GeriPal - A Geriatrics and Palliative Medicine Podcast – Details, episodes & analysis

Today's topic on palliative care for sickle cell disease may raise eyebrows with some of you.  You might think, wait, now we're doing sickle cell?  On top of liquid cancer and transplant, kidney disease, liver disease, and survivorship?  Where does it end?  Do we have staff for all of this?

Well I implore you, dear listeners, to keep an open mind and listen to this podcast.  Our guests do a fabulous job of stating the case for palliative care in sickle cell disease, to the point that we ask: why haven't we been doing this all along?

Our guests today are Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa, three palliative care docs who have been advancing the practice in palliative care for sickle cell for a long time. Our discussion ranges from what is sickle cell; to outcomes; to social determinants and discrimination; to PCAs, ketorolac, and bupenorphine; and to the importance of the interdisciplinary team.

I would also encourage you to check out Eberechi's NEJM Perspective on Involving Palliative Care to Improve Outcomes in Sickle Cell, which includes a table of the challenges and action items needed to move the field forward. I'd also encourage you to sample this AAHPM Flight on the same topic (we learned that a flight is similar to a flight of drinks - a quick sampling).

As Eberechi notes at the start, we should be grateful for the community of people who are advancing palliative care in sickle cell.  Thank you for being a friend (song hint!).

-Alex Smith

Last month, the "Billing Boys"—Chris Jones and Phil Rodgers—joined the GeriPal podcast to demystify medical billing and coding in palliative care. This month, we're back with part two, shifting the focus to geriatrics. While billing and coding may not be the most exciting topic, they're essential for ensuring fair reimbursement for the complex care we provide and for supporting the work of our interprofessional teams, many of whom can't bill directly for their services. When we underbill or leave money on the table, we not only shortchange ourselves but also devalue the critical role of geriatrics in the healthcare system.

This time, we're joined by experts Peter Hollmann, Ken Koncilja, and Audrey Chun to dive into key questions: Why does billing matter, and who does it benefit? What's the difference between CPT, E&M, and ICD-10 codes (if you need a refresher, check out our chat with the Billing Boys here)? We explore how to think about billing for complexity versus time, and unpack new and impactful codes like the Cognitive Assessment and Care Plan Services code (99483), advance care planning (ACP) billing codes, and G2211, which acknowledges the added work of managing patients with chronic conditions. We also highlight the new APCM G-codes for 2025, a set of HCPCS codes that could provide substantial financial support for interdisciplinary teams in geriatrics.

Finally, we discuss the advocacy behind these codes. The American Geriatrics Society (AGS) plays a vital role on the AMA's RUC committee, helping to improve reimbursement for the complex care of older adults. Tune in to this week's GeriPal podcast for expert advice, practical strategies, and insights that will help you optimize your billing practices and sustain the future of geriatrics!

Here are some of the resources we also talked about:

• The physician fee schedule look up tool Wwere you can find out CMS expected charge based off where you practice 

• AGS's annual coding update

• Geriatrics at Your Fingertips, which has a one-pager on billing

• Medicare Claims Processing Manual

👉 NOTE:
Eric and Alex are giving UCSF Geriatrics Grand Rounds on Wednesday November 5, 4-5pm Pacific Time.  The topic is, "What we've learned from nearly 400 GeriPal podcasts." Join us! This will be highly interactive. If you'd like to join via Zoom, you can use this link: https://ucsf.zoom.us/webinar/register/WN_qLJSlL0wSlq3SwASXw_S4w.  Or join in person, grand rounds are open to all! We will be speaking at the main UCSF Campus, 500 Parnassus Ave, in the Health Sciences West Building, 3rd floor, room 303.  You can ask for directions when you arrive at UCSF, or email Alex to arrange for someone to meet you at the front (https://profiles.ucsf.edu/alexander.smith).  

In today's podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment.  We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including:

• What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment?

• Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it?

• Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle.

• Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions)

• How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)?

• How long does it take to conduct a comprehensive geriatrics assessment?

• What's the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment? 

• What are the outcomes we hope for from the comprehensive geriatrics assessment?  

That final point, about outcomes, bring's us to Eric Wong's study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics).

As an aside, as the editor at JAGS who managed this manuscript, I will say that we don't ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what 'CGA provided in the combination of acute care and rehab was non-dominated' means).

We published this article because its bottom line is of great interest to geriatricians.  In Eric's study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting.

And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it's cost effective for the health care system).

I'll close with a couple of "mic drop" excerpts from Thiago's accompanying editorial:

Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab. 

Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.

 -Alex Smith

Hospitals are hazardous places for older adults. These hazards include delirium, malnutrition, falls, infections, and hospital associated disability (which about ⅓ of older adults get during a hospital stay).  What if, for at least some older adults who need acute-level care, instead of treating them in the hospital, we treat them at home? That's the focus of the hospital-at-home movement, and the subject we talk about in this week's podcast.

We talk with Bruce Leff and Tacara Soones about the hospital-at-home movement, which has been shown to reduce costs, improve outcomes and improve the patient experience. In addition to discussing these outcomes, we also discuss:

• The history of the hospital-at-home movement.

• The practicalities of how it works including who are good candidates, where does it start (the ED?), what happens at home, do you need a caregiver, what happens if they need something like imaging?

• How is it financed and what comes next?

If you are interested in learning more and meeting a community of folks interested in hospital-at-home, check out the hospital-at-home user group at hahusersgroup.org or some of these publications: 

• Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of Int Med. 2020

• Hospital at Home-Plus: A Platform of Facility-Based Care. JAGS

• Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Network Open

The comprehensive geriatric assessment is one of the cornerstones of geriatrics.  But does the geriatric assessment do anything?  Does it improve outcomes that patients, caregivers, and clinicians care about?

Evidence has been mounting about the importance of the geriatric assessment for older adults with cancer, the subject of today's podcast.  The geriatric assessment has been shown in two landmark studies (Lancet and JAMA Oncology) to reduce high grade toxicity, improve patient and caregiver satisfaction, and improve completion of advance directives (can listen to our prior podcast on this issue here). 

Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their guidelines for care of older adults to state that all older adults receiving systemic therapy (including chemo, immuno, targeted, hormonal therapy) should receive geriatric assessment guided care. 

We talk about these new guidelines today with William Dale, a geriatrician at City of Hope and lead author of the guideline update in the Journal of Clinical Oncology, Mazie Tsang, palliative care/heme/onc physician-researcher at Mayo Clinic Arizona who authored a study of geriatric and palliative conditions in older adults with poor prognosis cancers published in JAGS, and John Simmons, a retired heme/onc doctor, cancer survivor, and patient advocate.  We talk about:

• What is a practical geriatric assessment and how can busy oncologists actually do one? (hint: 80% can be done in advance by patients or caregivers)

• Why is it that some oncologists are resistant to conducting a geriatric assessment, yet have no problem ordering tests that cost thousands of dollars?

• What can you do with the results of a geriatric assessment?

• How does the geriatric assessment lead to improved completion of advance directives, when the assessment doesn't address advance care planning/directives at all?

• How does palliative care fit into all this?  Precision medicine?

• What groups are being left out of trials?

• What are the incentives to get oncologists and health systems to adopt the geriatric assessment?  

And Mazie, who is from Hawaii, requested the song Hawaii Aloha in honor of the victims of the wildfire disaster on Maui.  You can donate to the Hawaii Red Cross here.

Aloha,
-@AlexSmithMD

Additional Links:

Brief ASCO Video of how to conduct a practical geriatrics assessment
Brief ASCO Video of how to use the results of a practical geriatrics assessment
Time to stop saying the geriatric assessment is too time consuming

How do people react when they hear they have a serious illness?  Shock, "like a car is rushing straight at me" (says Bill Gardner on our podcast).  After the shock?  Many people strive, struggle, crawl even back toward a "normal" life.  And some people, in addition or instead, engage in deep introspection on how to make meaning or live with or understand this experience of serious illness. 

Today we talk with deep thinkers about this issue.  Bill Gardner is a psychologist living with advanced cancer who blogs "I have serious news," Brad Stuart is an internist and former hospice director whose book is titled, "Facing Death: Spirituality, Science, and Surrender at the End of Life," and Juliet Jacobson is a palliative care doc who wrote a paper finding that geriatricians do NOT consider aging a serious illness.   We have a wide ranging conversation that touches on how to place aging, disability, and multimorbidity in the context of serious illness conversations, "striving toward normal," stoicism, existentialism, psychedelics, the goals of medicine, medical aid in dying and more.  We could have talked for hours! And I get to play a Bob Dylan song that's been on my bucket list to learn.

Enjoy!

-@AlexSmithMD

Additional links:

Bill Gardner's article about MAID in Comment Magazine
https://comment.org/death-by-referral/

Bill Gardner's articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/
https://mbird.com/religion/testimony/in-the-electors-school/

Brad Stuat's website:
https://bradstuartmd.com

Juliet mentioned:
On existential threat and terror management:
The Worm at the Core: On the role of death in life by Soloman, Greenberg, and Pyszczynski

On how existential threat is stored in the brain.
https://pubmed.ncbi.nlm.nih.gov/31401240/

Papers on "striving toward normalcy" in the setting of serious illness
https://pubmed.ncbi.nlm.nih.gov/36893571/
https://pubmed.ncbi.nlm.nih.gov/35729779/

I hear the word dignity used a lot in the medical setting, but I'm never sure what people mean when they use it.  You'd imagine that as a seasoned palliative care doc, I'd have a pretty good definition by now of what "maintaining dignity" or "loss of dignity" means, but you'd be sadly wrong.

Well that all changes today as we've invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast.  Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches.

We talk with Harvey about how he defines "dignity" and how we can understand what it means to our patients. We also talk about easy and quick ways to address dignity and personhood by using the Patient Dignity Question (PDQ), which asks "what do I need to know about you as a person to give you the best care possible."  In addition, we talk with Harvey about some other recent publications he has written, including one on "Intensive Caring" and one on the "Platinum Rule" (do unto others as they would want done unto themselves).

So take a listen and if you are interested in learning more, check out these wonderful links:

• Harvey's latest book is called, Dignity in Care: The Human Side of Medicine

• Intensive Caring: Reminding Patients They Matter 

• Michael J. Fox gives patients hope there may be a place that illness doesn't touch

• Depression is a Liar

• Why is Being a Patient Such a Difficult Pill to Swallow

• Better Patient Care Calls for a 'Platinum Rule' to Replace the Golden One. Scientific American 

• Letter to the Editor: Response to Downar et al. Medical Assistance in Dying and Palliative Care: Shared Trajectories 

It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab).  Praised by the FDA, Alzheimer's Association (AA), and Pharma as a "game changer", but derided by others for the drug's lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words "rife with irregularities". Instead of Biogen's expected billions of dollars of revenue from Aduhelm, they brought in only $3 million in revenue for all of 2021 (here is my Twitter summary of this fiasco).

The outlook on amyloid antibodies are looking brighter though in 2023.  Phase III studies for lecanemab and donanemab have been published showing less worsening of cognition and function receiving these agents versus placebo. This led the FDA to give full approval for lecanemab, which will likely be followed by full approval of donanemab sometime this year. However, as noted in our editorial published with the donanemab trial, the modest benefits of amyloid antibodies would likely not be questioned by patients, clinicians, or payers if amyloid antibodies were low risk, inexpensive, and simple to administer.  However, they are none of these. 

So what is the role of individuals like geriatricians in prescribing amyloid antibodies and caring for individuals who are receiving them?  We invited three geriatricians and memory care doctors, Nate Chin, Sharon Brangman, and Jason Karlawish, to talk about this question and many others swirling around on how to safely prescribe these drugs and manage patients on them (like what to do about anticoagulation).

Lastly, we also spend a little bit of time talking about the NIA-AA draft statement on redefining Alzhiemers disease.  There is a lot to digest with these draft clinical guidelines but the big change from the 2018 guideline is moving Alzheimers to a biological diagnosis (biomarker evidence only) not just for a research framework but now from a clinical one.  One outcome would be a very large population of older adults with normal cognition could now be classified as having Alzheimer's disease (maybe about a 1/3 of cognitively normal 75 year olds based on PET). So if you have thoughts on the matter, please give your feedback here to the NIA and AA. https://aaic.alz.org/nia-aa.asp

By: Eric Widera

Insomnia. We've all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you're not falling asleep as you have a busy day coming up. Insomnia sucks.  Chronic insomnia sucks even more.

For those with serious illness, sleep problems and insomnia are all too common.  Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia.

We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).

There's a saying, "never let a crisis go to waste."  The pandemic was horrific in many ways.  One positive change that came about was the lifting of restrictions around the use of telemedicine.  Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic.  Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others.  So now that the emergency response has ended, what's to be done? 

In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brook Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness.  This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world.  Now is the time to act, dear listeners!  You can:

• Write an Op-Ed to your local paper as Carly Zapata and colleagues did.  Start with a story as Carly did in her Op Ed.  Stories trump data.

• Write to your congressperson. See the AAHPM Legislative Action Center https://www.votervoice.net/AAHPMORG/home

• Write to the DEA, with guidance from AAHPM's comments to the DEA March 2023.

• Advocate for the CONNECT for Health Act, which would permanently expand access to telehealth for Medicare beneficiaries: https://www.schatz.senate.gov/imo/media/doc/connect_for_health_act_2023_summary1.pdf

Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth.  Enjoy!

-@AlexSmithMD