There may be plenty of room for debate about whether some aspects of everyday life cause cancer — whether it’s drinking too much coffee, eating too much sugar or talking too much on a cell phone.
But the opposite seems to be true regarding the causal link with obesity, according to a scientific review by the International Agency for Research on Cancer.
Fourteen years ago when the IARC, based in Lyon, France, first reviewed relevant studies, its expert panel issued a report finding sufficient evidence that excess body fat increases the risk of certain cancers. Now, the group’s latest reassessment, published Wednesday in the New England Journal of Medicine, reaffirms those findings — and adds eight more cancers to the list.
“Since 2002 there have been a lot of new studies conducted. We felt like it was the right time to review the literature and maybe confirm the science that has been established,” said Beatrice Lauby-Secretan, lead author of the article and an IARC scientist responsible for the agency’s Handbooks of Cancer Prevention Series. The IARC is part of the World Health Organization.Use Our Content This KHN story can be republished for free (details).
A working group of 21 independent international cancer experts reviewed more than 1,000 studies on cancer risk and excess body fat published since the IARC’s 2002 report. That evaluation identified that preventing weight gain can reduce the risk of colon and rectum cancer; a stomach cancer called esophagus adenocarcinoma; kidney or renal cell carcinoma; postmenopausal breast cancer and cancer in the endometrium of the uterus. This year’s reassessment added to this list gastric cancer, liver, gallbladder, pancreas, ovary and thyroid cancers as well as the blood cancer multiple myeloma and meningioma — cancer that affects the tissue surrounding the brain and spine.
“The number of cancers that are linked to obesity has increased a lot, which means a much higher proportion of cancer that occurs today is due to obesity,” Lauby-Secretan said. Public health messages should be tailored to raising awareness about this fact, she added.
Results also were consistent for children, adolescents and adults younger than 25.
Overweight adults are defined in the study as those with body mass indexes (BMI) of 25.0 to 29.9, while obese adults have BMIs above 30. According to the study, an estimated 640 million adults worldwide were obese in 2014, which is six times more than in 1975. Around 110 million children and adolescents were obese in 2013, two times more than in 1980.
Meanwhile, the report also found that an estimated 4.5 million deaths in 2013 were related to overweight and obesity, a number that may increase as more cancers are found to be related to the condition.
“The epidemic of obesity has become a global concern,” Lauby-Secretan said.
Not all cancers have positive correlations with obesity, though. For example, there is only limited evidence of this link for fatal cancer of the prostate, breast cancer in men and diffuse large B-cell lymphoma, the most common blood cancer. Evidence is inadequate for cancers of the lung, testis, urinary bladder, brain or spinal cord. While excess fat does lead to higher risks of postmenopausal breast cancer, it does not have the same effect for premenopausal breast cancer.
The reason obesity may increase cancer risks, Lauby-Secretan said, is because excess body fat has been known to trigger chronic inflammation. It also disturbs the regulation of sex hormones. Both are common pathways for the development of cancer cells in the body.
But the awareness about the link can be low especially when Americans are inundated with news about how many substances — coffee or sugar, for instance — may or may not cause cancer. According to the American Institute for Cancer Research’s biennial survey released in February 2015, a little more than half of Americans realize that being overweight can increase cancer risk, a slight increase over prior surveys.
Alice Bender, head of nutrition programs for AICR, said there will always be studies that disprove or prove links — but when you look at the whole body of research, there is a scientific consensus on this particular point. And people can actively reduce cancer risks from excess body fat, Bender said, by eating healthier meals and exercising more.
“Oftentimes people are concerned about exposures in the environment or genetics or things you can’t control,” she said. “Rather than increase fear about this, we can see this as an empowering message: Here is something I can do to help myself lower the risk for many of these cancers … here are some lifestyle changes that I can make.”
This is a guest post by Patience Tyne. Patience is working in the Collection Services Division of the Law Library of Congress as part of the Library of Congress’s Junior Fellows Program. The program’s focus is to increase access to our collections for our various patron groups.
The project that I am working on in the Junior Fellows Program this summer is called the Hispanic Legal Documents Collection Description Project. Seventy-five years ago, the Law Library of Congress purchased a massive collection of Hispanic legal documents from a dealer in Barcelona. The collection contains a broad selection of documents from Spain and its colonies during the 15th-19th centuries. It includes correspondence, civil, criminal, and ecclesiastical legal proceedings, newspapers, royal decrees and seals, educational promotions, charts, maps, and other previously inaccessible rare documents housed in 96 document boxes. The purpose of the project is to create metadata for these Hispanic documents. This means that I have been asked to go through the documents in the collection and record certain targeted pieces of information about each one that will help future researchers estimate the documents’ research potential. The description I provide includes a summary, location, date, personal names, signatures, stamps, and other pertinent information. The information will later be compiled to create a finding aid that will make these documents, which until now have been mostly invisible to researchers, visible.holdings on Spanish paleography. No less of a challenge was the content of the documents, which proved much more difficult than I had anticipated. In this area also, thanks to unlimited resources available at the Library of Congress, I found materials to help with my research.
In addition to creating metadata, I had the opportunity to present items from this collection at Display Day. Display Day is the culmination of the Junior Fellow internship program during which fellows from every participating division in the Library of Congress present interesting collection items that they found in the course of their projects. In my selections for the display, I tried to represent the significant categories of documents that you might find in the collection I am working with. The overall theme of the presentation I put together was “Threats to the Public Tranquility.” Here are the items I presented: State Department correspondence concerning local bandits in Michoacán (1848), treasury allocation for military expenses in Veracruz (1822), an imperial tax decree from Córdoba (1757), a civil case recorded in ornate handwriting (1607), a nineteenth century handwritten map of Chihuahua, and the record of a criminal investigation of a licentious priest with a scandalous portrait (1849).Mexico, was engaging in immoral liaisons with the wives of several members of his parish. The investigation, at which several counts of the criminal charge of adultery were alleged against Acosta, took place in the criminal court of Morelia, with notaries taking the testimonies in Santa Clara. The documents associated with the investigation include twelve letters, some formal and some informal, that accompanied the court documents as they circulated among the court officers during the pretrial phase, and a series of documents recording the testimony of the persons concerned in the accusations against Crecencio.
Over the course of a series of affidavits, this story unfolds like a modern telenovela. The first testimony is the most intriguing, as well as the most risqué of the investigation. Francisco Saenz, one of Crecencio’s parishioners, had heard rumors about Father Acosta’s frequent visits to the homes of women in the community. However, his suspicion increased when he saw the priest one day wearing a ring identical to one Francisco had given his wife engraved with her initials. After a frenzied search of his wife’s jewelry box, Francisco confronted Acosta demanding to see the ring. But word of Francisco’s suspicions must have gotten to Acosta who now wore a different ring, while his wife’s ring mysteriously had been returned to the box. Francisco now was on high alert and when sometime later he saw Acosta caress his wife’s face, he devised a plan to catch them in the act. Announcing that he had an obligation across town, he pretended to leave the house but instead doubled back and hid by a hole in the wall waiting to see whether they would take advantage of the opportunity to meet. His testimony covered everything that he witnessed. In one letter to the court, Francisco mentioned a painting that Crecencio had given to his wife, describing its contents: a colorful champagne ad that was “very indecent, very lascivious, very scandalous” as it depicts a woman in a revealing dress drinking champagne and is captioned in French, saying: “Champagne with dessert promotes folly, and a woman who is a little foolish is always more lovely”. Nine other townsmen testified similar stories accusing Acosta of flirtatious behavior, but Francisco’s wife María Castañeda testified in favor of Acosta and swore that her husband was confused and crazy. Ultimately, the tribunal acquitted Acosta of the criminal charges because even with the overwhelming evidence, the husband and wife had created reasonable doubt with their contradictory testimonies. The bishop ordered Acosta to be transferred to a nearby parish and decreed a monition to end his vices.
Kentucky Governor Matt Bevin today submitted a proposal to the Centers for Medicare & Medicaid Services (CMS) that would change the state’s Medicaid expansion, leading to tens of thousands of people becoming uninsured. While Gov. Bevin says the changes are necessary to improve Kentuckians’ health, research shows that Medicaid expansion has already fueled tremendous improvements in the health of the state’s residents.
ROCKLIN, Calif. — The headaches were excruciating and wouldn’t go away. Her doctor said they were migraines. Then, one morning a few weeks later, Jamie Hancock stood up from the couch and discovered she couldn’t move the right side of her body. When she spoke, her speech was slurred.
At the hospital, doctors told her she was having a stroke. The 32-year-old Hancock, whose children were just 1 and 3, had a sobering epiphany: “My whole life is changed forever.”
Now, six years later, no one would know she is a stroke survivor. A lifelong dancer, she is fit and muscular. She speaks clearly and walks quickly as she shuttles her kids around, runs errands and teaches dance classes.
But the effects — for her and other young stroke victims — linger just below the surface. They are there when she gets mad at her family, when she can’t remember what she needs at the grocery store, when she tires after working for a few hours. The noise and light can be unbearable, forcing her to escape to a dark room.
Some days Hancock tries to be the energetic and sociable working mom she was before the stroke. Then she crashes.
“I sort of forget I have a disability and I think I can do everything anyone else my age can do,” she said. “But I can’t.”
Hancock is among a growing number of younger adults who’ve had strokes, which occur when blood flow to the brain is blocked or a vessel in the brain bursts. Because strokes are most often associated with old age, symptoms in younger adults may be overlooked, according to patients, advocates and physicians. And their need for rehabilitation — to return to active lives as parents and employees, for instance — can be underestimated.
“The American public is still very locked on stroke being an [affliction] of the elderly,” said Amy Edmunds, who started a nationwide advocacy and support organization called YoungStroke. “But we are an emerging population … and we really need to be recognized.”
The rate of hospitalization for strokes dropped nationwide by 8 percent between 2000 and 2010 (from 250 to 204 per 100,000), but in those same ten years it increased almost 44 percent for people ages 25 to 44, though from a much smaller base (from 16 to 23 per 100,000), according to research published in May in the Journal of the American Heart Association.
The reasons for the rising prevalence among young people are not clear, but physicians believe that growing risk factors such as hypertension, smoking and obesity contribute. And because younger patients aren’t as aware that they can get strokes, they may not be proactive about controlling those risk factors. Older patients, by contrast, may be more inclined to exercise, eat healthy and take preventive medications.
“Older people are educated and understand they need to take care of themselves and are doing all the things to prevent strokes,” said Lisa Yanase, a stroke neurologist at Providence Health & Services in Oregon. “Young adults … think they are bulletproof. They haven’t had the realization that these things can actually be bad for them.”
Some young people also may have strokes because of drug abuse, and others because of undiagnosed genetic conditions. Hancock’s stroke was caused by a tear in the artery.
Strokes are still more common among older adults though. People ages 18 to 50 years old account for only about 10 percent of the 795,000 strokes that occur each year, according to the American Heart Association.
When their patients are younger, doctors don’t always immediately recognize strokes, said Lucas Ramirez, a physician at Keck Hospital of USC and one of the co-authors of the journal article. Young adults may also be unaware they are having a stroke, jeopardizing their chances of receiving critical, time-sensitive treatment.
Common symptoms, for all ages, include sudden confusion or numbness, slurred speech or severe headache.
Hancock said she had no idea of the warning signs. “I had heard about strokes, but I thought they were for the elderly,” she said.
Years had passed since the stroke, and now the Fourth of July was just a few days away. Hancock had promised her children they could buy fireworks. Blythe, 9, and Andrew, 7, selected several sets. But when the clerk handed the bag to the kids, one of Andrew’s wasn’t inside.
“Mom, where’s my rocket man?” he asked.
Hancock told her son to stop. But he asked again — and again.
“Hold on!” she yelled. “I’m trying to focus on paying. You know I have a hard time with focusing.”
Hancock said she never used to be that way. Now, she has trouble multitasking and gets angry about minor things — her daughter playing music too loud, her son bouncing the ball inside the house. “My family pays the price,” she lamented.
Both children say they’ve learned what to do when their mom gets stressed. Andrew gives her hugs. Blythe helps her take deep breaths. “Sometimes she has really good days and sometimes she has horrible days,” Blythe said.
In addition to the emotional roller coaster, Hancock said she has lost the cognitive ability to do some things, such as handling the family finances.
There is less money to go around, too. Just a few months after the stroke, Hancock returned to her job as an executive assistant at the California Restaurant Association. But she had trouble concentrating, couldn’t manage her time or meet deadlines — and she eventually left. She later got fired from a subsequent job.
“I would get distracted really, really easily,” she said. “I still do.”
Hancock said she spiraled into depression, which therapists later told her was likely a symptom of the stroke. She also became addicted to a painkiller prescribed to treat her headaches. She said it helped her get through the day without feeling exhausted.
With the assistance of Suboxone, a medication to treat opiate addiction, Hancock got sober. But that didn’t stop her mood swings. There were times when she slammed cabinets so hard they fell off their hinges.
Her husband, Ken Hancock, said the stroke and its aftermath nearly tore their family apart. At first, he just felt scared. For a while, his wife couldn’t wash her own hair or pick up their children. When she cooked, one of her hands shook.
He concentrated on getting his wife to appointments and taking care of her and their children. But as she got better physically, he said, she became worse emotionally. The addiction didn’t help, and they argued frequently. “It was a terrible, terrible cycle,” he said. “It took a long time to realize better things were around the corner.”
Now, the family is in a better place, he said. Jamie Hancock sees a therapist and takes medication that is normally used to treat schizophrenia. The volatility has subsided.
Ken Hancock said his wife’s brain injury isn’t visible, but it’s there. “She is still trying to recover, and we are sort of in the same boat with her,” he said.
On a June afternoon, Hancock sat in her living room with another young stroke survivor, Jen Ruzicka Lee, an ER nurse and longtime runner who was stricken last year at age 43. Lee returned to nursing part-time in April, but she still stutters and uses a walker.
They laughed and nearly cried as they talked about the impact of different medications, becoming intimate with their husbands again and the daily guilt they felt about the effect of the strokes on their children.
Both women said they had attended a few stroke support groups but couldn’t relate to the older participants. “They would say, ‘You need to nap,” Hancock recounted. “That’s great, but I can’t. I have kids.”
Support groups and rehabilitation programs are typically designed for older adults, said Edmunds, the YoungStroke founder, who was hit by the disease at age 45. Many young stroke survivors have to figure out how to continue raising children and working while dealing with the effects of a stroke.
“It’s a different landscape for younger adults,” Edmunds said. “We need skills to help us get on with our lives post-stroke, which could conceivably be as long as pre-stroke.”
Hancock and Lee, along with two other women, have become an informal support network. They text often and meet for coffee when they can. This month, they had a family barbecue.
Being a young stroke survivor, Hancock said, “is a whole different ballgame.”
Hancock tried to return to dancing soon after her stroke. She couldn’t do a single turn on the floor, and walked out in tears.
“I had to learn to walk again so I don’t know why I thought in my brain I could take an advanced dance class,” she said.
Over time, Hancock regained her strength. She said she doesn’t think her brain will ever be able to handle a 40-hour work week. Teaching dance part-time can even be too tiring some days.
On this evening, however, Hancock energetically stepped into a brightly lit dance studio. She and five young students warmed up to music. Hancock instructed them to run through the dance routine they had practiced the previous night.
“Let’s see what you remember,” she said.
Then she smiled. “Let’s see what I remember, too.”
KHN’s coverage in California is funded in part by Blue Shield of California Foundation.
At 10 a.m. on a recent Wednesday, a line of parents pushing strollers filed into a conference room at the Sacramento County Courthouse. They sat at rows of narrow plastic tables, shushing their babies and gazing up at a man in a black robe.
Hearing Officer Jim Teal sounded his gavel. “This is the time and place set for Early Intervention Family Drug Court,” he began, gazing sternly at the rapt faces of parents who sit before him. “Graduation from this court is considered a critical factor in determination that the children of participants will be safe from any further exposure to the danger and destructive impact of parental substance abuse.”
Substance abuse is a factor in up to 80 percent of cases in which a child is removed from home. Recently, the number of children entering the foster care system has surged after years of decline. Roughly 265,000 kids entered foster care last year — the highest number since 2008, according to a recent government report. And there are signs that the opioid epidemic may be to blame.This KHN story also ran on NPR. It can be republished for free (details).
Parents who receive addiction treatment are much more likely to get their kids back, but four in five parents fail to complete their treatment regimen.
The Early Intervention Family Drug Court in Sacramento aims to change that by helping parents complete treatment before their children enter the foster care system. If they fail, they’ll be sent next door to a formal family drug court, where their children are taken away and given attorneys of their own.
But before that, the parents get this opportunity to enter recovery, through a mix of support, medication-assisted treatment and tough love.
Many parents in the court entered the system after having babies born dependent on opioids or other drugs, while others were reported to Child Protective Services by friends or family. All are at risk of losing custody of their children because of their drug abuse.
Emma, 20, a striking woman with long blond hair, approached Teal’s podium. California Healthline is withholding her last name to protect the child’s privacy.
“Good morning,” said Teal. “Who do you have with you there?”
“My daughter, Cailynn,” Emma answered proudly, bouncing her cooing baby on her hip.
Emma started using drugs when she was just 16. At first it was methamphetamines, but she quickly transitioned to heroin. Then she got pregnant.
When Cailynn was born, the baby tested positive for opioids. Child Protective Services came to the hospital and took her into custody.
“I regret every moment of it. It’s hard. But I’ve gotta keep my head up and keep going,” Emma said. She wanted her daughter back.
Usually, Sacramento County has a three-month wait for people who need substance abuse treatment. But by volunteering to participate in the early intervention court program, Emma was able to get treatment right away.
“So Emma, it says here you’re 63 days compliant,” Teal said from the podium. “And 63 days in the program, so you’ve been good. You’ve been doing what you’re told. Congratulations.”
The other parents in the room burst into applause — this is a major accomplishment. The six-month program is rigorous. In addition to monthly sessions at the court, the parents must attend almost daily group meetings, submit to random drug tests and take parenting classes. Many, like Emma, go to inpatient rehab. Medication-assisted therapy for opioids is also available. And once or twice a week, they get a home visit from their social worker.
Emma attributes much of her success in the program so far to social worker Matthew Takamoto, whom she calls “amazing.”
Takamoto has been a social worker for 20 years and has been part of the early intervention program since it began six years ago. The program, he said, is an important change in way the county handles addiction.
“In the olden days, we were quicker to send them to court,” he said. Their approach was “more blaming the addict verses giving them the tools they need.”
In the afternoon following the court meeting, Takamoto drove to the inpatient residential facility where Emma lives with her daughter. In the back is a grassy yard with a small jungle gym. Several mothers watch their children play. Emma sat in a plastic chair, holding Cailynn in her lap.
Takamoto seemed happy with her progress. “You take these clients from the very beginning where they’re broken and it’s the worst day of their life. And to see them slowly get back up as they have days of clean time, it’s been incredible,” he said.
But he said the hardest part of his job is realizing that not all parents are going to make it through the program — in fact, just one-third of parents end up graduating. “If these parents aren’t successful, it’s the kids [who] pay the price,” he said. “The parents are doing what they want to do, but the kids don’t have a choice.”
Just 5 to 10 percent of families in the country who could use family drug courts have access to them, according to Children and Family Futures, an organization that advises and evaluates family drug courts. Sacramento’s program is one of about 350 in the country, though most work with families after their children have entered the foster system.
Sherri Z. Heller, director of Sacramento’s Health and Human Services Department, describes family drug courts as a success story.
“People can overcome addiction if the motivation is strong enough, and this is the most effective motivation I have ever seen,” said Heller. She points to the early intervention court as evidence.
Just 10 percent of kids with families in the program end up being removed from their home, compared to 30 percent of children in families who do not participate. That represents a major savings to the county — about $21,000 a year for every kid who doesn’t have go into the court and foster system, for an annual savings of $7 million.
“The rush that comes with getting high is pretty spectacular. And it’s very hard physically, once the addiction happens, to overcome,” said Heller. “But if there is one thing that matters to people more than the thrill of getting high, it’s the thrill of doing the right thing for your children and keeping your family intact.”
Emma clearly wants to be a good mom. Asked by Teal how she sees her future in six months, Emma said she wanted to have her own apartment with her daughter. “Have a good life. Clean. Don’t have to have drugs no more,” she said.
DENVER — Inside a senior center here, nestled along a bustling commercial strip, Vivian Malveaux scans her bingo card for a winning number. Her 81-year-old eyes are warm, lively and occasionally set adrift by the dementia plundering her mind.
Dozens of elderly men and women — some in wheelchairs, others whose hands tremble involuntarily — gather excitedly around the game tables. After bingo, there is more entertainment and activities: Yahtzee, tile-painting, beading.
But this is no linoleum-floored community center reeking of bleach. Instead, it’s one of eight vanguard centers owned by InnovAge, a company based in Denver with ambitious plans. With the support of private equity money, InnovAge aims to aggressively expand a little-known Medicare program that will pay to keep older and disabled Americans out of nursing homes.
Until recently, only nonprofits were allowed to run programs like these. But a year ago, the government flipped the switch, opening the program to for-profit companies as well, ending one of the last remaining holdouts to commercialism in health care. The hope is that the profit motive will expand the services faster.This KHN story also ran in The New York Times. It can be republished for free (details).
Hanging over all the promise, though, is the question of whether for-profit companies are well-suited to this line of work, long the province of nonprofit do-gooders. Critics point out that the business of caring for poor and frail people is marred with abuse. Already, new ideas for lowering the cost of the program have started circulating. In Silicon Valley, for example, some eager entrepreneurs are pushing plans that call for a higher reliance on video calls instead of in-person doctor visits.
The business appeal is simple: A baby boom-propelled surge in government health care spending is coming. Medicare enrollment is expected to grow by 30 million people in the next two decades, and many of those people are potential future clients. Adding to the allure are hefty profit margins for programs like these — as high as 15 percent, compared with an average of 2 percent among nursing homes — and geographic monopolies that are all but guaranteed by state Medicaid agencies to ensure the solvency of providers.
The goal of the program, known as PACE, or the Program of All-Inclusive Care for the Elderly, is to help frail, older Americans live longer and more happily in their own homes, by providing comprehensive medical care and intensive social support. It also promises to save Medicare and Medicaid millions of dollars by keeping those people out of nursing homes.
For decades, though, the program has failed to catch on, with only 40,000 people enrolled as of January of this year.
“PACE is still a secret in the minds of the public,” Andy Slavitt, Medicare’s acting administrator, said at the National PACE Association meeting in April. The challenge, he said, was to make PACE “a clear part of the solution.”
Several private equity firms, venture capitalists and Silicon Valley entrepreneurs have jumped into the niche. F-Prime Capital Partners, a former Fidelity Biosciences group, provided seed funding for a PACE-related startup, as have well-regarded angel investors like Amir Dan Rubin, the former Stanford Health Care president, and Michael Zubkoff, a Dartmouth health care economist.
And no company has moved with more tenacity than InnovAge. Last year, the company overcame protests from watchdog groups to convert from a nonprofit organization to a for-profit business in Colorado. And in May, InnovAge received $196 million in backing — the largest investment in a PACE business since the rule change was made — from Welsh, Carson, Anderson & Stowe, a private equity firm with $10 billion in assets under management.
“For years we were pariahs, and no one wanted anything to do with us,” said Julie Reiskin, executive director of the Colorado Cross-Disability Coalition, a nonprofit group that advocates for people with disabilities, many of whom are eligible for PACE.
“Now that there’s money involved,” Reiskin said, “everyone is all interested.”
Even the program’s supporters acknowledge that the movement needs fresh momentum. But they worry that commercial operators will tarnish their image in the same way many for-profits eroded trust in hospice care and nursing homes.
Three decades ago, after Congress authorized Medicare to pay for hospice care, commercial operators displaced the religious and community groups that had championed the movement. As recently as 2014, government inspectors found that for-profit hospice companies cherry-picked patients and stinted on care.
In addition, elderly patients with dementia and chronic ailments have frequently been targets of abuse and neglect at nursing homes, something advocates for the elderly say is correlated with the increased commercialization of that industry.
“I’m not wild about every knucklehead running around trying to do PACE,” said Thomas Scully, former Medicare administrator under President George W. Bush. “I would rather keep it below the radar.”
Not Quite Able
Early last year, Malveaux was drowning. She lived alone in a tidy red-brick home in a leafy Denver neighborhood that she paid for by working shifts at a Samsonite luggage factory, now closed.
Laundry piled up. Bills went unpaid. Doors were left unlocked. Pans sometimes burned on the stove as her memory failed.
“I had lost my mind,” she recalled, sitting on her couch in a pink velour robe. “I couldn’t keep up my house.”
For Americans who find themselves in this situation, the next stop is often a traditional nursing home. Malveaux’s son took her instead to visit an InnovAge day center.
The $9 million building south of downtown Denver is designed to calm people with dementia. It has subdued lighting and winding hallways that encircle the first floor like a running track and discourage “exit-seeking behaviors,” where patients search for ways out of a building.
For the frightened Malveaux, it seemed like paradise: a flower garden, a beauty salon and day trips to casinos and candy factories. And, most importantly, it had a team of doctors, nurses, psychiatrists, dentists, physical therapists, nutritionists, home health aides and social workers whose purpose was to help her live safely in her beloved brick home.
After joining the center in June 2015, Malveaux began seeing a psychiatrist and went on medication for depression. A social worker coached her grandson, Jermaine Malveaux, on how to care for someone with dementia. Three days a week, an InnovAge van picks up Malveaux at home and takes her to the center to share lunch with other older adults and try her luck at bingo and ceramics.
“I make friends easily,” she said with a smile. “And the guys flirt with me.”
The InnovAge center, like other PACE facilities, is inspired by Britain’s much-lauded Day Hospitals, outpatient health care facilities that arose in the 1950s that became a hub of daily life for many older people. In the United States, the earliest incarnation of PACE was started in San Francisco in 1971 by a group of Asian and Italian immigrant families seeking alternatives to the American nursing home.
Federal health officials allowed the group, called On Lok — Cantonese for “peaceful, happy abode” — to test what was then a novel and prophetic approach to health care financing. Instead of physicians billing Medicare each time they treated a patient, the government would pay a fixed amount to the center for each member. On Lok would assume the financial risk, similar to an insurance company. In 1990, Medicare officially sanctioned the model.
In exchange for a capped monthly payment from Medicare and Medicaid, PACE staff members arrange and pay for all of a patient’s doctors’ visits, medications, rehabilitation and hospitalizations. At the same time, they are supposed to pay attention to the patient’s daily needs — meals, bathing, housekeeping and transportation to day centers, where older people can ward off isolation and cognitive decline by socializing. (Studies have found that the intensive caretaking reduces costly hospital stays.)
Comparing the cost effectiveness of PACE against nursing homes is difficult, partly because state Medicaid agencies pay a variety of rates. But all the states are required to keep their rates below what they would pay for nursing home care. In Colorado, for example, that amounts to 7 percent less per patient.
On average, Medicare and Medicaid pay PACE providers $76,728 a person a year, about $5,500 less than the average cost of a nursing home. And the money going to PACE covers the all of the person’s health and social needs, unlike nursing home care, which doesn’t include hospitalizations and other expensive medical care.
The flat government payment pushes the organizations to invest in maintaining a patient’s health and safety to avoid big hospital bills. Dentistry — excluded from traditional Medicare coverage — is a crucial focus: Programs invest heavily to fix broken teeth and dentures to avoid costly infections or poor nutrition that can cause cascading health problems.
Providers are also generous with rehabilitation, setting few limits on training sessions that strengthen injured muscles and sturdy patients against falls.
“If you’re neglecting these patients, the odds they’ll call an ambulance and go to the hospital and spend a week there because they’re really sick is pretty high, and that all comes out of the payment,” said Bob Kocher, a former senior health care adviser to President Barack Obama.
Profits are in no way guaranteed, though. The centers still face major financial risk — it just takes a few patients with serious medical conditions to upend the books.
Dan Gray, a PACE financing consultant at Continuum Development Services, said too many trips to the emergency room or an expensive hospital stay can flip fortunes. One organization he advises had $300,000 in hospital medical claims in a month that he refers to as “Black August.”
“I had a nervous twitch,” he said.
High-Tech vs. High-Touch
In January, at the health care industry’s leading matchmaking event, the J.P. Morgan Healthcare Conference in San Francisco, word quickly spread that PACE programs could save states and the federal government up to 20 percent a patient. And suddenly, the program became one of the hottest topics of discussion.
“Every other conversation was, ‘What do you think we should do with PACE?’” said Bill Pomeranz, a managing director at Cain Brothers, who helped finance the nation’s first PACE program in the 1970s.
The message appeared to travel down Highway 101 as well, to the heart of the technology industry. At least eight startups have circulated PACE-related pitches to Silicon Valley venture capital firms, hoping to tap into new capital and create technology-enabled versions of the program.
The interest of the tech industry is so far only nascent. But the possibility that Silicon Valley, notoriously aggressive and extremely deep-pocketed, could play a significant role in PACE underscores the changes that may lie ahead.
Building a center requires medical offices, rehabilitation equipment, food service and fleets of handicapped-accessible vans. On average, it takes up to $12 million just to get it off the ground. That is a lot of money for most nonprofits but relatively little in the technology world. Opening new centers may become less of a hurdle.
The tech industry and nonprofit world are driven by different impulses. The early centers were closely tied to local cultures, making them difficult to replicate. An aversion to aggressive marketing among the center’s leaders didn’t help, either. Tech likes to move as fast as possible.
“PACE reminds me of religious orthodoxy,” said Mr. Pomeranz, who said he had affection for the program. The movement’s leaders come from the world of public health and have a “social work mentality,” he added.
The pitches circulating among investors envision technology-enabled programs that would rely, in part, on video visits and sensors. Some studies have found that telemedicine can help patients better control certain chronic conditions and reduce health care spending. But those technologies are largely untested in geriatric care.
“The entrepreneurs coming into this space all believe there are much lower-cost ways to check on patients every day than driving them all to one building,” said Mr. Kocher, who is now a partner at the venture capital firm Venrock, which invests in health care companies.
These sorts of pitches, while promising, have not been universally welcomed. They’ve even been used as evidence that opening PACE up to for-profit companies might lead to unwanted consequences.
Veteran PACE providers, for example, are skeptical of virtual medicine’s benefits to seniors, especially those with dementia.
“Socialization goes a long way to improve the health of the participants we serve,” said Kelly Hopkins, president of Trinity Health PACE, a nonprofit health system that operates PACE centers in eight states. “It’s naïve to think you can do it virtually.”
Supporters of the change say the necessary safeguards are in place. The for-profit centers were approved, to little fanfare, after the Department of Health and Human Services submitted the results of a pilot study to Congress in June 2015. The demonstration project, in Pennsylvania, showed no difference in quality of care and costs between nonprofit PACE providers and a for-profit allowed to operate there.
The Centers for Medicare and Medicaid Services has vowed to closely track the performance of all PACE operators by measuring emergency room use, falls and vaccination rates, among other metrics. The National PACE Association, a policy and lobbying group, is also considering peer-reviewed accreditation to help safeguard the program. Oversight is now largely left to state Medicaid agencies.
Maureen Hewitt, InnovAge’s chief executive, said, “At the end of the day, we’re held to the same quality and care standards.”
Dr. Si France, a founder of WelbeHealth, an early-stage company based in Menlo Park, Calif., says startups can use technology to improve clinical communication, help caregivers make treatment decisions and monitor patients at home or in a hospital. But he insists even a high-tech PACE program cannot veer from its origins.
“It’s not a way to get rich or generate outsize returns,” said Dr. France, the former chief executive of GoHealth, a chain of urgent care centers acquired by TPG Capital, a private equity firm. “We think this is an arena for missionaries, not mercenaries.”
Will Money Change Things?
Families enrolled in InnovAge’s PACE program in Denver appeared to be unaware of its conversion into a for-profit enterprise. The company did not announce the change directly to its participants, but notified a patient advisory group.
Kathy Baron, 68, who lives in subsidized senior housing, was left disabled by breast cancer and debilitating nerve pain. Her daughter, Leah van Zelm, struggled to take care of her. So Baron, fearful she would be deemed unfit to stay in her apartment, signed up for InnovAge’s program.
“I would rather be dead than go into a nursing home,” Baron said.
She says InnovAge has been generous with services, echoing interviews with other patients. Each week, an InnovAge housekeeper changes the sheets on her bed, launders her clothes and cleans her apartment, a service provided to those unable to tidy their own homes. The few times her requests for special equipment or services were denied, Baron appealed and won.
But she worries new investors will skimp on what outsiders might view as unwarranted services. The company’s commercials, promising “Life on Your Terms” and voiced by the actress Susan Sarandon, have reinforced those concerns.
It’s a concern echoed by Malveaux’s family. “Anytime you involve money,” said Malveaux’s grandson Jermaine, “there’s always the concern for greed, especially with the elderly.”
At least in the near future, the number of companies getting into PACE programs will be limited. Most states currently cap enrollment in PACE centers. And each state — as Colorado did, opening the window for InnovAge — likely needs to amend its law to allow the for-profit companies. So far, it appears only California has done so.
Yet there is a growing realization among longtime PACE providers that new competition looms.
In a newsletter to the generally placid PACE community, one adviser warned that providers who failed to become bigger would face new entrants who “will find a way to meet the needs of persons in your community.”
Those needs will only grow as the adult children of baby boomers face difficult decisions about how to care for their parents.
In the meantime, for people like Van Zelm, the anxiety that once pervaded her daily life has diminished.
“When she’s stable,” Van Zelm said of her mother, “my daily life stress is reduced.”