Instruction: create a high quality summary of the given input

Input:
Sonnen virtual power plant concept gets US makeover
 In Germany, startup Sonnen has been operating a nationwide shadow utility of networked home solar and storage systems for several years. But when the company arrived in the U.S., the policy landscape made that grand vision impractical to replicate.

After a few years of selling energy storage as a premium alternative to the early home battery contenders, the company has now compiled a landmark deal that will single-handedly dwarf the residential market, such as it is.

Lacking the deregulation that gave Sonnen access to the wires in Germany, the company tackled the project from the other end: the home.

Over the next few years, Sonnen will outfit a high-efficiency housing development built by Mandalay Homes in Prescott Valley, Arizona, stocking some 2,900 new houses with its signature storage system.

As told by U.S. Senior Vice President Blake Richetta, this effort bypasses the “bullshit bingo” that plagues industry discussions of virtual power plants, in which buzzwords and small pilots stand in for substantive action.

“Sonnen is a company that likes to get things done: We want the virtual power plant to really exist, and it does exist in Germany,” Richetta said. “We’re not going to be paralyzed by pilots anymore in this country.”

Residents won’t need to worry about paying extra for pricey storage; they won’t even have to own or maintain it. Mandalay has wrapped that equipment, along with a modest solar array, high-tech insulation and other energy saving measures, into a package that will cost marginally more than high-efficiency homes already on the market.

For an approximately 1 percent premium, the homeowners will pay 40 to 60 percent less to operate their homes than currently available high-performance homes, said Mandalay CEO Dave Everson.

Once built, the companies will have a massive distributed power plant on their hands. With just the first fifth complete, the neighborhood will have 10 megawatts of dispatchable power at the ready, far beyond the miniscule pilots that pass as virtual power plants these days.

Notably, Mandalay is moving ahead without a utility contract in hand. There isn't really a model yet for virtual power plant aggregation in Arizona. By going ahead and building it, Mandalay will then have a model to take to the utility, rather than the other way around.

All about the home

For Mandalay, storage represents the latest addition in a five-year effort to design the highest-performing homes it can make.

“It’s not a jump; it’s more like a half step from where we were,” Everson said.

The model home that implements these ideas has been in service since May, and recently secured the company’s third Housing Innovation Award from the Department of Energy.

That effort includes iterative refinement of the building envelope to enable passive heating and cooling, cutting down the energy needed. A final piece of this involves the AeroBarrier, an aerosol spray developed out of UC-Davis that fills the house and seals any remaining leaks that would let it escape.

Minimizing load means the buildings don’t need much solar power. In fact, the economics worked against large solar capacity. Mandalay decided on a standard configuration of 3.9 kilowatts of solar (a fraction of a typical home capacity) and an 8-kilowatt-hour Sonnen battery.

The designers did not try to maximize onsite generation; they tried to get the best economic return for the capacity included. This makes for a more targeted use of storage compared to retrofitting it on inefficient older homes with lots of load and lots of solar generation.

“It’s a totally different value proposition now,” Richetta said. “It’s not about storage versus bill savings; it's about the whole.”

Nor was the goal to turn the home into a self-reliant microgrid: Grid interaction sits at the heart of the design, he said.

Finding the right rate

In Everson’s vision, the homes will power themselves during daylight hours with rooftop solar, storing the excess for later. That should last through the evening peak.

The battery can then charge up in the wee hours of the night, on the cheap and production from must-run generation, which tends to be cleaner than at high-demand times. That powers the early morning activities until the sun comes back out.

The development will utilize a new pilot retail rate from Arizona Public Service designed to incentivize peak demand reductions from residential customers.

The rate combines a $0.50 per day service charge with a very low per-kilowatt-hour energy rate (around $0.05) and a stiff monthly on-peak demand charge (up to $20.25 per kilowatt). Customers have to have a number of distributed energy assets like rooftop solar, energy storage or electric vehicle to qualify.

This rate structure means families that can minimize their demand during the peak hours of 3 p.m. to 8 p.m. on weekdays stand to benefit from low overall energy rates. The structure of the Mandalay home design suggests customers can expect to use very little, if any, grid power during the peak.

This would save money for the homeowners, but it also tackles a real need for the broader grid. Arizona has a growing supply of surplus daytime solar generation, such that batteries soaking that up provide value to the grid. The utilities also grapple with meeting peak load, which drives costly purchases of gas peaker plants that are used only rarely, but are very expensive to operate.

Adding more standalone solar on new homes contributes marginally to both challenges. Sizing new solar systems to an onsite battery allows for home energy optimization with the ability to assist utilities in navigating the emerging distributed grid.

Untapped grid asset

The value of distributed assets for the grid is something that many smart people are trying to define, but little consensus has been established thus far.

Investment in aggregation only pays off once there is some mode of getting paid for it. Outside of select markets, that has stymied the business case for distributed fleets of storage acting as a capacity or grid services tool.

Mandalay sidestepped the issue by making the economics work without needing a utility contract.

“They’re not waiting for the utility companies; they’re doing this with or without them,” Richetta said. “That is the secret sauce to us getting out of the ‘paralyzed by pilot’ mode.”

Once the companies have battery and solar systems operational -- the first phase will include 600 homes -- they’ll have greater credibility to offer that network for grid services. They’ll also have the option of installing additional battery capacity if a deal comes along, Everson said.

Under current plans, the full 2,900-home project will total 11.6 megawatts of power input and output and 23 megawatt-hours of energy storage capacity, the companies said. They think that could be enough clean, flexible capacity to knock out a coal peaker plant in northern Arizona.

There’s much to figure out in terms of how the community would deliver peak capacity to the grid while maintaining the local needs of each homeowner.

Then again, Sonnen has been operationalizing that concept with its network in Germany for several years. Its challenge now is to pull that off amid the peculiarities of the American grid.

--

Join GTM for a deep dive into the budding domestic energy storage market at the U.S. Energy Storage Summit 2017. Utilities, financiers, regulators, technology innovators, and storage practitioners will all come together for two full days of data-intensive presentations, analyst-led panel sessions with industry leaders, and extensive, high-level networking. Learn more here.

Output:
Sonnen has reworked its virtual power plant model for the US market in a project built by Mandalay Homes. The 3,000-home development in Arizona will provide every property with an 8 kWh Sonnen battery and a relatively small 3.9 kW of rooftop solar. The idea is that the properties power themselves with solar energy during the day while charging the battery, which keeps the lights on during the evening. The battery is topped up overnight using cheap grid electricity and powers the house in the morning before the sun comes up.
Technology: Advanced solar, Smart grid


Instruction: create a high quality summary of the given input

Input:
Japan to spur fintech innovation with new regulatory regime
 TOKYO -- The Japanese government aims to make it easier for businesses to partner up in financial technology by leveling the regulatory playing field for different industries, hoping to prompt innovation that helps make financial services less costly.

Such enterprises as banks, e-money businesses and credit card companies are now subject to different laws according to their industries, even for the same services. The Financial Services Agency sees this compartmentalization as stifling competition.

Output: Japan's businesses could find it easier to partner on financial technology projects if proposed regulatory changes by the country's Financial Services Agency are adopted. It is seeking to stimulate competition by switching the focus of regulation to services rather than businesses. Under the changes, which are proposed for 2018, all firms would be held to the same standard, regardless of size. Although non-banking companies would face more precise operating regulations, fintechs might be able to break the banks' monopoly on lucrative remittance and settlement operations.


Instruction: create a high quality summary of the given input

Input:
Institutional investors to work with fewer managers: PGIM CEO
 As the Federal Reserve begins to shrink its balance sheet and put an end to so-called quantitative easing, investors are concerned that this unprecedented process could negatively affect markets.

David Hunt, President and CEO of PGIM, Prudential's investment arm, is one of those keeping an eye on it.

"I think that remains one of the big risks that investors face," he told Business Insider's deputy executive editor Matt Turner recently.

Turner recently caught up with Hunt, to ask him about central bank policies, stock markets, real estate, and more. PGIM has more than $1 billion in assets invested around the world. Here's what he had to say:

This interview has been lightly edited for length and clarity.

Matt Turner: You guys have over $1 trillion in assets, with offices in 16 countries, so I wanted to first ask, when you look around the world, what do you see?

David Hunt: For us, the most important thing that we focus on is our investment performance. We believe fundamentally that investors — and most of our investors are long-term, sophisticated institutions, so pension funds, sovereign wealth funds, central banks — what they're looking for from their investors is somebody who's actually going to be able to beat their benchmarks and add excess return for them.

We're an active manager, which you know has been somewhat unpopular recently, but we believe we've been a very successful one.

We're an active manager, which you know has been somewhat unpopular recently, but we believe we've been a very successful one.

We've been successful because we do deliver real excess returns for our clients.

Turner: In terms of those excess returns, where do you see opportunities for investors? Where are your investment managers seeing an opportunity to make money?

Hunt: I would say the major thrust has been threefold. One has been for many institutional investors around the world, the race for yield has been incredible. We may not love the interest rates in this country, but if you are in Japan or you're in Europe, all of that actually looks really good.

We've really been able to bring the search for yield home to many of those investors. Secondly, we've been very successful in finding real returns from real assets. By that, I mean real estate — both debt and equity — but also everything ranging from agricultural investment, infrastructure debt, and other real assets that are generating both income and capital gains.

Turner: When you look at US markets, how do you see what's going on? Are there any opportunities at home?

Hunt: We absolutely believe that there are significant opportunities. And indeed, we believe that the US economy is in very good shape. We've actually recently upped some of our estimates for GDP growth. We would say the US is growing faster than its real potential GDP, which ultimately leads to a bit of an uptick in inflation, but at the moment we remain pretty optimistic.

We would say the US is growing faster than its real potential GDP, which ultimately leads to a bit of an uptick in inflation, but at the moment we remain pretty optimistic.

I would say the most important part of that optimism is based on seeing a return of business investment. Before, mostly it was on the consumer side, and businesses were leveraging but using a lot of that to buy back shares. In the last 18 months that dynamic has changed. Buybacks have come well down and we're seeing real business investment into this country. We like that story on the equity side. We like what a lot of that means for fixed income and higher-yielding fixed income. We remain very constructive on most aspects of the real estate sector, maybe with retail as an exception.

Turner: On the equity side, you said earlier in the year that the stock market had maybe gotten ahead of itself in terms of betting on the success of various administration policies that might give the economy a boost. Where are we now? Obviously, a lot has changed since last summer. It seems like things are changing every day. Where are we now?

Hunt: It's a very interesting thing in terms of the market sentiment. At the beginning of the year, there was without a doubt the famous Trump trade that came on, which was a belief in tax cuts, infrastructure, and deregulation as a package driving growth. We saw over the first quarter and second quarter, that trade really went to zero. The basic belief that that would happen diminished a great deal in investors minds.

President Trump gives his inaugural address on January 20. AP Photo/Patrick Semansky

Of course, at the same time, the real economy — in a sort of different, parallel universe from politics — was doing even better, so real growth rates were picking up and a general belief that the economy was doing better began to take over market sentiment. I'd say the market was driven higher by that belief, not really related to the Trump policies. Now in the last two weeks, we've started to see that shift again. I do think that with the at least outline of a tax plan on the table, you've begun to see some of the Trump trade animal spirit come back in. But for most of the year, I would say that hasn't really been a factor in the markets.

Turner: We talked about the opportunities. Where are there risks? Particularly, in my conversation with investors, a lot of people talk about the Fed and there being the uncertainty around who might lead it, and whether they might raise rates or move too soon. So how do you see that dynamic?

Hunt: There's no question that we have real policy risk. I mean, never before in the last thirty years have we seen so much of economic activity dependent on, not just the Fed, but I would generalize it to central banks around the world and the very accommodative policies. So there is a lot riding on the fact that they can begin to normalize those policies in an effective way. And that isn't just when they decide to raise rates, and at what pace, but also what they do with the balance sheet.

Federal Reserve Chairman Janet Yellen speaks during a news conference after a two-day Federal Open Markets Committee (FOMC) policy meeting in Washington Thomson Reuters

One of the big challenges for the Fed is going to be at what pace they begin to unwind that balance sheet, and I think that remains one of the big risks that investors face.

Turner: One of the research notes that I received this morning made the point that monetary policy is going to dominate stock trading for the near time. Do you agree with that? Or do you think there's more to the story than that?

Hunt: I think that there is quite a bit more to the story. There's no question that it today's valuation — if you look at the S&P overall, forward PE's are about 18.5, the long-term average is more like 15.5 — you could say that it looks a little bit rich. But at today's interest rates, actually, it looks pretty fairly priced. If we had a sudden rise in rates you would begin to think probably that the current prices are, without a doubt, a touch frothy. But we would not say that's the base case. We actually think the base case is that we're quite constructive on equities at the moment, but we do think that the risks of a gradual normalization remain around the balance sheet of the Fed.

Turner: Going back a step, you mentioned the Japanese market and Europe. Outside of the US, where do you see opportunity? You mentioned India as well.

Hunt: There's no question we would certainly have Japan at the top of our list. We do believe that there are large institutional investors there who are looking very actively to put their money to work outside of Japan and to move into higher-yielding assets. I would've said that their search for yield 1.0 was to move into the US and to move to kind of investment grade corporates. We're now really seeing a search for yield 2.0, which has to do with high-yield, emerging markets, and structured products, which as you know, we hadn't seen for quite some time from the Japanese. We do believe that there is a lot more yet to run on the movement of money out of Japan.

Turner: Just turning to the money management business for a moment, the industry is changing dramatically, what's going on there and how does the search for yield fit into that?

You're seeing the rationalization of managers, you're seeing fees come down for many types of products, and you're seeing the continued growth of passive.

Hunt: The money management industry is absolutely reflecting the pressure that the clients are facing. In this very low return environment, you think about what the big institutions are doing. One, they're very worried about fees, so there's a real focus on that. Two, they're wondering where should they pay for active management, which is more expensive than indexing, and what should they index, where they just want to buy cheap beta. And three, how many managers should they be working with? Many of them have a large roster of managers, and is that really the most effective way to manage a full portfolio? So you're seeing that play out right now across the industry. You're seeing the rationalization of managers, you're seeing fees come down for many types of products, and you're seeing the continued growth of passive.

Turner: One of the things that people in the industry often talk about when it comes to money management is this barbell, where as you said you have low-cost, passive index tracking funds and at the other end you have higher fees, higher active share, things like private debt which you mentioned, and it's those in the middle that are charging higher fees for something that looks quite a lot like beta that are really going to struggle. Is that what we're looking at?

Hunt: Yes I would very much subscribe to that. I think that firms that are charging high active share prices but delivering something that really actually hugs the benchmark are going have a very difficult time. That's just fine. I actually think that's competition that is leading to investors having a better proposition. I do believe investors over time will, instead of saying 'is it active or passive?', will say 'how can active and passive work together?' so we have cheap beta where that makes sense. There's plenty of room to run with active management on all kinds of other strategies where you're going to need that excess return if you're going to pay for retirement over twenty years.

Turner: In terms of those strategies that do offer excess return, which of those are you pushing into? Would there be acquisitions that might make sense to accelerate your growth in those areas?

We see lots of room around specialist strategies like biotechnology and senior housing.

Hunt: Well currently we would say that we have most of the strategies that we need to do that. For us, we are such a big player in real assets. That is our real estate business in particular, both debt and equity, that's a lot of where we see excess returns coming from active management. But we would say the same thing in fixed income. We're the fourth largest fixed-income business in the world and we would say that that business is fundamentally one where active management makes a lot of sense. So for the passive piece of this we're really just talking about equities. We think the US equity markets will continue to gradually move more to passive, but we see lots of room around specialist strategies like biotechnology, senior housing type things, and we see plenty of opportunities in international and emerging markets where active management adds very significant value.

Turner: You're one of the biggest players in real estate. Where is there an opportunity for investors to make money?

Hunt: What we're seeing from investors' point of view is a little bit of a recalibrating of their risk. We do see demand for core going up quite a lot, and probably a little bit less in terms of demand for a real opportunistic. Core Plus also been a very popular. Within the sectors, we see a very large demand for logistics, for multifamily, which has continued to be one of the important pieces. We do think hotels are probably a little bit overdone and we've been selling in some selective, large kind of gateway cities. By and large, we still believe that the supply-demand dynamics in real estate mean there's plenty of excess returns to be had.

Turner: You mentioned the bond market. Earlier in the year there was definitely a sense that the stock market was saying one thing about the economy and the bond market was saying another. Is there a tension there, and has it been resolved?

Hunt: It hasn't necessarily been resolved in so much as just come into an equilibrium. I do think, as you put it before, that the equity market does rely on us having somewhat lower rates and the Fed normalizing policy fairly gradually. I think if that plan does play out, you probably have a pretty even balance of risk and reward. The important thing to recognize about interest rates is that the Fed only really controls the short end. We believe that there is so much money looking for a home in fixed income, that actually there will continue to be money that comes into the middle part of the curve and the longer part of the curve. That's going to mean it's going to flatten, and that's happened quite a bit already this year. We would expect it to happen even more. Just because the Fed raises rates doesn't necessarily mean that will happen uniformity, and I think that's important for your viewers to realize.

Output: As fees and performance become an increasing focus for instiutional investors, clients will look to work with fewer investment managers, according to David Hunt, CEO of PGIM. "Many of them have a large roster of managers, and is that really the most effective way to manage a full portfolio?" said Hunt of large institutions. These investors are also considering where they want to eschew active management for cheap, beta-producing products, Hunt added. PGIM, however, has had success pumping its active management capabilities around real assets and fixed income, added Hunt.


Instruction: create a high quality summary of the given input

Input:
Udacity partners with Google for US developer scholarships
 Google and online education program provider Udacity have launched a new scholarship initiative for aspiring Web and Android application developers.

The two companies will offer 50,000 scholarships to people wishing to pursue a career in either of these two fields. The scholarships will be available to U.S. residents age 18 or older at all skill levels from absolute newcomers to experienced developers, the two companies announced Oct. 12.

Scholarship recipients will receive free technical training in either Web development or the Android developers program.

The scholarship program is part of a broader “Grow with Google” initiative that CEO Sundar Pichai announced Thursday. Under the program the company will offer free tools, training and events in a bid to help people become more computer literate and better prepared for jobs requiring modern technology skills. The tools and courses are being aimed at a fairly wide cross section of people including job seekers, local business owners, teachers and developers.

“Grow with Google is there to give anyone in America the tools and training they need to get a job, for free,” Pichai said in comments on Google’s The Keyword blog.

Individuals accepted into the newly announced scholarship program will be placed into one of two tracks: a Beginner track for those with no prior software developer or technology experience and an Intermediate track for individuals with some Web or Android development experience. Up to 15,000 scholarships are available for the beginner track and 10,000 are available for those with intermediate level skills.

In the first phase of the program, scholarship recipients will get three months of free access to one of four courses ranging from an introductory course in HTML and CSS to an Android App development course for more advanced students.

The top 5,000 students from the first phase will qualify for an additional six-month scholarship to what Google calls a Nanodegree program. Students who qualify for one of the four available Nanodegree scholarship programs will receive free access to more advanced training material, as well as classroom time and access to experts in Web and mobile application development.

As part of the Grow with Google program the company is also working with Coursera to develop a professional certification program that the company says will prepare individuals for IT jobs in between 8 and 12 months.

The IT Support Professional Certificate program will launch in January 2018 and will offer 2,600 full scholarships. Google and Coursera will work with major employers to try and place graduates from the program into IT jobs.

Output: Google and edtech firm Udacity are offering 50,000 web and Android application developer scholarships to US residents aged 18 and over, according to a joint statement. The move is part of the "Grow with Google" initiative, recently launched by CEO Sundar Pichai. The first phase of the scholarship will see recipients given three months of free access to one of four courses, with the top 5,000 qualifying for an additional six-month scholarship to study for a nanodegree. Google is also set to launch the IT Support Professional Certificate programme, in partnership with Coursera, in January.


Instruction: create a high quality summary of the given input

Input:
Silicon kidneys may cut dialysis, ease transplant list pressure
 Every week, two million people across the world will sit for hours, hooked up to a whirring, blinking, blood-cleaning dialysis machine. Their alternatives: Find a kidney transplant or die.

In the US, dialysis is a roughly 40-billion-dollar business keeping 468,000 people with end-stage renal disease alive. The process is far from perfect, but that hasn't hindered the industry's growth. That's thanks to a federally mandated Medicare entitlement that guarantees any American who needs dialysis—regardless of age or financial status—can get it, and get it paid for.

The legally enshrined coverage of dialysis has doubtlessly saved thousands of lives since its enactment 45 years ago, but the procedure’s history of special treatment has also stymied innovation. Today, the US government spends about 50 times more on private dialysis companies than it does on kidney disease research to improve treatments and find new cures. In this funding atmosphere, scientists have made slow progress to come up with something better than the dialysis machine-filled storefronts and strip malls that provide a vital service to so many of the country's sickest people.

We thought, if people are growing ears on the backs of mice, why can’t we grow a kidney? Shuvo Roy, UC San Francisco

Now, after more than 20 years of work, one team of doctors and researchers is close to offering patients an implantable artificial kidney, a bionic device that uses the same technology that makes the chips that power your laptop and smartphone. Stacks of carefully designed silicon nanopore filters combine with live kidney cells grown in a bioreactor. The bundle is enclosed in a body-friendly box and connected to a patient’s circulatory system and bladder—no external tubing required.

The device would do more than detach dialysis patients—who experience much higher rates of fatigue, chronic pain, and depression than the average American—from a grueling treatment schedule. It would also address a critical shortfall of organs for transplant that continues despite a recent uptick in donations. For every person who received a kidney last year, 5 more on the waiting list didn’t. And 4,000 of them died.

There are still plenty of regulatory hurdles ahead—human testing is scheduled to begin early next year1—but this bioartificial kidney is already bringing hope to patients desperate to unhook for good.

Innovation, Interrupted

Kidneys are the body’s bookkeepers. They sort the good from the bad—a process crucial to maintaining a stable balance of bodily chemicals. But sometimes they stop working. Diabetes, high blood pressure, and some forms of cancers can all cause kidney damage and impair the organs' ability to function. Which is why doctors have long been on the lookout for ways to mimic their operations outside the body.

The first successful attempt at a human artificial kidney was a feat of Rube Goldberg-ian ingenuity, necessitated in large part by wartime austerity measures. In the spring of 1940, a young Dutch doctor named Willem Kolff decamped from his university post to wait out the Nazi occupation of the Netherlands in a rural hospital on the IJssel river. There he constructed an unwieldy contraption for treating people dying from kidney failure using some 50 yards of sausage casing, a rotating wooden drum, and a bath of saltwater. The semi-permeable casing filtered out small molecules of toxic kidney waste while keeping larger blood cells and other molecules intact. Kolff's apparatus enabled him to draw blood from his patients, push it through the 150 feet of submerged casings, and return it to them cleansed of deadly impurities.

In some ways, dialysis has advanced quite a bit since 1943. (Vaarwel, sausage casing, hello mass-produced cellulose tubing.) But its basic function has remained unchanged for more than 70 years.

Output: A team of US doctors and researchers are closing in on conducting human trials on an artificial kidney that has been 20 years in the making. The silicon-based device cleans and filters human blood without losing vital nutrients and amino acids, and 9,000 patients have signed up to participate in the trials. If all goes well, the bioartificial kidney could be approved by the US Food and Drug Administration as early as 2020.


Instruction: create a high quality summary of the given input

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Coalition demands county spend more homeless, hep A fight
 Former State Assemblyman Nathan Fletcher speaks during the opening ceremonies for the San Diego Memorial Stair Climb in November, 2016.

If the county could afford $150 million to help build a new stadium for the Chargers, some politicians say it should be able to spend that same amount on the homeless and public health.

A coalition of local, state and union officials made that argument as they gathered in front of the County Administration Center Thursday to announce what they called an “emergency action plan” that demands funding increases in several areas from staffing to public housing.

A county supervisor immediately accused the group of playing politics with the ongoing hepatitis A outbreak crisis.

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Led by former Assemblyman Nathan Fletcher, the group threw down the rhetorical gauntlet again and again, accusing current leadership of being more concerned about bank balances than delivering services.

Fletcher, who is running for county supervisor next year, said the county should have stood taller when the region’s hepatitis A outbreak began spreading rapidly.

“It is not a time for the chief public health organization in our region to say ‘it is not our responsibility,’ it’s a time for action,” Fletcher said.

County supervisors were quick to respond with statements of their own.

Board chair Dianne Jacob fired off a one-page missive and posted it on Twitter while the news conference was still underway that accused “City Hall and others” of “trying to score political points off this public health emergency.”

“This is nothing more than an attempt to shift the responsibility to the county for a homeless problem that has festered in the city for years,” Jacobs’ statement said.

Supervisor Ron Roberts added that his proposal for a $150 million bridge loan to help the now-departed Chargers build a new stadium was part of a larger proposal that called for a $200 million contribution from the city of San Diego. Neither funding proposal was ever approved by the county board of the city council.

“Perhaps the city should spend its own $200 million slated for the Chargers stadium before they or a perennial political candidate start asking others to do their job for them,” Roberts’ statement said, making an oblique reference to Fletcher’s bids for San Diego mayor in 2012 and 2013.

Others in the group made the case that the county, with $747 million in “unassigned” cash in its general fund, according to its most recent audit, could afford to do more.

In August, state Sen. Ben Hueso convinced the legislature’s Joint Committee on Legislative Audit to examine the county’s staffing of public health nurses. He alleges that understaffing has created a workload that is much too high across the region.

“We believe that this outbreak has something to do with the county’s refusal to hire adequate staff,” Hueso, D-San Diego, said at the news conference.

But Jacob bristled at the notion that the county has been handling the outbreak on the cheap.

“The county has spent about $3 million to date fighting Hep A with nurses, wash stations, hygiene kits, and vaccinations for nearly 70,000 people. And it plans to spend $1.5 million a month going forward,” Jacobs’ statement said.

She said the county already spends $300 million per year on services for homeless residents “including alcohol and substance abuse treatment and mental health services.”

Fletcher is running to replace Roberts who will be termed out of office in 2018. Fletcher faces, among others, former San Diego District Attorney Bonnie Dumanis in the race. In a statement issued after the news conference, Dumanis said “this is not the time for finger pointing.”

“I will call for an after-action investigation into the local government response so that we can identify breakdowns. As Supervisor, I am committed to taking the findings of this review and developing a regional response plan for any future public health crisis,” Dumanis said.

Most if not all of those at the news conference urging the county to do more are Democrats. All five supervisors are Republicans, as is Dumanis.

Several speakers during Thursday’s news conference made reference to the county’s funding of mental health services, which are seen as key to serving a homeless population that includes many with significant psychiatric needs.

Hueso said his research indicates that the county has more than $100 million in unspent state Mental Health Services Act funds which could be used to significantly increase the number of beds available and to hire additional case workers to work with the homeless. These proposals are included in the plan that the coalition released.

“I don’t know about you, but I don’t pay taxes for the county just to store that money away,” Hueso said. “I pay taxes so that the county will provide these essential services.”

That very topic was addressed just two days earlier with the board of supervisors passed a $197.5 million three-year mental health plan that would add 10 new psychiatric emergency response teams, additional funding for housing for people with mental illnesses, expansion of the Children’s Emergency Screen Unit and increased case management for older adults with serious mental illnesses.

County officials told the board that the expansion adds $15 million to previous spending levels, but Fletcher said he did not think the improvements go far enough.

“They’re talking about a three-year plan that will see a $5 million increase each year for three years. They’re (nominally) changing what the status quo was already going to do. If that was working, we wouldn’t be in the situation we’re in today,” Fletcher said.

County spokesman Craig Sturak said in an email sent Thursday evening that the county’s mental health services unspent balance is $123. 7 million with another $42 million set aside as a reserve. He said the new mental health plan approved by the supervisors, plus other expenses, should make a significant dent in that pile of cash.

“By the end of this current fiscal year, it is anticipated that our unspent balance will be reduced by approximately 40 percent from fiscal year 2014-2015 levels,” Sturak wrote.

San Diego City Council members Barbara Bry and Chris Ward, who also added their names to the list of officials who endorsed the Chargers approach, have asked the county to commit to case management, nursing and other services at the city’s new transitional camping area and at the three temporary big-tent shelters that will be set up for the homeless this winter.

Sturak said the county already had social workers and public health nurses visit the new campsite for vaccination and to enroll residents in safety-net programs. He said the county plans to continue those services, and offer others such as psychiatric emergency response teams and behavioral health outreach workers, at the three additional tent shelters when they open.

“The goal is to connect individuals at these locations to services to help them get health care, assistance and housing,” Sturak said.

Meanwhile, the region’s hepatitis A outbreak continues to grow with a total of 18 deaths and 490 cases announced earlier this week. The next update is due Tuesday.

Health Playlist × On Now Video: Leaders urge public to help extinguish hepatitis outbreak On Now San Diego starts cleansing sidewalks, streets to combat hepatitis A On Now Video: Scripps to shutter its hospice service On Now Video: Scripps La Jolla hospitals nab top local spot in annual hospital rankings On Now Video: Does a parent's Alzheimer's doom their children? On Now EpiPen recall expands On Now Kids can add years to your life

paul.sisson@sduniontribune.com

(619) 293-1850

Twitter: @paulsisson

Output: If the county could afford $150 million to help build a new stadium for the Chargers, some politicians say it should be able to spend that same amount on the homeless and public health.


Instruction: create a high quality summary of the given input

Input:
Congress Can’t Let Mr. Trump Kill Obamacare on His Own
 This editorial has been updated to reflect news developments.

Fed up with failed attempts in Congress to repeal the Affordable Care Act, President Trump on Thursday took matters into his own hands, stopping payments to insurance companies and signing an executive order that could significantly damage the health insurance market and harm millions of people.

Mr. Trump carried out his threat to stop paying insurers to lower the out of pocket costs for low-income and middle-class Americans. The loss of this money, expected to be $9 billion next year, will force insurers to raise premiums and stop selling policies in some parts of the country. Because most people who buy coverage on A.C.A. exchanges also receive subsidies to keep their premiums affordable, this change would actually cost the government money — about $2.3 billion more next year, according to the Kaiser Family Foundation.

Earlier in the day, the president directed his administration to effectively create an alternative health insurance system that does not include the safeguards of the A.C.A. and could sabotage that 2010 law, one of his predecessor’s biggest accomplishments. The president claims that this will help people obtain cheaper insurance. In reality, it most likely will force insurance companies to abandon the A.C.A.’s insurance exchanges and ultimately precipitate a collapse of an important part of Obamacare.

The executive order is made up of two main changes: to expand the use of short-term insurance policies and to make it easier for professional and trade associations to sell health coverage to members across the country. Officials at the Departments of Health and Human Services, the Treasury and Labor will now come up with a rule after seeking public comment over the next several months.

Output: Fed up with failed attempts in Congress to repeal the Affordable Care Act, President Trump on Thursday took matters into his own hands, signing an executive order that could significantly damage the health insurance market and harm millions of people.


Instruction: create a high quality summary of the given input

Input:
What Did Trump’s Health Care Executive Order Do?
 Such plans are currently exempt from most insurance rules. That means the plans can reject or charge higher prices to customers with pre-existing health conditions, can cover fewer benefits and can charge higher deductibles. Because they tend to be skimpier and insure only healthy customers, the plans’ prices tend to be lower. Under current regulation, such plans can last for only three months at a time. The order asks for a change to lengthen their duration, a directive likely to result in plans that last just under a year, the standard before this year. That change would make it easier to use such insurance as a substitute for Obamacare-compliant coverage.

It is possible that the association rule will allow self-employed people to join associations, but legal experts are skeptical that the labor laws will permit it.

If a lot of people decide to buy these short-term or association insurance plans, that will most likely leave fewer Americans in the Obamacare markets. And that smaller group is likely to have more people who care about comprehensive coverage and lower deductibles — that is, people with more health problems. The result could be higher prices for customers who remain. The loss of the cost-sharing subsidies will also prompt insurers to raise their prices. Most Obamacare customers get federal subsidies that help them buy insurance, and they would not feel the increases. But higher-income customers who choose to buy Obamacare insurance may need to pay more.

What will it mean for people with Medicaid or Medicare?

None of these changes directly affect them.

Will these changes lower the cost of insurance?

It’s complicated. If the rules are changed, some Americans will be able to buy insurance for a lower sticker price through the short-term market or an association. But that insurance is likely to cover fewer benefits, may not be available to people with a history of health problems, and may be more likely to be offered by a fraudulent company.

People who get insurance using government subsidies won’t notice much of a change in price, but they might see fewer options in the future, if the changes make the Obamacare market less attractive to insurers.

Output: President Trump signed an executive order on Thursday that he said would begin “saving the American people from the nightmare of Obamacare.” There’s a lot that’s still uncertain about how the order will change the health law. Here’s what we know so far.


Instruction: create a high quality summary of the given input

Input:
Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again
 WASHINGTON — President Trump will scrap subsidies to health insurance companies that help pay out-of-pocket costs of low-income people, the White House said late Thursday. His plans were disclosed hours after the president ordered potentially sweeping changes in the nation’s insurance system, including sales of cheaper policies with fewer benefits and fewer protections for consumers.

The twin hits to the Affordable Care Act could unravel President Barack Obama’s signature domestic achievement, sending insurance premiums soaring and insurance companies fleeing from the health law’s online marketplaces. After Republicans failed to repeal the health law in Congress, Mr. Trump appears determined to dismantle it on his own.

Without the subsidies, insurance markets could quickly unravel. Insurers have said they will need much higher premiums and may pull out of the insurance exchanges created under the Affordable Care Act if the subsidies were cut off. Known as cost-sharing reduction payments, the subsidies were expected to total $9 billion in the coming year and nearly $100 billion in the coming decade.

“The government cannot lawfully make the cost-sharing reduction payments,” the White House said in a statement.

Output: President Trump will scrap subsidies to health insurance companies that help pay out-of-pocket costs of low-income people, the White House said late Thursday. His plans were disclosed hours after the president ordered potentially sweeping changes in the nation’s insurance system, including sales of cheaper policies with fewer benefits and fewer protections for consumers.


Instruction: create a high quality summary of the given input

Input:
Most Healthcare Costs Can Be Attributed to Low-Value Care
 Low-cost, low-value health services contribute the most to unnecessary health spending in the United States and ultimately cost nearly twice as much as high-cost, low-value health service, according to a new study published in Health Affairs.

Low-value care has been characterized as health services that provide no net health benefit in specific clinical scenarios. While there has been previous research on the issue, spending on these health services still prevail.

“While many studies have focused on high-cost, low-value services, such as arthroscopic knee surgery for osteoarthritis, few have examined which low-value services contribute the most unnecessary costs,” wrote the authors.

The study analyzed data from the Virginia All Player Database in 2014, which included 5.5 beneficiaries of Medicare, Medicare Advantage, Medicaid, and private commercial insurers. The authors, which included co-Editor-in-Chief of The American Journal of Managed Care® A. Mark Fendrick, MD, assessed 44 services commonly deemed low-value. Each of the 44 services were categorized by cost into 4 groups: very low-cost, low-cost, high-cost, and very high-cost.

During that year, those 44 services were performed 5.4 million times. Using an algorithm that determined whether a service was high value or low value, the authors found that 1.7 million of the services performed were deemed low-value and 3.7 million were deemed high-value. Of the 1.7 million low-value services, 1.6 million were low- or very low-cost. Only 119,000 were high- or very high-cost.

The total cost of the low-cost and very-low cost, low-value services ($381 million) was almost double that of high-cost and very high-cost, low-value services ($205 million). With a total of $586 million, $9.90 was spent per beneficiary per month. This accounted for 2.1% of Virginia’s health care costs.

According to the authors, their findings should provide strong incentive for policy makers, healthcare systems, and clinicians to implement better ways to reduce unnecessary costs, without reducing the quality or access of care.

“Shared, nonpartisan health policy goals are to improve quality of care, enhance patient experience, and lower healthcare costs in the United States,” wrote the authors.

A seemingly easy answer to this issue is to identify, measure, and reduce the use of low-value care, but it has been harder to bring the answer to fruition, according to the authors. This is because the value of a specific health service fluctuates based upon who receives the service, who provides it, and where it is provided.

While changing a physician’s practice pattern has proven to be difficult in the past, even a small decrease in the performance of low- and very low-cost low-value services would make a difference.

Output: Low-cost, low-value health services contribute the most to unnecessary health spending in the United States and ultimately cost nearly twice as much as high-cost, low-value health service, according to a new study published in Health Affairs.


Instruction: create a high quality summary of the given input

Input:
The little red pill being pushed on the elderly
 CNN —

The maker of a little red pill intended to treat a rare condition is raking in hundreds of millions of dollars a year as it aggressively targets frail and elderly nursing home residents for whom the drug may be unnecessary or even unsafe, a CNN investigation has found.

And much of the money is coming straight from the federal government.

The pill, called Nuedexta, is approved to treat a disorder marked by sudden and uncontrollable laughing or crying – known as pseudobulbar affect, or PBA. This condition afflicts less than 1% of all Americans, based on a calculation using the drugmaker’s own figures, and it is most commonly associated with people who have multiple sclerosis (MS) or ALS, also known as Lou Gehrig’s disease.

Nuedexta’s financial success, however, is being propelled by a sales force focused on expanding the drug’s use among elderly patients suffering from dementia and Alzheimer’s disease, and high-volume prescribing and advocacy efforts by doctors receiving payments from the company, CNN found.

In her former nursing home, Lenore Greenfield was diagnosed with PBA and prescribed Nuedexta by California psychiatrist Romeo Isidro, a physician who has received hundreds of thousands of dollars in promotional payments from Avanir. Darcy Padilla for CNN

Since 2012, more than half of all Nuedexta pills have gone to long-term care facilities. The number of pills rose to roughly 14 million in 2016, a jump of nearly 400% in just four years, according to data obtained from QuintilesIMS, which tracks pharmaceutical sales. Total sales of Nuedexta reached almost $300 million that year.

Nuedexta is being increasingly prescribed in nursing homes even though drugmaker Avanir Pharmaceuticals acknowledges in prescribing information that the drug has not been extensively studied in elderly patients – prompting critics to liken its use to an uncontrolled experiment. The one study the company conducted solely on patients with Alzheimer’s (a type of dementia) had 194 subjects and found that those on Nuedexta experienced falls at more than twice the rate as those on a placebo.

Avanir declined repeated requests to be interviewed for this article. In an emailed statement, the company said PBA is often “misunderstood” and that the condition can affect people with dementia and other neurological disorders, which are common among residents in long-term care facilities. A company website states PBA can afflict up to roughly 40% of dementia patients – a figure that is based on an Avanir-funded survey and was repeatedly disputed by medical experts interviewed by CNN, including some of those paid by Avanir.

Nuedexta is approved by the Food and Drug Administration (FDA) to treat anyone with PBA, including those with a variety of neurological conditions such as dementia. But geriatric physicians, dementia researchers and other medical experts told CNN that PBA is extremely rare in dementia patients; several said it affects 5% or less. And state regulators have found doctors inappropriately diagnosing nursing home residents with PBA to justify using Nuedexta to treat patients whose confusion, agitation and unruly behavior make them difficult to manage.

“There has to be a diagnosis for every drug prescribed, and that diagnosis has to be real … it cannot be simply made up by a doctor,” said Kathryn Locatell, a geriatric physician who helps the California Department of Justice investigate cases of elder abuse in nursing homes. “There is little to no medical literature to support the drug’s use in nursing home residents (with dementia) – the population apparently being targeted.”

CNN identified dozens of cases across the country since 2013 in which state nursing home inspectors questioned the use of Nuedexta.

In a Los Angeles nursing home last year, regulators found that more than a quarter of its residents – 46 of 162 – had been placed on Nuedexta, noting that a facility psychiatrist had given a talk about the drug to employees. This psychiatrist was a paid speaker for Avanir.

At another facility in 2015, also in Southern California, an employee admitted to inspectors that a resident had been given a diagnosis of PBA to “somehow justify the use” of Nuedexta, even though its intended purpose was to control the resident’s “mood disturbances” and yelling out.

And an Ohio doctor paid by Avanir has come under government investigation for allegedly receiving kickbacks for prescribing the drug and fraudulently diagnosing patients with PBA in order to secure Medicare coverage – though the doctor has denied any wrongdoing.

Based in Aliso Viejo, California, the maker of Nuedexta, Avanir Pharmaceuticals, has been cashing in on nursing homes. Darcy Padilla for CNN

The federal government foots the bill for a big portion of the money being spent on Nuedexta in the form of Medicare Part D prescription drug funding, for people 65 and over and the disabled. In 2015, the most recent year for which data is available, this Medicare program spent $138 million on Nuedexta – up more than 400% from just three years earlier.

Medicare is supposed to pay for drug uses that have been proven safe and effective for the population they are intended to treat or that have been otherwise supported by a specific collection of medical research. Nuedexta is currently only approved by the FDA for patients who have PBA. So experts say that Medicare coverage of the drug, which has been crucial to its financial success, relies on the diagnosis of this single condition. So-called “off-label” prescribing, in which doctors use the drug to treat patients who have not been diagnosed with PBA, would typically not be covered.

The Centers for Medicare & Medicaid Services (CMS) declined to comment on the growing use of Nuedexta in nursing homes.

Thousands of the doctors prescribing Nuedexta have received money, or at least a meal, from its maker – a legal but controversial practice in the industry. Between 2013 and 2016, Avanir and its parent company, Otsuka, paid doctors nearly $14 million for Nuedexta-related consulting, promotional speaking and other services, according to government data. The companies also spent $4.6 million on travel and dining costs, both for speakers and for doctors being targeted by salespeople.

A CNN analysis also found that nearly half the Nuedexta claims filed with Medicare in 2015 came from doctors who had received money or other perks from the company (ranging from a few dollars’ worth of food or drink to hundreds of thousands of dollars in direct payments).

Pharmaceutical companies are allowed to pay a doctor to promote a drug to colleagues and other medical professionals. It is illegal, however, for doctors to prescribe the drug in exchange for kickback payments from a manufacturer.

Several of these paid advocates of Nuedexta argue that PBA manifests differently depending on the person. With dementia patients, they say, the typical crying or laughing outbursts seen in multiple sclerosis patients may be absent. Instead, symptoms may include moaning, wailing, hitting a wheelchair over and over again or repeating the same phrase. And they are adamant that the medication can be life-changing for patients, touting how safe and benign it is.

The patient seemed to be doing fine until she was placed on Nuedexta. Report to the Food and Drug Administration

“I never hear, ‘hey doc, we put a patient on this and had really bad side effects,’” said Jason Kellogg, a geriatric psychiatrist who sees patients at nursing homes across California. Kellogg has received $612,000 in payments, meals and travel from Avanir and its parent company between 2013 and 2016, according to government data. He was a top Medicare prescriber for the drug in 2015, the most recent year for which data is available.

Kellogg, who said he was involved in early company testing of the drug for PBA, said Nuedexta is “such a blessing in psychiatry.”

“In our treatments, we don’t have many meds that are well tolerated, and I would hate if someone took that away from me,” he said.

During the FDA approval process, two key doctors on the committee raised concerns about Nuedexta being used for PBA in Alzheimer’s patients. They both strongly recommended that Nuedexta only be approved for PBA in patients with MS or ALS. They argued that evidence it would be effective in other conditions was “weak,” that not enough was known about the safety of the drug in the elderly, and that it was unclear that PBA even existed in Alzheimer’s patients. Despite these concerns, the agency approved Nuedexta in 2010 for treating PBA in patients who have neurological conditions such as dementia.

Soon after Nuedexta hit the market in 2011, doctors, nurses and family members began filing reports of potential harm – ranging from rashes, dizziness and falls to comas and death. Nuedexta was listed as a “suspect” medication in nearly 1,000 so-called adverse event reports received by the FDA detailing side effects, drug interactions and other issues, CNN found. While the FDA uses these voluntary reports to monitor potential issues with a drug, a report does not mean that a suspected medication has been ruled the cause of the harm.

The FDA declined to comment on these adverse events or the concerns raised about Nuedexta during the approval process. But it did say that after any drug is approved, the agency continues to review safety information from a variety of sources (including adverse event data) and will take action as needed – such as updating a medication’s label, restricting its use or even taking it off the market entirely.

Lon Schneider, director of the University of Southern California’s California Alzheimer’s Disease Center, reviewed information from roughly 500 of the reports which CNN obtained through a Freedom of Information Act request. Schneider, a physician specializing in geriatric and dementia care, said he was concerned about the problems stemming from potential interactions between Nuedexta and other powerful medications intended to treat problematic behaviors.

He warned that given how medicated the elderly typically are, adding just one more pill – especially one that hasn’t been extensively tested – could be dangerous.

One report filed by a nurse practitioner in 2015 detailed the rapid decline of an 86-year-old Alzheimer’s patient after Nuedexta was added to the psychotropic medications she took including Zoloft (an antidepressant), Xanax (an antianxiety drug) and Risperidone (an antipsychotic). Nuedexta had been prescribed to treat PBA and “weeping with underlying Alzheimer’s dementia.”

I’m definitely pushing this a little bit, perhaps considered off label… Pharmacist and promotional speaker

Almost immediately, the woman experienced weakness and fatigue to the point that she was barely able to talk and was described as being “almost unresponsive.” The dose of Nuedexta was increased, and her symptoms worsened. The drug was discontinued about a week later, but she failed to recover. She remained unable to eat or drink and her kidneys failed – ultimately leading to her death.

“The patient seemed to be doing fine,” the nurse practitioner reported, “until she was placed on Nuedexta.”

Aggressive sales force

The combination of two generic drugs that makes up Nuedexta – a cough suppressant and heart medication – was once available from specialty pharmacists willing to combine the ingredients for less than $1 a pill, according to a US Senate report on rising prescription drug prices.

Now the FDA-approved medication costs as much as $12.60 a pill, wholesale pricing data from First Databank shows. That can add up to more than $9,000 a year, though the amount a patient actually pays depends on factors including individual insurance coverage. Medicare Part D spending on the drug averaged $3,400 per patient in 2015.

It is Avanir’s main product and biggest moneymaker. It has gained attention with the public through its television commercial featuring actor Danny Glover seesawing between laughter and tears. And it was this drug’s financial potential that attracted Japanese pharmaceutical giant Otsuka to the boutique California firm, purchasing Avanir for $3.5 billion several years ago. Otsuka declined to comment for this story.

Avanir investor documents have stated that only a small fraction – 100,000 of the 1.8 million patients suffering from moderate to severe PBA – live in long-term care facilities. Yet the company has described nursing homes as key to its growth.

On a 2013 earnings call, Rohan Palekar, a top executive who eventually became CEO but is no longer with the company, said Avanir had “just scratched the surface of its full potential” in nursing homes, according to an online transcript. He said the company aimed to get Nuedexta prescribed in far more facilities. Palekar did not respond to requests for comment.

To rack up these prescriptions, salespeople identified doctors, nurses and pharmacists who could serve as advocates for the drug, according to interviews with former Avanir employees and internal documents and emails reviewed by CNN. Salespeople then worked closely with these advocates to identify potential patients. In one case, a salesperson worked with a doctor’s office manager to pull patients’ charts, identify those who should be screened for PBA and make sure that Nuedexta brochures were inserted in their files. The sales force also coached doctors and facility employees on how to fight for Medicare coverage of the drug if it was initially refused.

Federal laws restrict the tactics pharmaceutical sales representatives can use to sell a medication. They can’t give favor or payments in exchange for a doctor prescribing the drug. They can’t have any contact with private patient records, without the patient’s consent. And they can’t promote use of a drug off-label, in a way that hasn’t been approved by the FDA.

Internal company emails obtained by CNN show a culture filled with intense pressure to get the drug sold and how Avanir sales representatives were encouraged to directly target dementia and Alzheimer’s patients – a practice which is legal as long as these patients also had PBA.

Nearly half the Nuedexta claims filed with Medicare came from doctors who had received payments or meals from the drugmaker. CNN analysis

In an email from several years ago, one of the company’s regional managers, Kevin Tiffany, bluntly urged his salespeople to spend “99.9 percent” of their time focused on such patients.

Devoting time to other conditions more commonly associated with PBA amounted to “diluting your chances,” wrote Tiffany, a senior sales manager in California.

“Give yourself the best chance to win,” Tiffany added.

Tiffany, who no longer works for Avanir, declined to comment through an attorney.

Other emails from managers show how the government’s crackdown on dangerous antipsychotic drugs – which were once widely used to control unruly and erratic behavior in nursing home patients – created an opportunity for Avanir.

After receiving the FDA’s most severe “black box” warning for an increased risk of death in elderly dementia patients, antipsychotics are now closely monitored by government regulators, who penalize and lower the ratings of facilities that overuse them. Internal company communications show Avanir salespeople were directed to specifically target facilities that historically used high levels of antipsychotic medications – facilities that would see Nuedexta as an attractive alternative.

Some of these tactics employed by Avanir salespeople cross into ethical gray areas, said medical ethicists and other experts who were read the emails and sales training documents or provided with details from them.

“It definitely feels like it is too much in the business of prescribing and not in the business of conveying information,” said Michael Santoro, a Santa Clara University professor and an expert in pharmaceutical industry ethics.”It feels like (the salespeople) are actually participating in the prescribing decision.”

In its statement, Avanir said that the company was committed to “an ethical culture,” uses methods “that are consistent with the law” and that its goal is “to give doctors truthful, accurate and balanced information so they can decide on the proper treatment for their patients.”

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Avanir executives have long touted plans for securing FDA approval for Nuedexta’s use to treat dementia patients who don’t have PBA – setting their sights on the more widespread condition of agitation in dementia and Alzheimer’s patients, characterized by emotional and physical outbursts and restless behaviors. The company announced clinical trials for testing a version of the medication for this use in 2015, but those have not yet been completed. Without additional FDA approval for the drug’s use in those conditions, salespeople cannot promote Nuedexta for that purpose. They can only market its use for dementia patients who also have PBA.

There are currently no FDA-approved drugs for treating dementia-related agitation, and other drug makers have been penalized for marketing drugs for this use. Abbott Laboratories Inc., for instance, pleaded guilty in 2012 to illegally marketing an anticonvulsant called Depakote in nursing homes as a way to control agitated and aggressive dementia patients. But the drug had only been approved for treating seizures, bipolar disorder and migraines. The company ultimately paid a total of $1.6 billion in civil and criminal penalties.

Those who care for the elderly remain eager for tools to manage these behaviors, however. Some caregivers say investments in increased staffing can reduce the need for medications. But such measures are expensive and don’t always work, so some facilities opt for pharmaceutical solutions that can help make their many patients easier to treat.”Rather than taking someone off an antipsychotic” and opting to treat the patient in ways that don’t require medication, “providers search for a different ‘magic bullet,’” said Helen Kales, a geriatric psychiatrist and University of Michigan professor.

In one case, the executive director of a California assisted living facility tried to push Nuedexta on a dementia patient to address her “aggressive” behavior, according to emails reviewed by CNN. The director at the facility, Oakmont of Mariner Point in Alameda, California, told the patient’s son, Jason Laveglia, that the medication wasn’t an antipsychotic and threatened to evict his mother if she wasn’t put on the medication.

An Ohio doctor paid by Avanir has come under investigation for allegedly receiving kickbacks for prescribing Nuedexta and fraudulently diagnosing patients with PBA.

“(I)f her behavior cannot be muted through prescription means, I would have no choice but to pursue delivering a 30-day eviction notice,” Joan Riordan wrote to Laveglia last year.

Laveglia turned to the state for help, and by the time officials investigated weeks later, Riordan no longer worked at the facility. Social service officials ultimately found that her eviction attempt had violated state law. A spokesperson for the facility would not comment on the state’s findings, but said it “does not endorse or recommend Nuedexta nor any other medication” and that staff should not be involved in medical decisions.

In an interview with CNN, Riordan disputed the idea that her emails served as an official eviction notice. Riordan, who is not a doctor, said that she had recommended Nuedexta after learning about the medication from a local psychiatrist and had seen it help a number of other aggressive dementia patients without the dangers and sedative effects of an antipsychotic.

“I’ve seen it just work wonders with people,” she said. “It was the only intervention I could come up with. We needed to do something not only for her own benefit, but also for the people around her.”

When asked whether her residents had PBA, Riordan told CNN she had never heard of the condition and had no knowledge of whether they had received such a diagnosis.

Red flags and questionable use

Across the country, the use of Nuedexta in nursing homes has prompted concerns among state regulators whose job is to ensure adherence to federal guidelines and protect residents from being given unnecessary drugs – especially those used as chemical restraints. But to date, the red flags raised by these regulators have been largely left buried in nursing home inspection reports and have drawn little public attention.

CNN identified more than 80 cases in 19 states since 2013 where inspectors cited nursing homes for inappropriate monitoring and use of Nuedexta – often because residents hadn’t exhibited any symptoms of PBA. Many of the cases – about 40% – were clustered in Southern California, where Avanir is based and where former employees said there has been aggressive marketing.

At the Montrose Healthcare Center near Los Angeles, three nursing home residents were given Nuedexta without a doctor’s prescription or approval, according to one inspection report. All were cognitively impaired. One was known to call out for help, while another would cry when their family left the facility. But employees acknowledged that they had never seen the residents laugh or cry involuntarily – the hallmark indicators of PBA.

Is your doctor being paid by a drug company? 02:18 - Source: CNN

Regulators learned of these prescriptions in 2015, after a family member discovered that her relative was receiving Nuedexta without her consent. While researching the medication, she learned it could be dangerous for her family member because of other medications she took for a serious heart condition.

The doctors for all three residents denied ever prescribing Nuedexta. State investigators later discovered nursing staff had obtained the prescriptions without a doctor’s approval, which they are not authorized to do. They also found that at least two nurses at the facility had attended a sales seminar about Nuedexta, where they were given a doctor’s sample prescription for the medication. The facility said in a statement that it had addressed the concerns raised by the state inspection report and suggested that outside pressure had been at play.

“Our Center does not condone the pressuring of nurses by pharmaceutical reps and physicians to favor certain medications,” the facility said. “Should they feel pressured to administer medications they do not feel are appropriate, our nurses can and should bring it to our immediate attention so we may assist them in advocating for their patients.”

In New Jersey, St. Vincent’s Healthcare and Rehab Center was cited by regulators last year because six residents were prescribed Nuedexta even though no symptoms of PBA had been documented. A representative of the facility told CNN it takes a “close look at all medications prescribed to ensure appropriate use.”

One resident in the report told the facility’s psychiatrist there was a legitimate reason for their sadness: “All I really want is a companion. I am lonely.” In the case of another resident given the medication, a nurse said the resident’s crying was an expression of frustration, and that this had improved with a change in routine.

It feels like they are actually participating in the prescribing decision. Ethicist Michael Santoro

Two other residents at the facility were originally prescribed Nuedexta for “Dementia with Behaviors.”

Those diagnoses were then crossed out or rewritten – replaced with “PBA.”

The pill pushers

At first, Alex Carington couldn’t figure out why her 85-year-old mother, Lenore Greenfield, was on Nuedexta, a pill Carington had never heard of. A psychiatrist had prescribed the medication after visiting the elderly woman in her Los Angeles nursing home while she was sleeping, Carington said. Even when the drug appeared to do nothing to ease her mother’s sadness, confusion or emotional outbursts as she battled dementia, she said the doctor kept her on it.

Alex Carington's mother, now 88, is no longer on Nuedexta and lives at a new nursing home. But Carington still questions why she was prescribed the pill in the first place. Darcy Padilla for CNN

“Something about this whole thing made me think money was behind it,” Carington, who lived near her mother’s facility and visited her often, wrote at the time in an online comment on the blog of a psychiatrist who had questioned Nuedexta’s aggressive advertising.

As she began to look into her mother’s doctor, she discovered he had received more than $100,000 from Avanir in just over a year.

Outraged, she finally got her mother taken off Nuedexta for good. Now, around two years later, she is in a new nursing home and Carington believes she is doing much better.

See photo story: Why was my mother prescribed this pill?

Her mother’s doctor was Romeo Isidro, a speaker for Avanir and one of the physicians paid the most by the drugmaker. Between 2013 and 2016, Isidro received more than $500,000 in payments, travel and meals from Avanir and its parent company. According to internal company documents, he was an advocate for Nuedexta as early as 2012, the year after it hit the market.

He had more than 100 patients in 11 facilities on the drug that year.

In Avanir training documents, a California salesperson explained how he worked to get Isidro to prescribe Nuedexta. Now a senior sales manager at the company, Chris Burch wrote in 2012 that he and his colleague saw or spoke to Isidro about twice a week – regularly calling and texting him, and visiting him at both his office and nursing homes. Burch wrote that Isidro was at first skeptical about the condition of PBA, but after he successfully used Nuedexta to treat possible symptoms of it in one patient, he became more comfortable prescribing the medication. Burch then explained how he had directly targeted facilities where Isidro worked, finding employees who could serve as “advocate(s)” to help identify potential Nuedexta candidates for Isidro.

“He is now a speaker and I ask him to advocate in his facilities, corporate facilities, and (to) other psychiatrists, internists and pharmacies,” Burch, who did not respond to requests for comment, wrote in a form used by the company to track certain prescribers.

Give yourself the best chance to win. Avanir sales manager

CNN attempted to contact Isidro by phone and by visiting his office, where two stacks of PBA and Nuedexta pamphlets sat on a table in the waiting room. He declined to be interviewed but ultimately provided a written statement saying that he had “never prescribed medication for financial incentives” and that he prescribes Nuedexta to patients who he has properly diagnosed with PBA.

He also wrote about the first success he had seen with the drug, and how it helped him wean an elderly patient off of dangerous psychotropic medications – noting that her inappropriate crying and screaming symptoms reminded him of a visit from a Nuedexta representative who had told him about PBA. He said Avanir approached him about becoming a speaker, and that he agreed in order to share his first-hand experience with the medication – not to promote it.

“Since learning about PBA, I have become more skilled at recognizing it in my patients, which would in turn produce increased numbers of patients on Nuedexta,” he wrote. “I am not an advocate for a particular drug or pharmaceutical companies. I am an advocate for my patients and their families.”

In response to questions about Carington’s mother, he said he couldn’t comment on specific patients but that memories are not “infallible.” He urged CNN to substantiate any claims with medical records about her case. Carington provided her mother’s records to CNN, which confirmed that Isidro had diagnosed her with PBA and prescribed her Nuedexta, which she remained on for months.

Montrose Healthcare Center, a nursing facility in Montrose, California. Darcy Padilla for CNN

A different speaker paid by Avanir, a pharmacist in northern California, appeared to suggest during a 2012 presentation that doctors could broaden the use of Nuedexta when prescribing, according to an audio recording obtained by CNN. A person in attendance, who recorded the event, identified the pharmacist as Flora Brahmbhatt.

“I’m definitely pushing this a little bit, perhaps considered off label … but maybe it’s effective on some of the other behaviors too that we find challenging,” the pharmacist said in her presentation, which was sponsored by Avanir. “There are certain nursing home chains, specifically in Southern California, that are saying, ‘Hey, if you have somebody with dementia that has a behavior issue, try them on Nuedexta before you put them on a psychotropic (medication.)’ It’s a little aggressive, I’ll say that. But CMS isn’t making it easy for us to use antipsychotics anymore.”

She went on to discuss how a PBA diagnosis was essential for the medication to be “covered by insurance and not be off-label,” as well as how PBA’s definition of inappropriate laughing and crying could be interpreted by physicians. At one point, she told an Avanir employee in the room that they could cover their ears.

“We don’t have anybody from the FDA in here. I’m telling you … you can extrapolate that to mean any kind of socially inappropriate behavior when you’ve ruled out other causes,” she said. “If they have an episodic behavior and they have an underlying neurological condition, you can pretty much come up with a diagnosis.”

When contacted by CNN about the event and asked about the recorded statements, Brahmbhatt said she hadn’t given presentations about Nuedexta for many years. She said she didn’t give permission to be recorded and didn’t recall making those statements. “I don’t know if I said this stuff,” she said. “It was five years ago, at best.” She was read several of the quotes from the recording but declined to listen to it. An attorney representing Brahmbhatt contacted CNN after publication and said that Brahmbhatt denies making the statements in the audio recording.

Former FDA investigator Larry Stevens, who now works for the consulting firm The FDA Group, said it is a violation of federal law for a paid speaker to promote a drug for anything other than its FDA-approved use.

Yet another paid speaker, the Ohio physician accused of accepting kickbacks in exchange for prescribing Nuedexta, has been under government investigation. Internal Avanir documents show Cleveland neurologist Deepak Raheja was a top prescriber of the drug from the beginning, in 2011. Between 2013 and 2016, he received $289,000 in payments, meals and travel.

In addition to allegedly accepting kickbacks, Raheja is accused of fraudulently diagnosing patients with PBA in order to secure Medicare coverage for off-label use and increasing dosages of Nuedexta beyond what is recommended, according to a letter obtained by CNN. The letter, circulated by the Centers for Medicare & Medicaid Services (CMS) in January, alerted insurance providers that work with Medicare about the fraud allegations so that they could take “appropriate measures.”

Medicare officials said the agency could not comment on pending or active investigations. When contacted by CNN, Raheja denied that he had received kickbacks or been involved in any kind of Medicare fraud in his 25 years of practice.

He also said he no longer prescribes Nuedexta.

After this story was published, the Los Angeles City Attorney announced an investigation into Avanir, as well as the marketing and prescribing of Nuedexta. Also, this story was updated to reflect a statement from Flora Brahmbhatt’s attorney made after publication.

Output: The maker of a little red pill intended to treat a rare condition is raking in hundreds of millions of dollars a year as it aggressively targets frail and elderly nursing home residents for whom the drug may be unnecessary or even unsafe, a CNN investigation has found.


Instruction: create a high quality summary of the given input

Input:
Walkable neighborhoods linked with more active older adults
 Credit: CDC/Amanda Mills

Older adults who lived in neighborhoods where it was easy to walk to daily destinations were more physically active than those in less walkable neighborhoods, a study in Barcelona, Spain, showed. The results have implications for efforts to allow older adults to remain healthy and independent while they "age in place" in urban neighborhoods.

"Physical activity is an important aspect of aging because it helps older adults maintain their functional capacity," says Oriol Marquet, a postdoctoral researcher at North Carolina State University and lead author of a paper on the topic. "Being physically active helps older adults postpone their physical decline and the onset of chronic diseases, and provides them with feelings of independence and empowerment that are highly valued for social and emotional health."

For the study, NC State researchers used physical activity data from the Catalan region's cross-sectional travel studies to determine how many older adults met the daily recommendation of 30 minutes of physical activity. Data was collected 10 years apart, for residents 65 to 75 years old in 2004 and for those 75 to 85 years old in 2014, though the study did not track activity for a specific group of participants over time.

Researchers analyzed the activity levels based on physical features of neighborhoods in the Barcelona Metropolitan Region, one of the European areas where the proportion of the population older than 65 is expected to triple over the next 50 years.

Experts calculated walkability scores for each neighborhood based on three factors: a neighborhood's population density; its mix of residential, public and commercial property; and the amount of land with desirable walking destinations such as retail stores, public facilities, service providers and historical areas.

Areas with high population density tended to have high-rise apartments rather than row houses or detached housing. A neighborhood with a good mix of homes, stores and workplaces made it more likely that residents would walk to do their errands or visit friends. Neighborhoods that lacked sidewalks or services within walking distance scored lower on walkability.

"Walking for transport is an important source of physical activity because it does not require special effort or investment, like going to a gym," Marquet said.

Residents 65 to 75 years old in walkable neighborhoods made more trips on foot than those in less walkable neighborhoods, and they were more likely to get in the recommended half-hour of daily physical activity. Those in the 75- to 85-year-old group were slightly less active, but those in more walkable neighborhoods took more trips on foot and spent significantly less time driving.

"This research matters because the U.S. and the world are aging, and where we are growing old matters for our health," said co-author Aaron Hipp, associate professor of community health and sustainability with NC State's College of Natural Resources. "In many of the Barcelona neighborhoods in the study, it's common for residents to stay in one place for long periods of time, maintaining their social ties. We need to find effective ways to build neighborhoods in Barcelona and in North Carolina that support healthy activity and allow older adults to age in place."

Myron Floyd, head of NC State's Department of Parks, Recreation and Tourism Management, said the Barcelona study provides valuable information because of its focus on walking.

"Walking is one of the most accessible forms of physical activity – all you need is a good pair of shoes," Floyd said. "We know the importance of activity in preventing health issues such as Type II diabetes, high blood pressure and obesity."

Floyd is a member of the advisory panel for a recently released national report card from the National Physical Activity Plan, which encourages Americans to become more active. The group's 2017 United States Report Card on Walking and Walkable Communities gave the U.S. only one passing grade – a "C" in adult walking behavior. The report card gave the U.S. a "D" for walkable neighborhoods and for pedestrian policies. In five other categories, the grade was an "F": children and youth walking behavior, pedestrian infrastructure, safety, institutional policies and public transportation. There was an "incomplete" grade for walking programs, based on a lack of data.

"We have a long way to go to increase walking and make neighborhoods more walkable in the U.S.," Floyd said. "But we know improvements will help with health outcomes, and they could be good for business as well by increasing local foot traffic in walkable areas. We hope the report can help in planning and decision-making at each level, with local planners, private industry, state departments of transportation and federal policymakers."

The Barcelona study, "Neighborhood walkability and active ageing: a difference in differences assessment of active transportation over ten years," is published in the Journal of Transport and Health.

More information: Oriol Marquet et al. Neighborhood walkability and active ageing: A difference in differences assessment of active transportation over ten years, Journal of Transport & Health (2017). DOI: 10.1016/j.jth.2017.09.006

Output: Older adults who lived in neighborhoods where it was easy to walk to daily destinations were more physically active than those in less walkable neighborhoods, a study in Barcelona, Spain, showed. The results have implications for efforts to allow older adults to remain healthy and independent while they "age in place" in urban neighborhoods.


Instruction: create a high quality summary of the given input

Input:
Philanthropy and opioids: why we must see beyond addiction
 3 min read

The opioid crisis is the story of many kinds of pain. What tends to dominate that story is an awful paradox: well-meaning efforts to kill pain began to kill people instead. But while the death toll is unquestionably horrifying, this crisis extends well beyond addiction.

The opioid crisis is the story of many kinds of pain. What tends to dominate that story is an awful paradox: fifteen to twenty years ago, well-meaning efforts to kill pain began to kill people instead.

But while the death toll is unquestionably horrifying, this crisis extends well beyond addiction.

It’s also causing huge collateral damage among people in every walk of life who are not addicted. It is creating community-wide aftershocks in child welfare, elder abuse, public safety, criminal justice, the workforce, the economy, caregiving, housing, and, of course, health care. It is ravaging rural America and menacing millions of older people.

This is a wake-up call for all of us, inside and outside of philanthropy, to look beyond addiction and respond to all the aftershocks of the opioid epidemic.

Widening the Lens: the Impact on Rural Communities and Older People

Small towns and rural places are feeling some of the worst impact.

Rural communities tend to be self-reliant, and also older than the rest of the country. Their resources can be limited and they are frequently overlooked. This is a dangerous mix: according to the CDC, people in rural counties are nearly twice as likely to overdose on prescription painkillers as people in cities. The resulting community chaos, personal pain, and economic loss are enormous as well.

A key strength of rural communities – cohesiveness – can actually make matters worse, particularly for older people who are drawn into the troubles of addicted children, friends, and extended family. Many are desperately trying to keep a struggling family member afloat, and the growing number of grandparents raising the children of addicted parents in “grandfamilies” has paralleled the growth of the epidemic.

These gestures of love are not without risk. An older adult living in public housing who tries to shelter an addicted child or grandchild risks eviction under anti-drug use regulations from the Department of Housing and Urban Development. A rise in elder abuse and financial exploitation is also attributed to the opioid crisis, as more adult children with addiction problems move back in with their parents.

Other problems include widespread chronic pain, which patients and geriatricians worry will go untreated as access to opioids is curtailed while alternative treatments remain hard to find, and the lack of age-appropriate treatment options for late-life chemical dependency.

A Blind Spot for Funders

Another stark reality is that philanthropic attention for rural America has historically been disproportionately low. This neglect has been costly for a huge part of the country that is crucial to agriculture, manufacturing, energy, and more. As former Agriculture Secretary Tom Vilsack has said to the philanthropic community about rural America, “Folks, this is an important place, and it needs to be treated as such.”

This is why the organization I lead, Grantmakers In Aging (GIA), has launched a three-year initiative, supported by Margaret A. Cargill Philanthropies, to encourage all types of funders to increase their involvement with rural America. Those interested can learn more at GIAging.org/rural-aging.

A Closer Look: Resources for Philanthropy

This multi-faceted crisis presents numerous entry points for philanthropies of all types and sizes. What’s important now is for funders to begin to help overwhelmed communities figure out what they need and where to start.

A new guide from GIA, Heartache, Pain, and Hope: Rural Communities, Older People, and the Opioid Crisis: An Introduction for Funders, offers information on many existing grant-funded programs and initiatives, such as:

The National Family Caregiver Support Program, and Kinship Navigator programs, which help grandfamilies get the legal and financial options, information, and support they need.

IAMNDN, which draws on the power of intergenerational ties between Native American elders and youth to help combat the culture of drug abuse.

Telepain consults, which use telemedicine to connect providers from rural, tribal, and medically underserved areas with pain medicine specialists.

Counseling services tailored to the needs and preferences of older people, such as Senior Hope Counseling in Albany, NY.

Taking a wide-angle view of the opioid crisis is the only way funders and our partners can hope to have a meaningful impact and help millions of individuals and communities in pain.

Output: The opioid crisis is the story of many kinds of pain. What tends to dominate that story is an awful paradox: fifteen to twenty years ago, well-meaning efforts to kill pain began to kill people instead.


Instruction: create a high quality summary of the given input

Input:
Is Cruise ship living a cheaper option for seniors than assisted living?
 Christy Bieber

The Motley Fool

During retirement, there may come a time when maintaining your current household just becomes too difficult. When the yard work and housecleaning become too much, or when you begin to struggle to get meals on the table, the obvious option many seniors consider: assisted living.

Unfortunately, assisted living can be very expensive and, for some seniors, moving to an assisted living community signals a loss of independence and the end to a retirement spent traveling and enjoying life.

But, assisted living isn't the only option for seniors who find living alone too burdensome. There's an alternative that could be less expensive while providing some of the same perks and benefits: life on the high seas.

That's right. Living on a cruise ship could be a lower-cost way for seniors to take advantage of similar amenities to those provided by assisted living facilities, like all-you-can eat meals, a swimming pool for low-impact exercise, regular companionship and entertainment, and even access to on-board doctors. How does living on a cruise ship compare with assisted living? Let's take a look.

Costs of cruise ships vs. assisted living

Cruise ship living is an attractive alternative for seniors because, in many cases, the costs of cruising are lower than costs of an assisted living facility.

Average costs for an assisted living facility, as of 2017, are around $3,750 per month, according to the Genworth Cost of Care survey. This is around $45,000 annually. The nightly cost of a cruise, on the other hand, averages around $100 per night or less.

A 12-night cruise of the Southern Caribbean, available for an average cost of $779 per person, is just $65 per night. For a senior couple traveling together, discounts of 50% for the second passenger lower combined costs dramatically. Senior discounts, points for frequent cruising, and booking with a rewards credit card keep costs down even further, especially if you opt out of pricey extras like alcoholic drinks or shore excursions.

Not all ships allow full-time residents onboard, but many cruise lines make accommodations for seniors who want to become long-term passengers and remain on the same ship for months or even years at a time. There are also options like Oceania's Around the World Voyage, which is a 180-day cruise happening annually from January to July.

For seniors looking for the very best prices, moving from ship-to-ship to see different areas of the world allows for extra adventure at an especially affordable cost. If you book cruises leaving from the same departure ports, you'll keep transportation costs low. While this makes it impractical to own many possessions, paying for an on-shore storage facility is an option at less than $200 monthly. When combined with an annual cost of a generous $100 per night for cruising, combined annual costs of around $38,900 for ship accommodations and storage are more than $6,000 cheaper than the average assisted living facility.

More: Caribbean cruises: What you need to know in the wake of Irma, Maria

More: 4 ways your home can provide retirement income

More: Caregiving for Alzheimer's patients at risk in coming years, report says

Amenities of assisted living vs. cruise ship living

For seniors considering cruise ship life, it's important to evaluate whether a cruise ship can provide the same level of service as an assisted living facility. The good news is, in most cases, seniors would get fairly comparable assistance.

Assisted living facilities are distinct from nursing homes because assisted living facilities provide less care and support than nursing homes. Nursing home staff helps with routine activities of daily living, such as bathing, using the restroom, and consuming food and drink. Seniors with dementia who require supervision and bedridden or wheelchair-bound seniors who rely on caregivers to tend to basic needs require nursing home care. Seniors in assisted living facilities, on the other hand, often have their own independent apartments or rooms, and the help they receive is typically limited to medication management, transportation, housekeeping services, entertainment, and some meal services.

Cruise ships offer similar amenities to paying passengers of all ages. Most cruise ships have all-inclusive food offerings available throughout the day. There are regular social activities aboard the ship, including games and shows. Cruise ships also have onboard pharmacy services as well as infirmaries with doctors and nurses. Medical staff is typically on-call 24-hours daily for emergencies, and ship healthcare facilities on most major cruise ships are largely comparable to ambulatory care centers.

While there is a cost to obtain medications or use the services of the ship's infirmary, health care services are typically not included at an assisted living facility, either. Medicare pays for covered services provided on cruise ships if those services are obtained within six hours of a U.S. port, although visiting a doctor covered by Medicare is easier for seniors residing at a U.S.-based assisted living facility than for a senior at sea. Seniors could also choose to purchase travel insurance to cover both the costs of treatment aboard the ship and more costly services, such as helicopter transport to a U.S. hospital in case of a serious medical emergency.

For seniors who need a higher level of services that only a nursing home can offer, or for seniors with complicated-to-manage medical conditions who need to see a doctor regularly, cruise ship living is not the answer. But for relatively healthy seniors who can no longer handle the demands of living alone and who want a fun alternative, a cruise ship may just be the ideal retirement option.

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Output: During retirement, there may come a time when maintaining your current household just becomes too difficult. When the yard work and housecleaning become too much, or when you begin to struggle to get meals on the table, the obvious option many seniors consider: assisted living.