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The burden of getting medical care can exhaust older patients

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Susanne Gilliam, 67, was walking down her driveway to get the mail in January when she slipped and fell on a patch of black ice.

Pain shot through her left knee and ankle. After summoning her husband on her phone, with difficulty she made it back to the house.

And then began the run-around that so many people face when they interact with America’s uncoordinated health care system.

Gilliam’s orthopedic surgeon, who managed previous difficulties with her left knee, saw her that afternoon but told her “I don’t do ankles.”

He referred her to an ankle specialist who ordered a new set of X-rays and an MRI. For convenience’s sake, Gilliam asked to get the scans at a hospital near her home in Sudbury, Massachusetts. But the hospital didn’t have the doctor’s order when she called for an appointment. It came through only after several more calls.

Coordinating the care she needs to recover, including physical therapy, became a part-time job for Gilliam. (Therapists work on only one body part per session, so she has needed separate visits for her knee and for her ankle several times a week.)

“The burden of arranging everything I need — it’s huge,” Gilliam told me. “It leaves you with such a sense of mental and physical exhaustion.”

The toll the American health care system extracts is, in some respects, the price of extraordinary progress in medicine. But it’s also evidence of the poor fit between older adults’ capacities and the health care system’s demands.

“The good news is we know so much more and can do so much more for people with various conditions,” said Thomas H. Lee, chief medical officer at Press Ganey, a consulting firm that tracks patients’ experiences with health care. “The bad news is the system has gotten overwhelmingly complex.”

That complexity is compounded by the proliferation of guidelines for separate medical conditions, financial incentives that reward more medical care, and specialization among clinicians, said Ishani Ganguli, an associate professor of medicine at Harvard Medical School.

“It’s not uncommon for older patients to have three or more heart specialists who schedule regular appointments and tests,” she said. If someone has multiple medical problems — say, heart disease, diabetes, and glaucoma — interactions with the health care system multiply.

Ganguli is the author of a new study showing that Medicare patients spend about three weeks a year having medical tests, visiting doctors, undergoing treatments or medical procedures, seeking care in emergency rooms, or spending time in the hospital or rehabilitation facilities. (The data is from 2019, before the covid pandemic disrupted care patterns. If any services were received, that counted as a day of health care contact.)

That study found that slightly more than 1 in 10 seniors, including those recovering from or managing serious illnesses, spent a much larger portion of their lives getting care — at least 50 days a year.

“Some of this may be very beneficial and valuable for people, and some of it may be less essential,” Ganguli said. “We don’t talk enough about what we’re asking older adults to do and whether that’s realistic.”

Victor Montori, a professor of medicine at the Mayo Clinic in Rochester, Minnesota, has for many years raised an alarm about the “treatment burden” that patients experience. In addition to time spent receiving health care, this burden includes arranging appointments, finding transportation to medical visits, getting and taking medications, communicating with insurance companies, paying medical bills, monitoring health at home, and following recommendations such as dietary changes.

Four years ago — in a paper titled “Is My Patient Overwhelmed?” — Montori and several colleagues found that 40% of patients with chronic conditions such as asthma, diabetes, and neurological disorders “considered their treatment burden unsustainable.”

When this happens, people stop following medical advice and report having a poorer quality of life, the researchers found. Especially vulnerable are older adults with multiple medical conditions and low levels of education who are economically insecure and socially isolated.

Older patients’ difficulties are compounded by medical practices’ increased use of digital phone systems and electronic patient portals — both frustrating for many seniors to navigate — and the time pressures afflicting physicians. “It’s harder and harder for patients to gain access to clinicians who can problem-solve with them and answer questions,” Montori said.

Meanwhile, clinicians rarely ask patients about their capacity to perform the work they’re being asked to do. “We often have little sense of the complexity of our patients’ lives and even less insight into how the treatments we provide (to reach goal-directed guidelines) fit within the web of our patients’ daily experiences,” several physicians wrote in a 2022 paper on reducing treatment burden.

Consider what Jean Hartnett, 53, of Omaha, Nebraska, and her eight siblings went through after their 88-year-old mother had a stroke in February 2021 while shopping at Walmart.

At the time, the older woman was looking after Hartnett’s father, who had kidney disease and needed help with daily activities such as showering and going to the bathroom.

During the year after the stroke, both of Hartnett’s parents — fiercely independent farmers who lived in Hubbard, Nebraska — suffered setbacks, and medical crises became common. When a physician changed her mom’s or dad’s plan of care, new medications, supplies, and medical equipment had to be procured, and new rounds of occupational, physical, and speech therapy arranged.

Neither parent could be left alone if the other needed medical attention.

“It wasn’t unusual for me to be bringing one parent home from the hospital or doctor’s visit and passing the ambulance or a family member on the highway taking the other one in,” Hartnett explained. “An incredible amount of coordination needed to happen.”

Hartnett moved in with her parents during the last six weeks of her father’s life, after doctors decided he was too weak to undertake dialysis. He passed away in March 2022. Her mother died months later in July.

So, what can older adults and family caregivers do to ease the burdens of health care?

To start, be candid with your doctor if you think a treatment plan isn’t feasible and explain why you feel that way, said Elizabeth Rogers, an assistant professor of internal medicine at the University of Minnesota Medical School. 

“Be sure to discuss your health priorities and trade-offs: what you might gain and what you might lose by forgoing certain tests or treatments,” she said. Ask which interventions are most important in terms of keeping you healthy, and which might be expendable.

Doctors can adjust your treatment plan, discontinue medications that aren’t yielding significant benefits, and arrange virtual visits if you can manage the technological requirements. (Many older adults can’t.)

Ask if a social worker or a patient navigator can help you arrange multiple appointments and tests on the same day to minimize the burden of going to and from medical centers. These professionals can also help you connect with community resources, such as transportation services, that might be of help. (Most medical centers have staff of this kind, but physician practices do not.)

If you don’t understand how to do what your doctor wants you to do, ask questions: What will this involve on my part? How much time will this take? What kind of resources will I need to do this? And ask for written materials, such as self-management plans for asthma or diabetes, that can help you understand what’s expected.

“I would ask a clinician, ‘If I chose this treatment option, what does that mean not only for my cancer or heart disease, but also for the time I’ll spend getting care?’” said Ganguli of Harvard. “If they don’t have an answer, ask if they can come up with an estimate.”



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Why New DTCC Directive Is Both Bullish and Bearish By U.Today

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U.Today – In a recent ruling, the Depository Trust and Clearing Corporation (DTCC) made a decision against exchange-traded funds (ETFs) that are exposed to or any other cryptocurrencies.

DTCC plans to change collateral policy

Consequently, the corporation has earmarked April 30 as the day to implement changes to its collateral value for these special securities during its annual line-of-credit facility renewal.

DTCC sees this as an avenue to revolutionize position values in the collateral monitor. For spot Bitcoin ETFs like BlackRock (NYSE:)’s IBIT, Fidelity Investment’s FBTC and other crypto ETPs, this would result in a 100% reduction in their collateral value.

Cryptocurrency enthusiast K.O. Kryptowaluty believes that this new development applies to only inter-entity settlement within the line of credit system. He further explained that the use of crypto ETFs for lending and as collateral in brokerage activities will continue without any consequences.

However, he pointed out that it is highly dependent on individual brokers’ risk tolerance.

DTCC’s collateral policy affects ETF investors

According to Autism Capital, DTCC’s announcement could potentially translate to less liquidity but also more risks for spot crypto ETF investors.

Looking on the bright side, such a decision may equally contribute to mitigating the negative interference of Wall Street companies in the growing crypto ETF niche. Only time will tell how it turns out for investors and other parties involved.

This article was originally published on U.Today





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Aircraft seat shortages hamper airlines’ efforts to upgrade planes

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A shortage of aircraft seats is adding to bottlenecks in the industry’s supply chains, hampering plans by airlines to refurbish cabin interiors and unveil new upgraded planes. 

Aircraft seats, in particular those for first and business class cabins, are among the most important differentiators for airlines in their bid to draw passengers. A combination of factors, including tighter certification rules and shortages of labour stemming from the pandemic, is continuing to hold up their production.

The supply chain wobbles have come as airlines race to unveil new cabins as the industry recovers from the impact of the pandemic. Lufthansa in Germany this month unveiled a new set of long-haul cabins as part of a €2.5bn investment, which was significantly delayed because of supply chain problems. 

Extensive refurbishment programmes by several airlines, including the biggest ever $2bn retrofit programme from Emirates, have added to the demands on suppliers. 

French jet engine maker Safran, which is also one of the biggest suppliers of aircraft seats, said on Friday that business-class seat deliveries fell 25 per cent in the first quarter as some shipments slipped into the second quarter. 

Olivier Andriès, chief executive, said certification rules by regulators had become “much more demanding” and were impacting the “entire interior industry”.  

Premium seats are “really important to airlines, they are part of the differentiation for passengers but are also really complicated to engineer, to manufacture and to certify”, said Nick Cunningham, analyst at Agency Partners. 

Executives from Boeing and Airbus said this week that the industry’s supply chain remains constrained, including supplies of cabin equipment.

Guillaume Faury, Airbus chief executive, said the company was still struggling with supplies of cabin equipment, not just limited to seats, as well as with supplies of aerostructures. “It reflects the diversity of the difficulties and challenges in the supply chain.”

Boeing, which is struggling to contain its latest crisis following the mid-air blowout of a section of one of its 737 Max aircraft in January, identified seats as a specific reason for constrained production of its 787 wide-body plane.

“Seat suppliers out there are in shorter capacity. A lot of that is buyer furnished, but nevertheless, it holds up an aeroplane,” Boeing chief executive Dave Calhoun told analysts. 

Mark Hiller, chief executive of Recaro Aircraft Seating, the world’s leading economy class seat maker, said electronics shortages for embedded in-flight entertainment systems were continuing to hamper deliveries of seats. Airlines typically order the electronics and provide them to the seat manufacturers for installation. 

“The increased demand and the ramp up in production means even if [suppliers] are delivering more than a year ago, the demand has increased significantly more and therefore there are still bottlenecks,” Hiller told the Financial Times. 

The company has introduced extra shifts, also on weekends, to cope with later deliveries. It has also installed seats on aircraft that are still waiting for the full complement of electronics. Recaro is having to work on a “bespoke solution” for every second customer order, he said, while declining to name any one in particular. 

Cunningham said: “Right now, there is such a recovery going on in long-haul air traffic in particular that it is a collective problem for everybody. What airlines really want is to get their new aircraft.”

Sir Tim Clark, the chief executive of Emirates, told the FT in an interview earlier this year that he was frustrated with the state of the aviation supply chain.

“I’m getting a little bit tired of hearing, years after Covid finished, that we’ve still got issues today . . . we are currently retrofitting at vast expense over 160 of our older aircraft. So I would have thought that any supply chain into that kind of organisation would be set forever,” he said.



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These incarcerated women are leaving prison with a certified license to make people feel beautiful. The program ‘gave me a chance to feel human again’

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Stephanie F., who asked Fortune to withhold her last name for privacy concerns, was 39 when she became incarcerated in 2018 at Coffee Creek Correctional Facility, a medium-security women’s prison in Oregon that holds anyone from drug charges to those serving life sentences without parole. At the time, she said, “I never really took care of myself,” and needed to learn to “control my temper and keep my mouth shut.” 

Five years into her sentence, she was desperate for a fresh start. Her release date in 2032 was a decade away, and prison could be demoralizing. That’s when she met another woman in custody who was enrolled in a cosmetology program at Coffee Creek, which awards graduates a state license in hair, esthetics and nails to practice as estheticians and cosmetologists upon release. It changed everything for her. 

“I saw this transformation that this person made and who they became,” she told Fortune in a phone interview, “and I just thought, I want that for my life. I want to be a better person.” 

Now age 45, Stephanie is 11 months deep in the two-year program, and is on her way to join a cohort of 36 graduates, nine of whom have been released. The corrections facility has been in partnership with skin therapy company Dermalogica on the program since 2019, with an aim to help women run their own businesses or secure a liveable income upon release. When she’s out, she’ll join the flock of about 650,000 people released from state and federal prisons every year—some of whom find freedom with “little more than a few dollars and a bus ticket,” according to a statement President Joe Biden released while proclaiming April as “Second Chance Month.” 

Historically, Americans with criminal records face an unwelcoming labor market. According to a report from the Bureau of Justice Statistics that tracked 50,000 people after leaving prisons in 2010, over a third found no employment four years after their release, and at any given time, no more than 40% were employed. But the tides are turning: in a survey of 1,000 job seekers conducted by Indeed, 92% said they would be comfortable with a co-worker who has a nonviolent criminal record. Companies, like Dermalogica, are committing more to equity efforts, too. In 2022, railroad company Union Pacific began hiring formerly incarcerated people, citing evidence that employment helps them avoid further arrests and makes their children less likely to be imprisoned. 

For formerly incarcerated people, re-entry into society is one of the “most significant challenges facing the criminal justice system,” according to a National Institute of Justice report. And with 78,000 women being released from prison each year, while the number of women entering prisons and jails is growing, it’s a problem that deserves attention. 

In addition to employment, the report states, challenges include securing housing and managing mental illness, family reunification, childcare and parenting. In fact, the majority of incarcerated women are parents to children under the age of 18. 

For Dermalogica’s partnership with Coffee Creek, the intention is to help women come out of prison with a few of those bases covered, namely the ability to earn a livable wage and provide support to their families. The partnership involves a 1,835-hour certification program in hair, skin and nails to cohorts of 20 women at a time.

The structure of the program involves two instructors from Dermalogica staff, which the prison hires on contract to teach monthly classes via Zoom while the women in custody practice techniques on each other and mannequins. They also study theory through textbooks and workbooks that the company provides. Dermalogica doesn’t release how much funding goes into the program, but provides upwards of 50 products like facial cleansers, exfoliators, moisturizers, brushes and LED machines for advanced skin care treatment twice a year, along with study materials for the license certification exams at the end of the program. 

In class, the women study how to treat different skin conditions, while also performing hands-on treatments. When a student completes 1,835 hours, another can begin on a rolling basis. The aim is to give women in custody a skillset they can rely on once they’re released—and that they can apply in a growing industry.

The professional skin care industry is growing at an accelerated rate, Dermalogica CEO Aurelian Lis told Fortune, adding that the program “works all around to train students for roles that will be more in-demand than ever.” 

Sure enough, the industry is growing: the professional skin care market size was valued at about $12.4 billion in 2022, and it’s forecast to grow to $15.3 billion by 2029, according to a Market Reports World report on LinkedIn. The Bureau of Labor Statistics also expects skin care specialists to grow 9% from 2022 to 2032, a rate that’s much faster than the average for other occupations. But the classes, which also cover entrepreneurship and soft skills, have been offering much more than just a good job outlook.

Lis described how the program is unique to a correctional facility because “it’s the only place that adults in custody are able to touch each other.” With the no-touching rule, “you lose that humanity,” she added, and it’s something many of the women struggle with. Stephanie agreed, noting she believes it’s normal human behavior to want to hug your friends and that physical touch can improve mental health.

Sarah E., a graduate of the program who spent five years in the facility until her release in February 2020, told Fortune that without the support and friendships she formed in class, she “might not be alive today,” adding that the program “gave me a chance to feel human again.”

“Sometimes our families just can’t support us in that place,” she said. “They’re living life outside, and we’re stuck in this box. We’re worried about what’s going on with our families and their lives, and the support and care from people in the same situation is huge.”

It’s not surprising the no-touch rule needs to bend for the program, where the incarcerated women learn skills like facials, chemical peels, hair coloring and styling and manicures, while practicing the services on other adults in custody and even prison staff. Practicing services on staff, Stephanie said, improved interactions that are often dehumanizing for both sides: she has a tendency to put “cop labels” on the guards, while she said they can often be “condescending.”

“It’s hard for them to see us as regular people,” she said.

But when she performs services that require communication and mutual agreements with staff members, “it lets them see that I’ve made choices in my life, but it doesn’t mean I’m not going to be their neighbor someday.” 

Tammy Kennedy, a trainer for the cosmetology program at the facility, told Fortune that staff can request haircuts, facials and skin treatments at beauty school prices, which are often a fraction of what salons charge. Other adults in custody can get treatments for free or for a small fee. Treating prison staff as clients has been a positive experience for the women, she said, because they “have to rise to a different level and learn to have appropriate conversations with people that aren’t about the stuff happening in the facility.” It puts a focus on conversational soft skills that are vital for salon workers.

Beyond that, the services are a way for women to earn a livable wage immediately upon their release.

That’s one reason the work resonated for Sarah, who felt the other courses offered at the facility—like call center training with the Department of Motor Vehicles and sewing courses—wouldn’t help her provide enough for her three kids, aged 22, 16 and 12. 

Before prison, she was working in the food industry, where she earned about $10 an hour. Now, she makes more than twice that, plus tips, but the beginning of her career was rough because of the pandemic. Sarah was released in February 2020, just as the pandemic had begun derailing industries that depend on close contact, like hers. 

In September of that year, she secured a job in the esthetics field, and when the salon shuttered its doors two years later in November 2022, she started a new job at a plastic surgery office in Eugene, Oregon, where she now works as an esthetician and medical assistant on services like Botox, fillers, facials, and one of her favorite treatments, chemical peels.

Along with a license to practice beauty, Sarah walked away from prison with friendships she believes will be “life lasting.” One of the women she graduated with, she said, hangs out with her at her house and spends time with her kids—and also helps her save upwards of $300 by doing her hair for free. 

The community the women gained from classes has also inspired them to give back to other women who might be having a hard time. For Stephanie, who has a 15-year-old daughter waiting for her outside prison, being incarcerated is difficult when she thinks of the events she’s missing in her daughter’s life, like first days of school and prom. When “you’re an incarcerated mom,” she said, “everything is limited. But you know that appearance can matter to them so much.” She hopes to give back to the program by offering to help other kids with incarcerated parents get ready for prom. 

For her part, Sarah believes the program’s skills can help sustain women into “life outside of those walls,” especially considering that many women are released with low credit scores, poor rental histories or work experiences. “It’s such a beautiful program,” she said, “I don’t know if I would have survived prison without it.”



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