medicine.
Six percent of US adults are now classified as extremely obese
“While once a relatively uncommon condition, the prevalence of class III, or extreme, obesity is on the rise. In the United States, for example, six percent of adults are now classified as extremely obese, which, for a person of average height, is more than 100 pounds over the recommended range for normal weight,” said Cari Kitahara, Ph.D., Division of Cancer Epidemiology and Genetics, NCI, and lead author of the study. Continue reading →
As states eye strategies to control the costs of caring for Alzheimer’s patients, a New York model is drawing interest, and findings from a study of Minnesota’s effort to replicate it shows it could lead to significant savings and improved services. Continue reading →
Dementia is the loss of thinking, memory, and reasoning skills to the extent that it seriously affects a person’s ability to carry out daily activities. Dementia is not a disease itself but a group of symptoms caused by certain diseases or conditions.
The most common form of dementia is Alzheimer’s disease. People with dementia lose their mental abilities at different rates and may eventually need total care.
Symptoms of dementia
Being unable to remember things.
Asking the same question or repeating the same story over and over.
Becoming lost in familiar places.
Being unable to follow directions.
Getting disoriented about time, people, and places.
Neglecting personal safety, hygiene, and nutrition.
Changing clarity in memory, language, and reasoning.
Changing moods and personality.
Losing the ability to perform daily activities like driving a car or handling money.
A person with dementia should be under the care of a health care provider. The health care provider might prescribe medications that may help maintain thinking, memory, and speaking skills, and that may lessen certain behavioral problems for a few months to a few years.
Family members and friends can help people in the early stages of dementia to continue their daily routines, physical activities, and social contacts. If you are concerned that you or someone you know has a serious memory problem, talk with your health care provider.
There are now drugs to treat diseases such as Alzheimer’s disease. Although these drugs do not stop the disease or reverse existing brain damage, they may be able to lessen symptoms of the disease for a time. This may improve a person’s quality of life, ease the burden on caregivers, or delay admission to a nursing home.
New findings suggest that breaking a sweat during regular physical activity may lower your risk of having a stroke.
Stroke is the fourth leading cause of death in the United States. It occurs when blood vessels that supply the brain become ruptured or blocked. As a result, brain cells die from lack of oxygen and other nutrients.
Even when a stroke isn’t fatal, the damage to brain cells can lead to permanent speech, movement or memory problems.
It’s still not known why most strokes occur, but various risk factors have been identified, including high blood pressure, diabetes and inactivity.
To investigate the relationship between physical activity and stroke, a team led by Dr. Michelle N. McDonnell from the University of South Australia and Dr. Virginia Howard of the University of Alabama at Birmingham analyzed data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
The dataset included information on more than 27,000 black and white participants, both men and women, from across the country. They were at least 45 years old at the time of recruitment and had no prior history of stroke.
The participants were asked how many times per week they exercised to the point of sweating. They were then contacted every 6 months to see if they had experienced a stroke or a mini-stroke known as a transient ischemic attack.
Participants were followed for an average of 5.7 years. Medical records confirmed their responses. The study was funded by NIH’s National Institute of Neurological Disorders and Stroke (NINDS). It appeared online on July 18, 2013, in the journal Stroke.
Participants who were inactive (exercising less than once a week) were 20% more likely to have a stroke or transient ischemic attack than those who exercised at least 4 times a week. After adjusting for traditional stroke risk factors (diabetes, hypertension, body mass index, alcohol use and smoking) exercise
was not a significant independent predictor of stroke risk, suggesting that the effect of physical activity is mediated through its association with obesity, hypertension and diabetes.
“Physical inactivity is a major modifiable risk factor for stroke,” Howard says. “This should be emphasized in routine physician checkups.”
“Exercise reduces blood pressure, weight and diabetes. If exercise was a pill, you’d be taking one pill to treat 4 or 5 different conditions,” McDonnell says.
One limitation of the study is that it included self-reported data on the frequency of exercise, but not on the duration of activity.
Official guidelines recommend that healthy adults (ages 18 to 64) get at least 2.5 hours of moderate aerobic physical activity each week. Activity should be done for at least 10 minutes at a time.
REGARDS will continue to assess stroke risk factors to look for long-term patterns in the study population. The findings will ultimately help researchers develop interventions aimed at preventing stroke and its consequences.
Joan Boice needed help. Lots of it. Her physician had tallied the damage: Alzheimer’s disease, high blood pressure, osteoporosis, pain from a compression fracture of the spine. For Joan, an 81-year-old former schoolteacher, simply getting from her couch to the bathroom required the aid of a walker or wheelchair.
The Alzheimer’s, of course, was the worst. The disease had gradually left Joan unable to dress, eat or bathe without assistance. It had destroyed much of the complex cerebral circuitry necessary for forming words. It was stealing her voice.
Joan’s family was forced to do the kind of hard reckoning that so many American families must do these days. It was clear that Joan could no longer live at home. Her husband, Myron, simply didn’t have the stamina to provide the constant care and supervision she needed. And moving in with any of their three children wasn’t an option.
These were the circumstances that eventually led the Boice family to Emeritus at Emerald Hills, a sprawling, three-story assisted living facility off Highway 49 in Auburn, Calif. The handsome 110-bed complex was painted in shades of deep green and cream, reflecting its location on the western fringe of the craggy, coniferous Sierra Nevada mountain range. It was owned by the Emeritus Corp., a Seattle-based chain that was on its way to becoming the nation’s largest assisted living company, with some 500 facilities stretching across 45 states.
Emeritus at Emerald Hills promised state-of-the art care for Joan’s advancing dementia. Specially trained members of the staff would create an individual plan for Joan based on her life history. They would monitor her health, engage her in an array of physically and mentally stimulating activities, and pass out her 11 prescription medications, which included morphine (for pain) and the anti-psychotic drug Seroquel (given in hopes of curbing some of the symptoms of her Alzheimer’s). She would live in the “memory care” unit, a space designed specifically to keep people with Alzheimer’s and other forms of dementia safe.
At Emerald Hills, the setting was more like an apartment complex than a traditional nursing home. It didn’t feel cold or clinical or sterile. Myron could move in as well, renting his own apartment on the other side of the building; after more than 50 years of marriage, the couple could remain together.
Sure, the place was expensive — the couple would be paying $7,125 per month — but it seemed ideal.
During a tour, a salesperson gave Myron and his two sons, Eric and Mark, a brochure. “Just because she’s confused at times,” the brochure reassured them, “doesn’t mean she has to lose her independence.”
Here are a few things the brochure didn’t mention:
Just months earlier, Emeritus supervisors had audited the operations of the memory care unit where Joan would be living. It had been found wanting in almost every important regard. In truth, those “specially trained” staffers hadn’t actually been trained to care for people with Alzheimer’s and other forms of dementia, a violation of California law.
The facility relied on a single nurse to track the health of its scores of residents, and the few licensed medical professionals who worked there tended not to last long. During the three years prior to Joan’s arrival, Emerald Hills had cycled through three nurses and was now employing its fourth. At least one of those nurses was alarmed by what she saw, telling top Emeritus executives — in writing — that Emerald Hills suffered from “a huge shortage of staff” and was mired in “total dysfunction.”
During some stretches, the facility went months without a full-time nurse on the payroll.
The paucity of workers led to neglect, according to a nurse who oversaw the facility before resigning in disgust. Calls for help went unanswered. Residents suffering from incontinence were left soaking in their own urine. One woman, addled by dementia, was allowed to urinate in the same spot in the hallway of the memory care wing over and over and over.
The brochure also made no mention of the company’s problems at its other facilities. State inspectors for years had cited Emeritus facilities across California, faulting them forfailing to employ enough staff members oradequately train them, as well as for other basic shortcomings.
Emeritus officials have described any shortcomings as isolated, and insist that any problems that arise are promptly addressed. They cite the company’s growing popularity as evidence of consumer satisfaction. They say that 90 percent of people who take up residence in assisted living facilities across the country report being pleased with the experience.
Certainly, the Boice family, unaware of the true troubles at Emerald Hills, was set to be reassured.
“We were all impressed,” recalled Eric Boice, Joan’s son. “The first impression we had was very positive.”
And so on Sept. 12, 2008, Joan Boice moved into Room 101 at Emerald Hills. She would be sharing the room with another elderly woman. After a succession of tough years, it was a day of great optimism.
Measuring the dimensions of his mother’s new apartment, Eric Boice sought to recreate the feel of her bedroom back home. He arranged the furniture just as it had been. He hung her favorite pictures in the same spots on the wall. On her dresser, he set out her mirror and jewelry box and hairbrush.
Joan, 5-foot-2 and shrinking, had short snow-and-steel hair and wintry gray-blue eyes. Eric looked into those eyes that day at Emerald Hills. He thinks he might have seen a flicker of fear. Or maybe it was just confusion, his mom still uncertain where, exactly, she was.
A Reform Movement Winds Up on Wall Street
The Emeritus Corp., the assisted living corporation now entrusted with Joan’s life, sat atop an exploding industry.
Two decades earlier, Keren Brown Wilson had opened the nation’s first licensed assisted living facility in Canby, Ore., a small town outside of Portland. Wilson was inspired by tragedy: A massive stroke had paralyzed her mother at the age of 55, forcing her into a nursing home, where she was miserable, spending the bulk of her days confined to a hospital bed.
Wilson aimed to create an alternative to nursing homes. She envisioned comfortable, apartment building-style facilities that would allow sick and fragile seniors to maintain as much personal autonomy as possible.
“I wanted a place where people could lock the door,” Wilson explained. “I wanted a place where they could bring their belongings. I wanted a place where they could go to bed when they wanted to. I wanted a place where they could eat what they wanted.”
These “assisted living” facilities would offer housing, meals and care to people who could no longer live on their own but didn’t need intensive, around-the-clock medical attention. The people living in these places would be called “residents” — not patients.
It took Wilson nine years to persuade Oregon legislators to rewrite the state’s laws, a crucial step toward establishing this new type of facility. After that, states across the country began adopting the “Oregon model.”
But what began as a reform movement quickly morphed into a lucrative industry. One of the early entrants was Emeritus, which got into the assisted living business in 1993, opening a single facility in Renton, Wash. The company’s leader, Daniel Baty, had his eyes on something much grander: He was, he declared, aiming to create a nationwide chain of assisted living facilities.
Two years later, Baty took the corporation public, selling shares of Emeritus on the American Stock Exchange, and piling up the cash necessary to vastly enlarge the company’s footprint. Many of Emeritus’s competitors followed the same path.
The company’s rapid growth was, at least in part, a reflection of two significant developments. Americans were living longer, with the number of those in the 65-plus age bracket ballooning further every year. And this growing population of older Americans was willing to spend serious money, often willing to drain their bank accounts completely to preserve some semblance of independence and dignity — in short, something of their former lives.
As the assisted living business flourished, the federal government, which oversees nursing homes, left the regulation of the new industry to the states, which were often unprepared for this torrent of expansion and development. Many states didn’t develop comprehensive regulations for assisted living, choosing instead to simply tweak existing laws governing boarding homes.
In this suddenly booming, but haphazardly regulated industry, no company expanded more aggressively than Emeritus. By 2006, it was operating more than 200 facilities in 35 states. The corporation’s strategy included buying up smaller chains, many of them distressed and financially troubled, with plans to turn them around.
Wall Street liked the model. Market analysts touted the virtues of the company and its stock price floated skyward. One of the corporation’s appeals was that its revenues flowed largely from private bank accounts; unlike hospitals or nursing homes, Emeritus wasn’t reliant on payments from the government insurance programs Medicare or Medicaid, whose reimbursement rates can be capped. As the company noted in its 2006 annual report, nearly 90 percent of its revenues came from “private pay residents.”
In filings with the Securities and Exchange Commission and in conference calls with investors, Emeritus highlighted many things: occupancy rates; increasing revenue; a constant stream of complex real estate deals and acquisitions; the favorable demographic trends of an aging America.
“The target market for our services is generally persons 75 years and older who represent the fastest growing segments of the U.S. population,” Emeritus stated in a 2007 report filed with the SEC.
Today, the assisted living industry rivals the scale of the nursing home business, housing nearly three-quarters of a million people in more than 31,000 assisted living facilities, according to the U.S. Department of Health and Human Services.
Keren Brown Wilson, the early and earnest pioneer of assisted living, is happy that ailing seniors across the country now have the chance to spend their final years in assisted living facilities, rather than nursing homes. But in her view, the rise of assisted living corporations — with their pursuit of investment capital and their need to please shareholders — swept in “a whole new wave of people” more focused on “deals and mergers and acquisitions” than caring for the elderly.
She speaks from experience. After her modest start, Wilson went on to lead a company called Assisted Living Concepts, and took it onto the stock market. Wilson left the company in 2001, and it has encountered a raft of regulatory and financial problems over the last decade.
“I still have a lot of fervor,” said Wilson, who now runs a nonprofit foundation and teaches at Portland State University. “I believe passionately in what assisted living can do. And I’ve seen what it can do. But for some of the people, it’s just another job, or another business. It’s not a passion.”
“A Phenomenal Deal”
Joan Boice, born Joan Elizabeth Wayne, grew up in Monmouth, Ill. It was a tiny farm belt community, not far from the Iowa border. Her father, a fixture in the local agriculture trade, owned a trio of riverfront grain elevators on the Mississippi and a fleet of barges. As a teenager, she spent her summers trudging through the fields, de-tasseling corn.
In 1952, accompanied by a friend, Joan packed up a car and followed the highway as far west as it would go. Then in her early 20s, she was propelled by little more than the notion that a different life awaited her in California. In a black-and-white snapshot taken shortly after she arrived, Joan is smiling, a luxuriant sweep of dark hair framing her pale face, gray waves curling in the background. It was the first time she’d seen the Pacific.
Joan had been a teacher for two years in Illinois, and she quickly found a job at an elementary school in Hayward, a suburb of San Francisco. In certain regards, her outlook presaged the progressive social movements that were to remake the country during the next two decades. She viewed education as a “great equalizing force” that could help to remake a society far too stratified by class, race and gender.
“She was just free-spirited and confident,” Eric, her son, said.
Joan met Myron Boice through a singles group at a Presbyterian church in Berkeley. On their wedding day, Joan flouted convention by showing up in a blue dress. The Boice children came along fairly quickly: Nancee, then Mark, then Eric.
Myron Boice was a dreamer. A chronic entrepreneur. He sold tools from a van. He made plans to open restaurants. He had one idea after another. Some worked; others didn’t.
Joan’s passion for education never dissipated. Even in her late 60s, she continued to work as a substitute teacher in public schools. After retirement, she began volunteering with a childhood literacy program.
But age eventually tightened its grip, and hints of a mental decline began surfacing around 2005. Eric grew worried when she couldn’t figure out how to turn on her computer twice in the span of a few months. Then she forgot to include a key ingredient while baking a batch of Christmas cookies. The cookies were inedible.
The elderly couple was still living in the San Francisco suburbs, when, in late 2006, a doctor diagnosed Joan with Alzheimer’s. As her mind deteriorated, Myron struggled to meet her needs. The situation was worsened by the fact that none of the children lived nearby. Mark was in Ohio. Nancee was about an hour away in Santa Cruz. And Eric and his wife, Kathleen, were roughly two hours away in the foothills of the Sierra.
“We offered my parents to come and live with us,” Eric recalled. But Myron said no. He and Joan wouldn’t move in with any of the kids. The family patriarch refused to become a burden.
A physician encouraged Joan and Myron to consider assisted living. It made sense. And so Myron sold their home in 2007 and the couple moved into a facility called The Palms, near Sacramento. The move put them approximately 40 minutes away from Eric and Kathleen.
“They were very attentive to every single thing she needed,” Kathleen Boice said of the staff at The Palms. “They actually re-taught her to eat with a fork and a knife.”
By 2008, however, Myron wanted a change. He wanted to be closer to his son and daughter-in-law and grandkids. He wanted different meals, a new environment. Myron began hunting for a new place to live, a search that led to Emeritus at Emerald Hills in Auburn.
Emeritus opened the Emerald Hills complex in 1998. It was, in many ways, a classic Emeritus facility, situated in a middle-class locale that was neither impoverished nor especially affluent. It was a sizable property, capable of housing more than 100 people.
In part because of its appetite for expansion, Emeritus was in the early stages of what proved to be a period of enormous stress. In 2007, the company had made its biggest acquisition to date, buying Summerville Senior Living Inc., a California-based chain with 81 facilities scattered across 13 states.
The purchase — which expanded Emeritus’s size by roughly one-third — helped the company make another major leap, bouncing from the low-profile American Stock Exchange into the big leagues of commerce, the New York Stock Exchange. News of the Summerville deal propelled the company’s stock to a new high. Emeritus was poised to become the nation’s No. 1 assisted living chain.
But the timing for this bold move turned out to be wretched. The real estate market was freezing up, and it would soon collapse, plunging the nation into an epochal recession. For Emeritus, the economic slowdown and then the housing crash posed direct challenges. Its services didn’t come cheap, so many people needed to sell their homes before they could afford to move into the company’s facilities. With the real estate market calcified, Emeritus’s customer pool shrank.
“Our stock price plummeted,” recalled Granger Cobb, Emeritus’s chief executive officer, who joined the company as part of the Summerville deal. The company’s occupancy rates had been trending skywards. Now they went flat.
At Emerald Hills, the economic slowdown that summer was making life tough for Melissa Gratiot, the lead sales agent.
“It was way harder to move residents in,” she remembered.
But there was some good news. She was close to a significant sale, this one to a couple. Gratiot worked the pitch. She talked with the family. She emailed. She gave them a tour of the facility’s memory care unit, called The Emerald City. She told the family she’d received approval from higher ups to offer the family “a phenomenal deal.”
Gratiot closed the sale. On Aug. 29, 2008, Myron and Eric signed the contract, and the family opened its wallet: A $2,500 initial move-in fee; $2,772 for Joan’s first two weeks in Room 101; another $1,660 for Myron.
There had been one oversight, though. No one at Emeritus with any medical training had ever even met Joan, much less determined whether Emerald Hills could safely care for her.
When the ambulance crew arrived, about 8:20 p.m., Joan Boice was in the TV lounge, face-down on the carpet. Her head had struck the floor with some velocity; bruises were forming on her forehead and both cheeks. It appeared she’d lost her balance and fallen out of a chair.
But no one at the assisted living facility could say precisely how the accident had occurred. No one knew how long Joan had been splayed out on the floor. She had defecated and urinated on herself.
Worried that Joan might have injured her spine, the emergency medical personnel gently rolled her over and placed her on a back board. They pumped oxygen into her nostrils.
It was Sept. 22, 2008 — just 10 days after Joan had first moved into Emerald Hills.
No Emeritus employees accompanied Joan to the hospital. And even though Joan’s husband, Myron, was living in the facility, the Emeritus workers didn’t immediately alert him that Joan had fallen and hurt herself. Joan, confused, injured, and nearly mute, ended up in the local hospital by herself, surrounded by strangers.
It was supposed to have been a festive night for Joan’s son Eric and his wife, Kathleen, who lived nearby. They were throwing a birthday party for their daughter, then in elementary school. The celebration was interrupted when a doctor called from the hospital with news of Joan’s fall. As Kathleen recalled it, the physician was somewhat baffled — he didn’t understand what Joan was doing in the emergency room without a family member, and he was having trouble deducing the extent of her injuries because she couldn’t communicate.
California law requires assisted living companies to conduct a “pre-admission appraisal” of prospective residents, to ensure they are appropriate candidates for assisted living.
But Emerald Hills took Joan in without performing an appraisal. It wasn’t for lack of time. The Boices had signed the contract to live at Emerald Hills more than two weeks before Joan moved in.
Joan, then, had taken up residence in the memory care unit at Emerald Hills. The unit — referred to as a “neighborhood” by the company — is a collection of abouta dozen small apartments on either side of a central hallway. At each end of the hallway are heavy doors equipped with alarms, which sound when anyone enters or leaves. The alarm system is meant to prevent residents from simply walking off.
On the day Joan moved into Room 101 in the unit, a company nurse named Margaret “Peggy” Stevenson briefly looked her over. The nurse realized that Joan needed to be monitored closely to keep her from falling — she wrote it down in her cursory assessment — but facility records show she didn’t craft any kind of detailed plan for her care and supervision.
Stevenson, asked years later about Joan, said she could recall nothing about her or her stay at Emerald Hills.
Kathleen had immediate suspicions about Joan’s fall. The family, she said, had warned the facility not to leave Joan sitting in a chair without supervision because she was liable to try to stand up, lose her balance, and topple to the floor. Joan had fallen several times during an earlier stay in an assisted living facility near Sacramento, but the staff had developed a specific plan to address the issue.
Despite the warning, Kathleen said that when she visited Emerald Hills during Joan’s first days there she often found her mother-in-law sitting in a chair alone.
The recent track record at Emerald Hills featured a host of falls similar to Joan’s, and ambulances were often called to take the injured off to the hospital. Falls are a particular hazard for the elderly, and assisted living facilities like Emerald Hills are required to report them to state regulators.
Internal company records documented 112 falls at Emerald Hills in 2008. Some residents fell repeatedly.
Consider the case of one Emerald Hills resident, 83-year-old Dorothy “Dottie” Bullock.
On April 5, 2008, an Emeritus employee discovered Bullock “on the floor in a semi-seated position” in the memory care unit, according to a state report. She “was unable to tell” the worker what had happened to her. The incident was described as a fall in state records. Emerald Hills sent her to the hospital.
On April 7, Bullock, back at Emerald Hills, fell again, according to the handwritten log of her personal attendant, who was hired by Bullock’s husband to give her extra help.
On April 8, Bullock, complaining of pain, was hauled by ambulance back to the hospital. Doctors concluded that she’d fractured her pelvis, but soon returned her to Emerald Hills. She fell again on April 12.
Bullock would fall again months later, for the final time.
Emeritus records show Bullock tumbled in front of her apartment and was found on the carpet with her aluminum walker beneath her. Blood spilled from her nose and a “bump” developed on her forehead, according to the company documents. The impact broke a vertebra in Bullock’s neck and crushed her nasal bones and sinus structures, hospital records show. A CT scan revealed possible fractures of both eye-sockets and the base of the skull.
Dottie Bullock died in the emergency room.
While Emeritus recorded the fatality in its internal logs, the company did not report her death to state regulators, a violation of California law. The state requires assisted living facilities to file reports on all deaths, even those believed to be from natural causes, so that it can look into suspicious or troubling incidents.
Emeritus said it lacked information about Bullock’s death and thus could not say why it had occurred.
Bullock’s personal attendant, Julie Covich, says Bullock was not supervised properly.
“I think there was neglect,” said Covich, who usually visited Emerald Hills once or twice a week to help out Bullock. “I would go in there and never see a caregiver.”
“It was hard to find anyone that was running the place,” she said. “It was crazy.”
“Heads on the Beds”
In early 2008, the year Joan Boice entered Emerald Hills, Emeritus rolled out a new business campaign. The company dubbed it the “No Barriers to Sales” effort.
The concept was straightforward: Move as many people as possible into Emeritus facilities. Wall Street was looking closely at the company’s quarterly occupancy numbers and a few percentage points could propel the stock price upward or send it tumbling down.
With the housing market foundering, Emeritus needed to step up its sales efforts.
In case there was any confusion about just how seriously the company took this new campaign, a company vice president sent a blast email to facility directors across California. In the body of the email, the vice president got right to it:“SALES and your commitment to sales is your highest priority right now.” Facility directors, the message concluded, would be “held responsible for census and occupancy growth.”
Emeritus employees across the country realized they were entering a new era.
“There was a different sense of urgency. The tone was different,” said a former Emeritus manager who ran a facility at the time. “The message from above was put as many people as possible in the beds and make as much money as possible. That’s what they said. Verbatim. Honestly.”
According to Lisa Paglia, a regional executive in California at the time, Budgie Amparo, the company’s top official for quality control, was openly critical when a Northern California facility declined to admit someone who did not have a doctor’s evaluation.
Such evaluations, which are designed to keep out seniors with problems that assisted living facilities aren’t equipped to handle, are required under a California law known as Title 22.
But on a conference call with roughly half a dozen California managers, Paglia said, Amparo declared that the Northern California facility should have admitted the resident.
“Our priority,” Amparo declared, according to Paglia, “is to get the heads on the beds.”
The issue arose again in October 2008 during a training session for approximately 25 facility directors and salespeople held at an Emeritus property in Tracy, Calif. During the seminar, a company vice president reiterated Amparo’s instruction to disregard California law, according to court records and interviews.
The mandate prompted something of a staff revolt.
At least one facility director spoke out at the meeting: His license to operate the facility was at stake, he said.
An employee who worked at the Tracy facility eventually alerted California regulators. The state dispatched an investigator, and state records show that the investigator met with employees who confirmed that a company official had approved the practice of admitting someone without a doctor’s report. The investigator reviewed a random sample of seven resident files, finding that two people had been moved in illegally, documents show.
Amparo, a nurse whose full title is executive vice president of quality and risk management, denies directing employees to violate the regulation. In a written statement, Emeritus said, “Neither Budgie Amparo nor any of our other officers issued a directive to violate Title 22 or any other law. Emeritus does not condone allowing residents to move in without the proper documents.”
Emeritus eventually fired Paglia, and lawyers for the company have since portrayed her as a poor worker who failed to do her job competently. Along with two other former Emeritus employees, Paglia sued the company alleging wrongful termination, and wound up settling on secret terms.
For assisted living chains such as Emeritus, there is a powerful business incentive to boost occupancy rates and to take in sicker residents, who can be charged more.
Emeritus, for its part, rejects any suggestion that a quest for profits has tainted its admission practices. But in interviews, former Emeritus executives described a corporate culture that often emphasized cash flow above all else. The accounts of the executives, who spoke independently but anonymously, were strikingly consistent.
“It was completely focused on numbers and not human lives,” said one executive, who worked for Emeritus for more than three years and oversaw dozens of facilities in Eastern states.
The company’s emphasis on sales and occupancy rates, the executive said, transformed the workforce into “a group of people who were grasping at every single lever they could pull to drive profitability.”
Emeritus operates a sophisticated, data-driven sales machine. There are occupancy goals for each facility, as well as yearly company-wide goals. The company tracks dozens of data points — including every move-in and move-out of residents — in a vast database. It posts a monthly snapshot of each facility’s sales statistics on an internal website, allowing employees to see which strategies are most successful.
Sales specialists are instructed on how to use psychology to persuade potential customers to sign on. One suggestion: Give the customer “a sense of control and choice by offering two possible options.” A 2009 Emeritus sales manual, which runs 181 pages, encourages sales people to generate publicity by hosting seminars on Alzheimer’s or organizing charity efforts in the event of a natural disaster like a “flood or earthquake.”
Emeritus motivates its workforce with a broad range of financial incentives. There are bonuses for hitting monthly occupancy goals. Bonuses for hitting yearly occupancy goals. Bonuses for boosting overall earnings. And the money doesn’t just go to sales people: The company hands out checks to maintenance workers, nurses, facility directors and other workers.
Nurses play a key role in assisted living, providing much of the hands-on care. But nurses at Emeritus facilities are also expected to be deeply involved in increasing revenue by making sales.
During more than a year of reporting, ProPublica and PBS Frontline spoke to 10 facility directors who said nurses were required to participate in weekly conference calls focusing on little but economics. Those accounts are backed by an internal Emeritus document that lays out the agenda for the weekly calls and that shows an overarching concentration on finances.
Doris Marshall was at the forefront of Emeritus’s efforts to have nurses play the dual roles of caregivers and salespeople. After receiving her nursing license in 1984, Marshall had spent many years tending to patients in the emergency department of a Southern California hospital, and she’d later gone on to help run a nursing school.
But Marshall was intrigued by the assisted living business and in March 2008 she signed on to supervise 10 Emeritus properties scattered across Northern California. Amparo, the company’s head nurse, convinced Marshall to take the job, telling her nurses “had a voice” at Emeritus.
Marshall was to oversee the well-being of roughly 800 elderly people. But her job description went well beyond that: She was to help with “marketing” and “attaining financial goals.” Her job, in the end, actually involved very little nursing.
Instead, she said, she was drawn into Emeritus’s evolving strategies aimed at upping its revenues. The company planned to bring in more seniors with Alzheimer’s and dementia because they could be charged more, she said. Her boss gave her a digital tracking tool showing how much more money Emeritus could make by admitting sicker, frailer residents.
By the fall of 2010 Marshall was worn out and disillusioned. She quit.
Emeritus’s extraordinary drive to put heads in beds — perhaps routine in, say, the hotel industry — has distorted the admissions process at some facilities, records and interviews show. Since 2007, state investigators have cited the company’s facilities more than 30 timesfor housing people who should have been prohibited from dwelling in assisted living facilities.
A 2010 episode at an Emeritus facility in Napa highlighted the perils of improperly admitting people. The facility rented a room to a 57-year-old woman with an eating disorder, depression, bipolar disorder and a history of suicide attempts. The woman, who was distraught over the death of her husband, taped a note to her door saying she wasn’t to be disturbed and committed suicide, overdosing on an amalgam of prescription painkillers.
The state’s investigation into the death was scathing: the woman should never have been allowed to move in; the staff had missed or ignored bulimic episodes and her obvious weight loss; no plan of care was ever developed or implemented despite the resident’s profound psychological problems.
Emeritus, asked to respond to the state’s investigation, said only that the woman had overdosed on drugs she had brought into the facility on her own, and that as a result they could not be faulted in her death.
“She Barely Even Talked to Us”
In the aftermath of her fall in September 2008, Joan returned to Emerald Hills. But the staff, inexperienced and often exhausted, worried about her.
“She couldn’t walk, she couldn’t feed herself, she barely even talked to us, and her health wasn’t that good,” recalled Jenny Hitt, a former medication technician at Emerald Hills.
But if concern was abundant at Emerald Hills, expertise was in short supply.
Alicia Parga ran Joan’s memory care unit. On some weekends, she managed the entire building — not only the wing of residents with dementia, but the rest of the three-story assisted living facility, one that could hold a total of more than 100 residents.
After Parga started on the job, it took Emeritus roughly 18 months to give her any training on Alzheimer’s and dementia. The state regulations were hardly substantial: Someone such as Parga was obligated to get six hours of training during her first four weeks on the job. But even that requirement wasn’t met.
Emeritus has insisted that Emerald Hills had properly trained personnel to care for Joan and others, and they described Parga as a woman deeply invested in tending to the residents.
But Parga, who had barely earned a high school degree, wasn’t even familiar with the seven stages of dementia. Though she was responsible for the well-being of 15 or more seriously impaired people, as well as the supervision of employees, Parga was paid less than $30,000 per year.
Catherine Hawes, a health care researcher at Texas A&M University, conducted the first national study of assisted living facilities. In her view, training is absolutely crucial. A well-educated employee can “interpret non-verbal cues” from people like Joan, intercept seniors before they wander away from the building, or keep residents from eating or drinking poisonous substances.
“You can do great care,” she said. “You just — you’ve got to know how.”
Other than the Emeritus employees working in the memory care unit at Emerald Hills, only one person saw Joan enough to know what kind of daily care she was getting: Her husband, Myron.
He was worried. And he did his best to sum up his concerns to his son Eric:
Getting to the emergency room within the first few hours of recognizing stroke symptoms can help prevent permanent brain damage, but a recent study in Ethnicity & Disease finds that Blacks are only half as likely as Whites to get timely treatment.
The study found that on average it took 339 minutes for Blacks to visit the emergency room for stroke treatment as opposed to 151 minutes for Whites. Delaying treatment can result in the death of vital brain cells.
“It has been estimated that nearly two million neurons die per minute during a stroke,” said Sheryl Martin-Schild, M.D., Ph.D., the study’s lead author. “Intravenous tissue plasminogen activator (IV tPA) is the only treatment during the acute phase of a stroke, the first 4.5 hours, proven to improve outcome in controlled clinical trials.”
Because IV tPA treatment breaks down the clots that obstruct blood flow inside the brain, delaying treatment within that narrow time frame puts patients at greater risk of permanent neurological damage.
The study, which followed 368 patients with a median age of 65 years, sought to identify racial disparities and the reasons for varying delays between symptom onset and emergency room treatment.
While the study found that Blacks and Whites received the same treatment once they arrived at the emergency room, reasons for the delay were not clear.
Socioeconomic standing did not seem to be a factor. Nor did the study find any bias in the way patients of different races were treated once they arrived in the emergency room.
There was no significant difference in the types of symptoms patients reported, with weakness being the most common symptom.
“Explanations for the delay could be numerous,” said Martin-Schild. They may include delayed symptom recognition, a lack of eagerness to call for help, fear of medical personnel and/or hospitals, social or environmental factors, a lack of local social support and/or longer transit time to hospital.
“Community education is vital in improving recognition of stroke symptoms,” said James McKinney, M.D., associate professor of neurology at Robert Wood Johnson Medical School in New Brunswick, New Jersey. “Unlike a heart attack, stroke is often painless, and many patients wait to see if their symptoms go away.”
McKinney suggests that further research is also needed to investigate the use of 911/EMS services, transport times and stroke center access. “All of these can decrease times from stroke onset to medical evaluation,” added McKinney.
The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.
About 16 percent of tobacco retailers in Washington state illegally sold tobacco to minors this year, up from 11 percent in 2011 and 10 percent in 2010, hitting the highest level in more than a decade, according to a new report.
Under law, if the rate of retailers selling tobacco to minors exceeds 20 percent, the state could lose nearly $14 million dollars in federal funding for drug, alcohol, and tobacco prevention and treatment.
The new report is the result of federal legislation that requires states to enact and enforce laws that prohibit the sale of tobacco products to minors and to conduct annual random, unannounced inspections of retailers to assure their compliance with the law.
These compliance checks are conducted by local health agencies and the state Liquor Control Board. The checks include having teens, working with law enforcement, visit randomly selected retailers to try to buy cigarettes and other tobacco products.
Clerks who sell tobacco to minors can be fined up to $100 and retail owners can be fined up to $1,500. After multiple violations, a retailers license to sell tobacco is permanently revoked.
The data on retailer compliance is compiled annually by U.S Substance Abuse and Mental Health Services Administration and published in a document called the Synar Report, named after Congressman Mike Synar of Oklahoma, who sponsored an amendment that mandated states to enforce laws restricting tobacco sales to minors.
Youth smoking rate in Washington state is currently about 13 percent, about half what it was in 2000, according to the Washington State Department of Health.
But in recent years, however, the decline in youth smoking rates has leveled off, state health officials said, and “the use of alternative tobacco products like chew, cigars, and hookahs is a growing concern.”
The state estimates that about 70,000 youths in Washington state currently smoke, with about 50 taking up the habit each day.
Efforts to educate youth about the dangers of smoking and retailers of their obligations under the law have been hampered by state and local government budget woes, health officials said.
“Meanwhile, the tobacco industry continues to invest huge amounts of money to attract new smokers. In 2010, the industry spent about $80 million on marketing activities in Washington alone,” they said.
Overall, about 7,900 people die every year in Washington from tobacco-related diseases.
Stroke is the No. 4 killer in this country and the leading cause of long-term disability.
Although 4 out of 5 American families will be touched by stroke, more than a third of Americans cannot identify a single warning sign for stroke.
A new ad series sponsored by the American Heart Association, the American Stroke Association and the Ad Council seeks to make the acronym F.A.S.T. an easy-to-remember tool for learning and recognizing the warning signs of a stroke.
F.A.S.T. stands for:
Face (face drooping),
Arm (arm weakness),
Speech (speech difficulty), and
Time (time to call 911).
Educating bystanders about the signs of stroke and urging them to call 911 immediately at the onset of symptoms may improve the chances of getting better, but only if you get help right away.
By Anusha Iyer, MD Valley Medical Center Fairwood Clinic
Is my blood pressure high?
I get asked this question time and again: what is considered normal blood pressure and what is high?
Generally speaking, in healthy adults a normal blood pressure (BP) is less than 120 systolic (the pressure on the arteries as the heart contracts (squeezes)), and less than 90 diastolic (the pressure on the vessels as the heart relaxes).
In common terms this BP would be expressed as 120 over 90. We call it high blood pressure or hypertension if the BP is greater than 140 systolic and greater than 90 diastolic.
What causes high blood pressure?
Genetics plays an important role. Obesity, weight gain, excessive alcohol use, high cholesterol, excessive use of salt (sodium), not enough activity and a sedentary lifestyle, and type A or having an aggressive personality have all been linked to high blood pressure.
Medications such as oral contraceptive pills, certain cold remedies, anti-inflammatory drugs and many other common medications can increase blood pressure.
Also certain medical conditions such as kidney disease, thyroid and adrenal gland disorders, and sleep apnea can lead to secondary hypertension.
Why is knowing my blood pressure important?
High blood pressure is a major risk factor for heart disease and stroke. Also, untreated hypertension can lead to damage to the eyes and kidneys.
What should I do if my blood pressure is high?
Eat less salt. Most patients don’t realize the high salt content of common foods like certain types of breads and canned soups. Be sure to read labels and choose items with lower sodium content.
Eat more servings of vegetables and fruits.Limit the amount of alcohol you consume. Try to get some cardio-exercise into your weekly schedule. And try to decrease your stress level. (Yeah right! That’s easier said than done!)
If you can you set aside 15 minutes in your day here is a simple meditation exercise to relax your mind and reduce your stress: sit in a quiet place, close your eyes and take slow deep breaths in and out; meditate on peace (choose a person, place or object that makes you feel calm and happy).
I believe that a peaceful and strong internal environment is as essential to a woman’s survival and success as is her external environment.
Keep track of your BP numbers and follow your doctor’s recommendations. You can check your BP with your own blood pressure cuff if you have one, or you can check it by using the free automatic blood pressure monitor available at many large pharmacies. Write down your numbers in a log book and show it to your doctor when you go for your appointment.
Discuss your blood pressure goals with your doctor and write it down. If you are taking medication to lower your BP, don’t forget to take your medication and report any side effects or concerns to your doctor.
Almost 30% of the US population is reported to have high blood pressure. Take control of your blood pressure and work towards a healthier you by adopting healthy habits and setting the right goals.
Dr. Iyer is a Internal Medicine physician in VMC’s Kent Clinic, located at 24920 104th Ave SE in Kent. Phone: 253.395.2000.
Nine in 10 U.S. adults get too much sodium every day
Main sources of sodium include many common foods
From the CDC
Nearly all Americans consume much more sodium than they should, according to a report from the Centers for Disease Control and Prevention. Most of the sodium comes from common restaurant or grocery store items.
The latest Vital Signs report finds that 10 types of foods are responsible for more than 40 percent of people’s sodium intake.
The most common sources are breads and rolls, luncheon meat such as deli ham or turkey, pizza, poultry, soups, cheeseburgers and other sandwiches, cheese, pasta dishes, meat dishes such as meat loaf, and snack foods such as potato chips, pretzels and popcorn.
Some foods that are consumed several times a day, such as bread, add up to a lot of sodium even though each serving is not high in sodium.
“Too much sodium raises blood pressure, which is a major risk factor for heart disease and stroke,” said CDC Director Thomas R. Frieden, M.D., M.P.H. “These diseases kill more than 800,000 Americans each year and contribute an estimated $273 billion in health care costs.”
The report notes that the average person consumes about 3,300 milligrams of sodium per day, not including any salt added at the table, which is more than twice the recommended limit for about half of Americans and 6 of every 10 adults.
Top Sources of Sodium in Our Diet
Breads and rolls
Cold cuts and cured meats
The U.S. Dietary Guidelines recommend limiting sodium intake to less than 2,300 milligrams per day. The recommendation is 1,500 milligrams per day for people aged 51 and older, and anyone with high blood pressure, diabetes, and chronic kidney disease, and African Americans.
Key points in the Vital Signs Report:
Ten types of foods account for 44 percent of dietary sodium consumed each day.
65 percent of sodium comes from food sold in stores.
25 percent of sodium comes from meals purchased in restaurants.
Reducing the sodium content of the 10 leading sodium sources by 25 percent would lower total dietary sodium by more than 10 percent and could play a role in preventing up to an estimated 28,000 deaths per year.
Reducing daily sodium consumption is difficult since it is in so many of the foods we eat. People can lower their sodium intake by eating a diet rich in fresh or frozen fruits and vegetables without sauce, while limiting the amount of processed foods with added sodium.
Individuals can also check grocery food labels and choose the products lowest in sodium. CDC supports recommendations for food manufacturers and restaurants to reduce the amount of sodium added to foods.
“We’re encouraged that some food manufacturers are already taking steps to reduce sodium,” said Dr. Frieden. “Kraft Foods has committed to an average 10 percent reduction of sodium in their products over a two year period, and dozens of companies have joined a national initiative to reduce sodium.
The leading supplier of cheese for pizza, Leprino Foods, is actively working on providing customers and consumers with healthier options. We are confident that more manufacturers will do the same.”
February is American Heart Month—a time to reflect on the sobering fact that heart disease remains the number one killer of both women and men in the United States.
The good news is you have the power to protect and improve your heart health.
NIH and other government agencies have been working to advance our understanding of heart disease so that people can live longer, healthier lives. Research has found that you can lower your risk for heart disease simply by adopting sensible health habits.
To protect your heart, the first step is to learn your own personal risk factors for heart disease. Risk factors are conditions or habits that make you more likely to develop a disease. Risk factors can also increase the chances that an existing disease will get worse.
Certain risk factors—like getting older or having a family history of heart disease—can’t be changed. But you do have control over some important risk factors such as high blood cholesterol, high blood pressure, smoking, excess weight, diabetes and physical inactivity. Many people have more than one risk factor.
To safeguard your heart, it’s best to lower or eliminate as many as you can because they tend to “gang up” and worsen each other’s effects.
A large NIH-supported study published last month underscores the importance of managing your risk factors. Scientists found that middle-aged adults with one or more elevated risk factors, such as high blood pressure, were much more likely to have a heart attack or other major heart-related event during their remaining lifetime than people with optimal levels of risk factors.
“For example, women with at least 2 major risk factors were 3 times as likely to die from cardiovasculardisease as women with none or 1 risk factor,” says Dr. Susan B. Shurin, acting director of NIH’s National Heart, Lung and Blood Institute. “You can and should make a difference in your heart health by understanding and addressing your personal risk.”
Protect Your Heart
Maintain healthy cholesterol levels and blood pressure.
Maintain a healthy weight.
Choose more heart-healthy foods.
Get and stay active.
Know your family history.
Learn the signs that something’s wrong.
Set a good example.
To tackle your heart risk factors, it helps to know your numbers. Ask your health care provider to measure your blood cholesterol and blood pressure. Then determine if your weight is in the healthy range.
The higher your cholesterol level, the greater your risk for heart disease or heart attack. High blood cholesterol itself doesn’t cause symptoms, so you can’t know if your cholesterol is too high unless you have it tested. Routine blood tests can show your overall cholesterol level and separate levels of LDL (“bad”) cholesterol, HDL (“good”) cholesterol and triglycerides. All of these blood measurements are linked to your heart health.
High blood pressure (hypertension) is another major risk factor for heart disease, as well as for stroke. High blood pressure is often called the “silent killer” because, like high cholesterol, it usually has no symptoms. Blood pressure is always reported as 2 numbers, and any numbers above 120/80 mmHg raise your risk of heart disease and stroke.
“Scientific evidence is strong that controlling high blood cholesterol and high blood pressure prevents cardiac events such as heart attacks,” says Dr. Michael Lauer, a heart disease specialist at NIH.
Your weight is another important number to know. To find out if you need to lose weight to reduce your risk of heart disease, you’ll need to calculate your body mass index (BMI, a ratio of weight to height). This NIH web page can help: www.nhlbisupport.com/bmi/bmicalc.htm. A BMI between 25 and 29.9 means that you’re overweight, while a BMI of 30 or higher means obesity.
Next, take out a tape measure. A waist measurement of more than 35 inches for women and 40 inches for men raises the risk of heart disease and other serious health conditions. Fortunately, even a small weight loss (between 5% and 10% of your current weight) can help lower your risk.
NIH has many tools available to help you aim for a healthy weight, including physical activity tips and a menu planner. To learn more, visit http://healthyweight.nhlbi.nih.gov/.
A heart-healthy diet includes a variety of fruits, vegetables and whole grains, as well as lean meats, poultry, fish, beans and fat-free or low-fat dairy products. Try to avoid saturated fat, trans fat, cholesterol, sodium (salt) and added sugar.
Regular physical activity is another powerful way to reduce your risk of heart-related problems and enjoy a host of other health benefits. To make physical activity a pleasure rather than a chore, choose activities you enjoy. Take a brisk walk, play ball, lift light weights, dance or garden. Even taking the stairs instead of an elevator can make a difference.
“At least 2 and a half hours a week of moderate-intensity physical activity can lower your risk of heart disease, stroke, hypertension and diabetes—a winner on multiple counts,” says Dr. Diane Bild, a cardiovascular epidemiologist at NIH.
If you have diabetes, it’s important to keep your blood sugar, or glucose, under control. About two-thirds of people with diabetes die of heart or blood vessel disease. If you’re at risk for diabetes, modest changes in diet and level of physical activity can often prevent or delay its development.
If you happen to be a smoker, the best thing you can do for your heart is stop. People who smoke are up to 6 times more likely to suffer a heart attack than nonsmokers. The risk of heart attack increases with the number of cigarettes smoked each day.
The good news is that quitting smoking will immediately begin to reduce your risk, and the benefit in reduced risk will continue to increase over time. Just one year after you stop smoking, your risk will have dropped by more than half.
Beyond controlling your risk factors, you should be alert to certain symptoms and get checked by a doctor. Common signals that something‘s wrong with your heart include angina—pain in the chest, shoulders, arms, neck, jaw or back—as well as shortness of breath, irregular heartbeat or palpitations (arrhythmia)
Be aware that the symptoms of a heart attack can vary from person to person. If you’ve already had a heart attack, your symptoms may not be the same if you have another one.
Finally, don’t forget that you can influence your loved ones’ heart health by setting an example. Do you have children, grandchildren or other young people who look up to you? If you follow a heart-healthy lifestyle, it’s more likely that they will, too. Because heart disease begins in childhood, one of the best things you can do for those you love is to help children build strong bodies and healthy habits.
The bottom line is, it’s never too late to take steps to protect your heart. It’s also never too early. Start today to keep your heart strong. Talk to your doctor about your risk and to create an action plan. Love your heart.
Washington state has prepared a guide to buying long-term care insurance
Don’t buy if the out-of-pocket cost for the coverage would be more than you can afford. Consumer Reports advises people that if their net worth, excluding their home, is below $300,000, long-term care insurance is not a good buy for them.
The National Association of Insurance Commissioners also recommends that consumers spend no more than 5 percent of their income on a long-term care policy.
If you need long-term care but have few financial resources, Medicaid should quickly kick in to pay, although that will probably limit your choices for care.
On the other hand, if you have a lot of resources (some financial advisers put that threshold at $2 million), you may be able to self-insure and pay the costs as they arise, thereby eliminating the need to buy a policy.
Unlike car insurance where you can switch carriers easily, it can be expensive to change long-term care policies because the premiums increase as you age and you lose the investments already made. Comparison shopping is critical.
Some companies and associations (such as alumni groups and AARP) offer group policies with relatively liberal eligibility, making it easier to obtain coverage if the policyholder has any health issues.
However, these policies may have more limited benefits than individually purchased plans.
If you are young or in excellent health, a group plan may also be more expensive; you may end up paying more to subsidize your less healthy peers.
And if you are certain you want LTC insurance, the younger you are, the better. Your annual premiums will be smaller, and you have less chance of being denied for health reasons.
Know what’s covered.
Policies differ greatly so know what you are buying:
What services are covered?
How long is the disability period before benefits kick in and what happens if you move from one facility to another?
How much does the policy pay per day for nursing home care, home-health care and assisted living?
How long will benefits last?
Is there an inflation adjustment that anticipates rising medical costs as you age?
How long are benefits extended (one, three or five years, or indefinitely)?
Who determines benefit eligibility — your doctor, or the insurance company’s doctor — and on what basis?
Are preexisting conditions excluded?
Does the policy cover mental or nervous disorders, alcoholism, drug abuse or self-inflicted injuries?
The National Association of Insurance Commissioners advises consumers to look for policies that include at least one year of nursing home or home health care coverage, including intermediate and custodial care; coverage for Alzheimer’s disease; inflation protection; a guarantee that the policy cannot be terminated because you get older or your health deteriorates; no requirement that the beneficiary has to first be hospitalized to receive benefits and a 30-day cancellation period after purchase.
Check out the insurance company.
Review a carrier’s record with your state insurance commissioner’s office. Find out how long it has been in business its complaint record and history of raising rates. Stick with a company that has an A financial rating.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.