Arizona became the first state to revamp its Medicaid regulations to make it easier for ride-sharing companies to participate in its nonemergency transportation benefit.

This article was first published on Thursday, September 26, 2019 in Kaiser Health News.

By Phil Galewitz

Arizona Medicaid Director Jami Snyder heard many complaints about enrollees missing medical appointments because the transportation provided by the state didn't show or came too late.

So this summer she hatched a solution familiar to millions of Americans looking for an efficient ride: She turned to Uber and Lyft.

Arizona became the first state to revamp its Medicaid regulations to make it easier for ride-sharing companies to participate in its nonemergency transportation benefit. Under the changes, Arizona eliminated several safety rules such as requiring all drivers to undergo drug testing and first aid training.

The strategy has added thousands of vehicles to the fleet serving Arizonans on Medicaid, nearly 24% of the state's 7 million residents.

"It seemed like an obvious solution," Snyder said. "So far, our anecdotal reports have been very positive."

As they seek to lower costs and improve care, Medicaid and other insurers have begun to examine the transportation needs of patients — along with other so-called social determinants of health such as adequate food and housing. Whether states save money remains to be seen.

In 2017, more than 2 million Medicaid enrollees under age 65 ― about 4% of the program's members — delayed care because they lacked transportation, according to a federal survey.

Lyft is working with about 35 state Medicaid programs, according to LogistiCare, one of the nation's largest Medicaid transportation brokers. Uber works with Medicaid only in Arizona.

Lawmakers in Florida and Texas this year also relaxed state regulations to make it easier for Uber and Lyft to provide services for appropriate Medicaid patients. That service is expected to begin early next year.

Uber and Lyft can't handle all Medicaid transportation demands because they generally don't have enough drivers with cars fit to ferry people with serious disabilities, such as those who use a wheelchair. But Arizona's Snyder said many Medicaid enrollees are healthy enough to use a typical ride-sharing service.

Van Means, executive director of a company that Arizona pays to arrange transportation for Medicaid enrollees, said the expanded options help even some patients who can't use them.

"It gives us way more supply, it's faster and frees up space [in specialized transportation] for people who need more substantial help such as those in wheelchairs," he said.

In most traditional Medicaid transportation programs, patients need to reserve rides days ahead and then often must share a van. In contrast, the ride-sharing companies need little advance notice and can easily take solo passengers.

To ease the use of Uber and Lyft, states generally waive safety requirements that are standard for more traditional transportation. Those include mandates that drivers undergo drug testing and learn first aid and CPR. State officials said such mandates are not necessary since Uber and Lyft serve ambulatory enrollees who likely are in better health than those needing specialized transportation.

The ride-sharing companies already work with hospitals and health systems across the country, but participating in Medicaid could bring them millions of more riders.

Unlike typical Uber or Lyft riders, Medicaid enrollees don't order rides on their smartphones. Instead, these patients will continue to request transportation services by phone or computer through their health plan or a Medicaid transportation broker.

The Medical Transportation Brokerage of Arizona said about 15% of rides taken by Medicaid recipients this summer relied on Uber and Lyft.

So far, though, Means said the brokerage hasn't found the service substantially cheaper in most areas of the state.

Arizona officials did not have an estimate of cost savings.

Officials at Atlanta-based LogistiCare said working with Lyft in dozens of cities has added vehicles and helped speed service.

"The ride-sharing companies are cost-effective and for curb-to-curb, urban or suburban short-distance trips," said Effie Carlson, a LogistiCare executive vice president.

But she cautioned that the companies are not the ideal option for enrollees who need extra time getting in and out of their house because drivers typically leave within five minutes of arriving.

Uber and Lyft are often cheaper than using taxis or other private transportation companies, but not always. She noted that when companies raise prices during peak-traffic hours, alternatives may be less expensive.

Carlson said her company decides whether ride-sharing services or more traditional transportation is most appropriate based on the health information provided about each Medicaid enrollee.

The Medicaid transportation benefit varies by state but typically includes rides by taxi services, wheelchair vans, private vehicles and public transportation. Enrollees are eligible for the services if they do not have another means of transport.

Despite states' growing interest in expanding transportation options, a University of Pennsylvania study, published last year in JAMA Internal Medicine, found providing ride-sharing services did not improve the no-show rate for primary care appointments among Medicaid patients in West Philadelphia. The no-show rate among patients offered free rides was 36.5%, compared with 36.7% for those who weren't offered free rides.

Krisda Chaiyachati, co-author of the study and a University of Pennsylvania associate professor of medicine, said reliability of transportation is not the only factor determining whether Medicaid enrollees show for medical appointments. "People on Medicaid tend to live more chaotic lives, so they may be more OK with missing primary care appointments," he said, referring to how low-income people often fear missing work, or have difficulties arranging child care and other necessities.

Still, Chaiyachati envisions Uber and Lyft playing larger roles for Medicaid.

"Their cars can be everywhere, and having a dispatcher draw upon that network is a no-brainer," he said. "It may not solve the transportation needs for everybody, but it's certainly an answer for many."

Megan Callahan, vice president of health care at Lyft, said she expects more states to adopt ride-sharing.

"I think what we are seeing is the beginning of a domino effect," she said. "Our overall driver availability and speed are the big advantages that will have an impact on Medicaid members' satisfaction."

Uber officials said in about dozen cities they are developing a fleet of drivers trained to work with patients who must travel with fold-up wheelchairs, walkers and scooters.

"From a cost standpoint, we can save states significant dollars," said Dan Trigub, head of Uber Health.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Managing the condition requires other essential, often lifesaving medical supplies. And patients frequently face hurdles in getting access to those supplies — hurdles put in place by insurance companies.

This story was first published on Tuesday, September 24, 2019 in Kaiser Health News.

By Bram Sable-Smith

In the first three months after getting his Dexcom continuous glucose monitor, Ric Peralta said, he reduced his average blood sugar level by 3 percentage points.

"It took me from not-very-well-managed blood sugar to something that was incredibly well managed," said Peralta, a 46-year-old optician in Whittier, Calif., who was diagnosed with Type 1 diabetes in 2008.

Peralta was so enthused that he became a "Dexcom Warrior," a sort of grassroots spokesman for the product. It became hard to imagine life without his new monitor, a device that lets him track the trends in his blood sugar 24 hours a day on his smartphone. And yet, he has spent weeks at a time without the device over the past year because of insurance restrictions. Physician groups and patients consider those rules burdensome, but insurers defend them as necessary.

Diabetes activists and legislators have started to focus attention on the surging price of insulin, leading to legislative pushes, lawsuits and congressional hearings. But insulin isn't the only thing people with Type 1 diabetes are struggling to get. Managing the condition requires other essential, often lifesaving medical supplies. And patients frequently face hurdles in getting access to those supplies — hurdles put in place by insurance companies.

A Life-Changing Device
 

Peralta learned about the latest version of the Dexcom continuous glucose monitor from the mother of one of his patients. He visited the company's website and, within two weeks, the device was shipped to his front door.

"I still didn't 100% appreciate exactly how it was going to change my life," Peralta said. "It was amazing."

Typically, people with Type 1 diabetes check their blood sugar by drawing a drop of blood from a finger and placing it on a disposable test strip that's read by a blood glucose meter. Doctors suggest checking blood sugar this way between four and 10 times a day. These readings are crucial for helping people with diabetes manage their blood sugar — keeping it from getting too low, which can lead to sudden seizures and loss of consciousness, as well as from getting too high, which can cause vision loss and nerve damage and can even, over time, lead to amputations.

Instead, Peralta's continuous glucose monitor gave accurate blood sugar readings every five minutes. That's 288 readings a day, or about 278 more readings than even the most conscientious patients get the old-fashioned way.

"When I had to do the old-fashioned finger prick test, I was only doing that right before I ate, so I could see how much [insulin] I was supposed to take," Peralta said. (People with Type 1 diabetes have to take multiple daily shots of insulin to keep their blood sugar within the normal range because their bodies stop producing the naturally occurring hormone.)

"I didn't realize that I had rather severe [blood sugar] peaks and valleys in between my mealtimes," Peralta said.

Tighter control of blood sugar can reduce the risk of heart disease, kidney failure and nerve damage. For Peralta, it also offered peace of mind.

The monitor sounds an alarm when his blood sugar gets dangerously low; Peralta said his co-workers have started bringing him sugary snacks when they hear the alarm, to help him raise his blood sugar back to normal. When he takes his family on road trips — a favorite activity — he no longer has to worry about the possibility of passing out while driving.

"It even syncs with my car so I can just say, 'Siri, what's my blood sugar?' And it will come over the car stereo system," Peralta said. "I'm safe for my family."

Prior-Authorization Requirements
 

When common chronic conditions such as diabetes are well controlled, it prevents worsening disease and saves money for the health system and the patient.

But Peralta said his efforts to use this new tool consistently to manage his diabetes have been stymied by insurance problems that began about a year ago.

The newest Dexcom continuous glucose monitor has three parts: a sensor that measures glucose levels, a transmitter that sends out the sensor's readings wirelessly and a receiver that displays those readings on a screen.

For each of these parts, Peralta needs "prior authorization" — a requirement that his physician get approval from his insurance company before prescribing the device.

The Dexcom sensors last about 10 days each, and Peralta's insurance allows him to buy a three-month supply at a time. But he also has to get prior authorization for each supply, meaning every three months his doctor needs to reconfirm with his insurance company that the sensors are medically necessary. Same goes for the device's transmitters — which last about six months each.

"I have to jump through hoops and they have to jump through hoops to get information from my insurance to get authorization," Peralta said in frustration, adding that "for the last year, basically every time there's been something that's gone wrong."

"Prior authorizations are in place to protect patients, to improve safety and to try to make sure that the care they receive is as safe as possible and also as affordable as possible," said Kate Berry of the trade group America's Health Insurance Programs.

But to Ric Peralta, the requirement is a burden.

The most recent snafu happened in March. Peralta ordered a new supply of sensors directly from Dexcom but said the company submitted a request for approval of a new transmitter as well. And because his insurance approves the sensors and transmitters on different authorization timelines, the whole claim was denied. Peralta estimates he spent four hours on the phone with Dexcom and his insurer over the next month and a half to sort it all out. During that time he had to revert to finger-stick tests.

"It's maddening," Peralta said. "If I do not have my proper management of this disease, I'm going to die from it. And they're making it as difficult as possible."

A Burden On Doctors, Too
 

Prior authorizations have become a major concern of physicians across the U.S. health care system, as evidenced by a December survey by the American Medical Association.

Of the 1,000 physicians surveyed, 91% said prior authorizations "have a negative impact on patient clinical outcomes"; 75% said the requirements "can at least sometimes lead to patients abandoning a recommended course of treatment"; and 28% said the prior-authorization process had "led to serious or life-threatening events" for their patients.

"In my practice, we have five individual physicians, and we hired five full-time employees whose primary duty is obtaining prior authorization and dealing with insurance companies," said Dr. Bruce Scott, an otolaryngologist from Kentucky and speaker of the AMA House of Delegates.

"Prior authorization is a burden on providers and diverts valuable resources," Scott said. "That's a problem."

The AMA has even created a website that catalogs stories of patients and providers who say they've struggled to gain access to important medical products and procedures because of problems with getting prior authorization from insurers — everything from pain medication for a cancer patient to X-rays in the ER. Scott said the AMA doesn't expect insurers to completely do away with requirements for prior authorization, "but we believe that it should be focused and that it should be better planned."

The American Association of Clinical Endocrinologists — an organization of the physicians whose specialty is often associated with diabetes treatment — goes further.

"We feel that physicians that are specialists in endocrine disease should not be required to fill out prior authorizations for endocrine treatments," said Dr. Scott Isaacs, an endocrinologist from Atlanta and a member of the board of directors of AACE.

"It's a huge burden for the patients trying to get this sorted out. Sometimes it's red tape; sometimes it's a true denial," Isaacs said. "It's a huge burden for the doctors as well, and the doctors resent it."

Berry, of America's Health Insurance Programs, acknowledges there's room for improvement in the prior-authorization process. In fact, in January 2018, the AMA and AHIP signed a consensus statement identifying five areas for improvement. It was co-signed by the American Hospital Association, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association.

Who Bears The Greatest Burden?
 

For Ric Peralta, the ultimate burden of getting all these prescriptions filled falls on him and other patients like him.

After his latest mix-up with the sensors in March, he discovered the battery in his transmitter had died.

Peralta made another frustrated call to Dexcom, and recently got a complimentary transmitter to get him back on the system while his formal order goes through the approval process.

"I'm quite nervous about what's going to happen again in two months when I am needing to call in orders again," Peralta said.

"Am I going to have to go through this whole thing over again?"

This story is part of NPR's reporting partnership with Kaiser Health News. 

Bram Sable-Smith: @besables

Non-disciplinary programs monitor doctors and nurses for a number of years and are monitored by addiction specialists and state authorities.

This article was first published on Thursday, September 19, 2019 in Kaiser Health News.

By Emma Yasinski

Dr. Wesley Boyd, an associate professor of psychiatry at Harvard, has spent years working with state programs that help doctors, nurses and other health care workers who have become addicted to opioids get back on their feet professionally.

He supports these non-disciplinary programs, in which doctors and nurses enroll for a number of years and are closely monitored by addiction specialists and state authorities as they seek to maintain or restore their medical licenses. But, he said, he is perplexed as to why these programs and other efforts to help health care providers generally do not stress a recovery method that has long been shown to be effective: the use of drugs like buprenorphine and methadone, known as opioid agonists, to relieve cravings.

"Obviously the data are clear that medication-assisted treatment is the best course of action," said Boyd, who worked for Massachusetts' Physician Health Services (previously known as the Society to Help Physicians) from 2004 to 2010. "Whether they're doctors, nurses or anybody else, [they] can function perfectly well at work and in their lives generally while they're using medication-assisted treatment."

Furthermore, he said, "the odds that they're going to stay clean and sober while using medications for treatment are better."

Clinical studies show medication-assisted treatment significantly decreases the rate of relapse and overdose more than other interventions alone. Most advocates advise using it in conjunction with regular therapy or counseling. Legal and medical researchers also made this point in the New England Journal of Medicine last month, calling it "ironic that clinicians, who are better positioned than most people to acquire and afford opioid-agonist therapy, are often denied it."

But some health care professionals believe opioid agonists are just a substitute for the drugs a doctor is addicted to, and, since they bind to the same brain receptors as opioids, may affect providers' ability to do their jobs. The opioid agonists help reduce relapses and cravings by stimulating the same pathways opioids do, but in a controlled manner that prevents a person from feeling high.

Non-Disciplinary Treatment Programs For Addiction
 

Non-disciplinary treatment programs have been operating in most states since the 1970s to help health professionals overcome their addiction. Instead of revoking the license of an individual who is found to be impaired on the job, these peer-run programs try to get participants back to work with mandated treatment plans that include intensive therapy, monitoring their behavior in and out of the workplace and, of course, drug testing. Throughout treatment, participants are actively discouraged, if not outright banned from, using opioid agonists that could aid their recovery.

Members of the non-disciplinary program may advocate for a participant's return to work when they believe the individual is ready, but, ultimately, it is the state board that determines when an individual is fit to care for patients.

Bill Kinkle, a registered nurse in Pennsylvania, developed an addiction to opioids more than a decade ago and lost his license. He tried several recovery programs but relapsed and overdosed several times.

He has been working with the state's Peer Nurse Assistance Program to get his license back. When he asked if he could use Suboxone, a brand name for a combination of buprenorphine and naloxone, he was told that the nurse assistance program would not allow it unless he had a detailed plan for tapering off the drug.

So he is treating his addiction through the state program without the medication. He was required to participate in a 30-day inpatient program, undergo partial hospitalization (in which a participant is treated for several hours a day but can go home in the evenings) for an additional three weeks, receive three months of intensive outpatient therapy, attend Alcoholics Anonymous meetings three to five times a week and pay for expensive random urine screenings.

The Peer Nurse Assistance Program did not respond to requests for comment.

Some state officials are beginning to consider the use of drugs like methadone and buprenorphine. The North Carolina Medical Board, which handles physician licensing and discipline, is encouraging the state program for doctors with opioid addictions to introduce these medications.

Critics argue that the non-disciplinary programs can, in fact, feel more disciplinary than supportive and don't help as many people as they could if opioid agonists were made available.

The programs "have no independent oversight and patients don't have a recourse," said Dr. Peter Grinspoon, an internist in Boston who had an opioid addiction and was both a participant in, and eventually a board member of, Massachusetts' Physician Health Services program for addicted doctors.

Grinspoon, who also teaches at Harvard, said that although he was unaware of any formal state policy against medication-assisted treatments, none of the program's participants with opioid addictions used opioid agonists while he served.

Impairment in Safety-Sensitive Positions
 

Scott Teitelbaum, medical director at the University of Florida Recovery Center, which treats health care professionals from all over the country, said he sometimes prescribes the medicines to the half of his patients who don't work in "safety-sensitive positions."

But, he said, it makes sense to have a different strategy for patients in those positions. When the programs ask him if a person should return to practice, they're not asking what's best for the individual; they're asking whether it's safe for the public. And when patients are using agonist therapies, Teitelbaum, who also was treated for cocaine and marijuana use, said he isn't sure it is.

A review in Mayo Clinic Proceedings of several studies in 2012 showed small effects of both methadone and suboxone on performance in measures such as reaction time and memory. The review was criticized for weak evidence and a lack of appropriate control groups.

Grinspoon noted that doctors could be taking other medications that affect their performance but face no repercussions. For example, he said, they may take benzodiazepines for anxiety or Ambien to help them sleep.

"There are tons of pharmaceuticals that could affect our performance — all of which doctors are allowed to take," he said. "And it's just because of the stigma that they're singling out addiction."

Success Rates
 

Critics of medication-assisted treatment often point to the overwhelming five-year success rates reported by the non-disciplinary programs — generally between 70% and 90%.

But Boyd is wary of those rosy statistics. First, he noted, they rarely count people who dropped out of the program or died by suicide. He said some professionals who never suffered from substance use disorder are forced into the program by bad evaluations.

So far, Kinkle, the nurse in Pennsylvania, has stayed on track, "white-knuckling it" without Suboxone. If all goes according to plan, his license will be reinstated in another 13 months.

"My wife found me multiple times after an overdose lying on the floor unconscious," said Kinkle. "All that could have been prevented had I been offered" Suboxone.

For older adults, health care facilities can be difficult to navigate and, occasionally, perilous.

This article was first published on Thursday, September 12, 2019 in Kaiser Health News.

By Judith Graham

A month ago, during a visit to her doctor's office in Sequim, Wash., Sue Christensen fell to her knees in the bathroom when her legs suddenly gave out.

The 74-year-old was in an accessible stall with her walker, an older model that doesn't have brakes. On her left side was a grab bar; there was nothing to hold onto on the right.

Christensen tried to pull herself up but couldn't. With difficulty, she rearranged her clothing and, inching forward on her knees, exited the stall. There, she tried calling the front desk on her cellphone but was placed on hold by the automated phone system.

Altogether, Christensen, who has a herniated disk in her back, was on the floor for almost half an hour before a nurse and her husband, who'd been parking the car, lifted her to her feet.

"I just wish there had been a button that I could have pushed indicating that someone in the restroom needs assistance," she said.

For older adults, especially those who are frail, who have impaired cognition, or who have trouble seeing, hearing and moving around, health care facilities can be difficult to navigate and, occasionally, perilous.

Grab bars may not be placed where they're needed. Doors may be too heavy to open easily. Chairs in waiting rooms may lack arms that someone can use to help them stand up.

Toilets may be too low to rise from easily. Examination tables may be too high to get onto. Lettering on signs may be too small to read. And there may not be a place to sit down while walking down a hallway if a break is needed.

"Most hospitals and clinics have been designed for 40- or 50-year-olds, not 70- or 80-year-olds," said Dr. Lee Ann Lindquist, chief of geriatrics at Northwestern University's Feinberg School of Medicine in Chicago. "Additional thought has to be given to seniors who have functional disabilities."

What changes could be made to better accommodate older adults' needs? I asked geriatric specialists and seniors to identify practical issues that should be addressed. Here are a number of suggestions that came up repeatedly.

Parking

Difficulties start in the parking lot, which may not be adjacent to the medical center.

That's the case at Long Island Jewish Medical Center, a large teaching hospital in New Hyde Park, N.Y. Every day, Dr. Maria Torroella Carney, a geriatrician at the hospital, crosses a busy road from the parking lot to the hospital's entrance.

"It's challenging. There isn't clear signage indicating where to cross safely, and if you need to stop and rest there aren't any benches nearby," said Carney, who is also chief of geriatrics at Hofstra/Northwell School of Medicine.

Dr. Michael Wasserman, a California geriatrician on the board of the American Geriatrics Society's Health in Aging Foundation, observed that accessible parking spaces are often in short supply. "Even then, not all older adults who need help have a handicap sticker," he noted.

The University of Florida's Senior Care Clinic has a solution: valet services. "When an older patient comes by themself, if they need help, the valet will call our clinic and someone will come down and take the patient up," said Dr. Bhanuprasad Sandesara, division chief of geriatrics.

Signage

All too often, easy-to-read signs indicating where patients should go can't be found, either inside or outside medical centers. For older patients, this can lead to confusion and unnecessary wandering, accompanied by pain, fatigue and annoyance.

Last year, a committee examining how Long Island Jewish Medical Center should handle patients with special needs (for instance, people with cognitive impairments or hearing or speech problems) identified better signage as a priority.

Now, signs in the parking lot and outside the medical center are bigger, with larger type. Inside the medical center, large signs have been placed at bathrooms, showing clearly if they're accessible to those with disabilities. And the staff is creating a comprehensive map of the hospital campus — a handout — to help patients find their way more easily, according to Roseanne O'Gara-Shubinsky, associate executive director for quality management at Long Island Jewish.

Appointment cards were also altered: Carney persuaded the hospital to print phone numbers in large type on cards for seven geriatricians at its senior clinic.

At Northwestern, Lindquist realized that older patients were having trouble seeing whiteboards in their hospital rooms listing scheduled procedures and the names of physicians and nurses responsible for their care. Upon Lindquist's urging, the hospital bought whiteboards that are more than double the normal size.

Getting Around

At a recent talk in the San Francisco Bay Area to promote her new book, "Elderhood," Dr. Louise Aronson was approached by an older woman who uses a portable oxygen tank to breathe and relies on a rollator walker (with a seat and basket attached).

The woman was new to the area and had been visiting various medical facilities. "Some of these places have ramps, but the angle is so steep I can't push my rollator up," she complained. "Whoever designed them wasn't thinking of someone like me."

At the University of Arkansas for Medical Sciences, Dr. Jeanne Wei, who heads the geriatrics department and the Donald W. Reynolds Institute on Aging, has seen many older adults injure themselves while pushing someone in a wheelchair up an incline. She has insisted that parking lots be on the same level as medical buildings and that sidewalks around facilities be kept in good shape to minimize older adults' risk of falling.

Also, at the University of Arkansas' Thomas and Lyon Longevity Clinic for older adults, examination tables are wider than usual and their height can be adjusted electronically. "Sometimes, it's difficult to navigate lying in a narrow strip" and many older adults are afraid of falling, Wei said.

The staff at Long Island Jewish didn't realize there weren't enough walkers and wheelchairs at the hospital's entrance until the issue came to light during deliberations by the special needs committee. Now, "we've made sure that we have plenty of these available," O'Gara-Shubinsky said.

Something as simple as having a hook to hang up a cane can be a thoughtful touch. "You see this a lot: An older patient sits down, there's nowhere to put a cane, and it falls on the floor," said Dr. Diana Anderson, a geriatric medicine fellow at the University of California-San Francisco, who's also a board-certified architect.

Doors

Diane Ashkenaz, 68, has fibromyalgia, chronic pain and a ruptured tendon. She also has undergone two knee replacements. Most of the time, she uses a walker when she visits doctors in the Washington metropolitan area.

Doors are often a problem. "Neither my primary care doctor nor my orthopedic surgeon have doors to their offices that open automatically," Ashkenaz said.

Not long ago, she said, the staff at a pain clinic's front desk handed her a pen and clipboard and asked, "Can you fill this out please?" How was Ashkenaz supposed to hold those items while finding her way to a chair? No one seemed to realize there was a problem.

At the clinic Sue Christensen visits in Washington, the front doors open wide automatically and a nursing assistant helps her into the exam room. But once her appointment is over, she's directed to an exit door that she must open herself.

"It's pretty heavy and hard to manage while trying to clunk my walker through," Christensen said. "I don't know why they don't have a door system that would be easier for people who don't have much strength or dexterity."

Seats

Ashkenaz has another pet peeve: chairs in waiting rooms with seats that are too low or without arms that she can grab to push herself up into a standing position.

At her cardiologist's office, there's a sofa with deep seats. "It looks nice, but I'd do anything not to sit there," Ashkenaz said. "I just can't get up from it."

Wei's clinic at the University of Arkansas has brought in chairs that are 4 inches taller than usual, with arms, for older patients. "These chairs are always occupied," she said.

Also, exam rooms at the clinic are large enough to accommodate chairs for multiple family members. "We'll bring everyone in to talk about Mom or Dad so they can hear what the other person is saying," Wei said.

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or suggestions for how medical facilities could become more age-friendly.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham