Love Conquers Alz

ASST. ATTY GENERAL RICK MOUNTCASTLE (HULU'S DOPESICK) & LEAD INVESTIGATOR JOHN PEIRCE - The TRUTH About Nursing Home Neglect

May 16, 2022 Rick Mountcastle, John Peirce Susie Singer Carter and Don Priess Season 4 Episode 56
Love Conquers Alz
ASST. ATTY GENERAL RICK MOUNTCASTLE (HULU'S DOPESICK) & LEAD INVESTIGATOR JOHN PEIRCE - The TRUTH About Nursing Home Neglect
Show Notes Transcript

In episode 56 of Love Conquers Alz, my outstanding guest co-host, Rosanne Corcoran and I have a very candid and extremely important conversation for anyone who has a loved one in a nursing home or anyone planning to live a long and fulfilling life.
 Like me, Rosanne cared for her mother, Rose, over a 12 year span.  in 2019, Rosanne started a regional Daughterhood Circle in the Philadelphia suburbs . In November of that year she created Daughterhood The Podcast: helping Caregivers navigate their new role. You can also visit Rosanne on her website HeyRoe.com for  information, inspiration and a little company. Previously, I spoke with Rick Mountcastle -Assistant Attorney General for the Commonwealth of Virginia and retired Federal Prosecutor.  Rick and his partner, Randy Ramseyer, led the investigation and prosecution of Purdue Pharma, for falsely marketing OxyContin as told in the Hulu miniseries "Dopesick", where I literally gasped out loud when it was revealed in the last episode that they were going to go after Abbott Laboratories for falsely marketing  Depаkote, to nursing homes- the drug responsible for rendering my physically healthy mother non ambulatory and incontinent in a matter of seven days.
Rick led the investigation and prosecution of Abbott Labs which resulted in criminal and civil penalties totaling $1.5 Billion.  He is back to continue the  conversation we started along with one of his lead investigators, John Peirce – who had boots on the ground inside Nursing Homes  across the US. and  witnessed the many negative results of understaffing that is now too common in too many nursing homes - where people are viewed as commodities and compassion is a liability.  John  was employed as a Special Agent – Criminal Investigator with the Criminal Investigation Division of the IRS in western VA, eastern TN, & western NC.  investigating numerous cases of tax fraud and financial crimes In 2007, John was hired as a Criminal Investigator by the Virginia Office of the Attorney General, Medicaid Fraud Control Unit. In 2013, he was promoted to Investigative Supervisor. While employed by the OAG, he assisted in several healthcare fraud investigations of providers including physicians, pharmaceutical companies, nursing homes, & pain clinics. Many of these investigations were conducted in conjunction with the US Attorney’s Office before he retired in 2021.
Note: There are many facilities that still provide excellent care,  but there is nevertheless a crisis that must be stopped now.
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Don Priess:

Alzheimer's sucks, it's an equal opportunity disease that chips away at everything we hold dear. And to date, there's no cure. So until there is we continue to fight with the most powerful tool in our arsenal. Love. This is love conquers all is a real and really positive podcast that takes a deep dive into everything Alzheimer's, The good, the bad, and everything in between. And now here are your hosts Susie Singer Carter, and me, Don Priess.

Susie Singer Carter:

Hello, I'm Susie Singer Carter and This Is Love Conquers Alz and today is actually a very special day because not only do I have two amazing, outstanding and adorable guests today and I do mean adorable, but I also have an equally outstanding and adorable co host with me today. And her name is Rosanne Corcoran. And like me, Rosanne cared for her mother rose for over a 12 year span starting as a as she puts it a stealth caregiver to a full time caregiver to an in home sandwich caregiver for her mother in her final six years and after finding herself a part of this growing caregiving community like me, and in need of both support and critical information. She has conducted an exhaustive research into caregiving strategies for aging parents, and to assist the community and share information and provide support Rosanne started a regional daughter hoods circle which is incredible look it up and will be in the show notes, some wonderful organization in the Philadelphia suburbs in 2019. And then in November of that year, she created Daughterhood, the podcast, you can also visit Rosanne on her website, HeyRoe.com for caregiver information, inspiration, and a little company...I want to emphasize a little because I become very possessive of this woman as my new BFF. And you're about to see why. So please welcome Rosanne Corcoran.

Rosanne Corcoran:

Thank you, Susie. Susie, so much fun. I've looked forward to this all week Susie to be on the be on the same in the same show with you is just too. So thank Well, thank you for the opportunity.

Susie Singer Carter:

This is the best part of being one of the best parts of being part of this community is meeting really, really fabulous, fun loving, heart centered. People like Rosanne who brings a whole she her podcast is amazing. And she brings a whole other perspective and voice to what we're would talk about all the time. And that's what's so great about this community because everybody has a voice and No, no two situations are alike. So you try to find voices that resonate with you. And and maybe a lot of them do, and maybe just one but honestly, this lady is is fantastic. And I have leaned on her so much that I can't believe that she still likes me. So... She's been my rock during this whole thing with my mom in the hospice situation. And actually the whole, which is why I wanted her on this this particular episode, because we're going to be talking about this nursing home crisis, which is all part of a system that we're all we're all up against. And so she has her experience. I have my experience. And then our two amazing guests have their experience. Right.

Rosanne Corcoran:

Absolutely. Very excited to talk to them.

Susie Singer Carter:

Yeah. And Rosanne lost her mom about a year ago. So her journey is from that perspective over her shoulder, but still well in it still well in the grief and the you know, looking back in the assessment of the whole of the whole process, right?

Rosanne Corcoran:

Yes, absolutely. And I, you know, I cared for her at home. But I still have experience and I know a lot of people who have gone down the same road that your enthusiasm for it, you know, in that trying to navigate the entire system. And anyway, if you're at home or if you're at a community, it's still the same system. There's definitely differences, but overall as as we will find out with Rick and John, it's a system and we're up.

Susie Singer Carter:

It's hard.

Rosanne Corcoran:

It's hard.

Susie Singer Carter:

Yeah. Whether you have it at home or not, because you're still that system is still that system. So...

Rosanne Corcoran:

You're still a commodity.

Susie Singer Carter:

You're still a commodity. Right. Yeah. Okay, well, let's I think we should just jump into an axe. I want to just get into it, let's say absolutely. And I just want this as a part two, which is very exciting for us and this is my first part two I believe in Episode 51. If you haven't listened to it, please do. We dropped it just earlier in January this year. And Don my my A loving co host who is busy golfing today, thanks and well deserved. And I spoke with Rick Mont Castle who is the Assistant Attorney General for the Commonwealth of Virginia, and the retired federal prosecutor. And in my humble opinion, a bonafide hero. And I mean that. And Rick, along with his partner, Randy Ramseyer led the investigation and prosecution of Purdue pharma, which was falsely marketing oxycontin which my family was also a victim of. My brother was addicted to it, and it's, it's a horrific drug. This case was the center of Dopesick, which was a riveting Hulu miniseries of the same name in which Rick is beautifully beautifully portrayed by Peter Sarsgaard, and I literally gasped out loud in episode nine, when I found out that they announced that their next case is going to be going after Abbott Labs, right? Who we're falsely marketing, Depakote, another drug that my family's been a victim to, it's a drug that supposed to treat epilepsy, but instead they were targeting nursing homes to treat agitation, which is associated with dementia and Alzheimer's, which my mom was exhibiting and was falsely diagnosed when she was going to a doctor's appointment as some kind of mental breakdown. And they locked her up into, you know, a mental hold for 72 hours, which turned out to be seven days. It just makes your heart feel so a little bit lighter, that there's people out there that actually care.

Rosanne Corcoran:

Absolutely. It gives you hope. And in that there is someone who has integrity and honesty and wants to stand up for the thing. And it just it gives me it gives me Yeah, it gives everybody that there are still people out there.

Susie Singer Carter:

Yeah. And Danny Strong, who wrote and directed it was such a, he did such a great job of putting a face to this crisis. You know, faces actually not a face a lot of faces. And that's what we're trying to do with Love Conquers Alz and, and Daughterhood the Podcast. So we're so grateful to have brick mountcastle back again to continue this important conversation that we started before, along with one of his lead investigators John Peirce. But let me just brag on John a little bit. So from 1973 to 2005, John Peirce was employed as a special agent, a criminal investigator with the Criminal Investigation Division of the IRS in western Virginia, eastern Tennessee and western North Carolina. He investigated numerous cases of tax fraud as well as financial crimes associated with illegal activities, including drug trafficking, gambling, manufacturing of illegal liquor, cigarette smuggling and investment fraud. In 2007, John was hired as a criminal investigator by the Virginia Office of the Attorney General Medicaid Fraud Control Unit. In 2013. He was promoted to investigative supervisory, he assisted in several health care fraud investigations of providers, including physicians, pharmaceutical companies, nursing homes and pain clinics. Many of these investigations were conducted in conjunction with the US Attorney's office before he retired in 2021. Not only did they find that, Abbott Labs was not the only farmer targeting nursing homes. They witnessed firsthand the negative consequences of understaffing, which is unfortunately too common in too many nursing homes where people are viewed as commodities and compassion as a liability. And since COVID, we've seen the resident to staff member ratio exponentially increase out of control, resulting in a huge uptick in the cases of nursing home neglect and abuse. Now, obviously, there's amazing places my mom has been at them, and they're very competent and caring and compassionate. But that's also not to say that these other situations don't occur and occur too often. So, without further ado, please, please, please help me welcome the Honorable Attorney General Rick Montcastle, and his ace investigator, John Peirce. Hey guys,

Rick Mountcastle:

Hi Susie, Roseanne,

Susie Singer Carter:

Thank you for being here. And I know you have to do your disclaimer.

Rick Mountcastle:

I am. I am currently an assist, the Assistant Attorney General with the Virginia Attorney General's office. I'm actually going to be leaving that position sometime in June. It's time for me to maybe go off to pasture. But I needed to say this disclaimer because I'm still working for him. And that is that any of my statements or comments during this podcast, are my personal views or opinions and are not in any way related to my position with the Office of the Attorney General. So that's the legal disclaimer.

Susie Singer Carter:

So back off everybody.

Rosanne Corcoran:

We're just having a conversation.

Susie Singer Carter:

Yeea, Wer'e just chatting. talking amongst yourselves. John, thank you for coming. I know I don't know if you've done a podcast before, but I don't think so i think i think we're your first is that correct?

John Peirce:

Thank That's correct. I'm glad to be here today. Appreciate the opportunity. But yeah, this is my first experience with this.

Susie Singer Carter:

Well, it's, it's, we're delighted to have you. And we're delighted to meet such a lovely person with such a gigantic heart. And I love your accent. And

John Peirce:

Somethings you just gotta live with

Susie Singer Carter:

You gotta live with it. Yeah. Um, so I just want to just jump in. Rosanne, do you want to start talking? Yeah.

Rosanne Corcoran:

Sure. I mean, you know, I think that we all as, as people, as caregivers, as people that are our advocates, we feel like the healthcare system is here to help us in some way, shape, or form. We take our, our parents, our spouses, our children, what whoever, and we go into the healthcare system, and think that we're going to work together to solve this problem, or to solve whatever issue that we have. And as, as both of you have pointed out, it's more that it's a system than then an actual cooperation between us. It's not about patient centered care, it's kind of moved into spreadsheet care, unfortunately. And I don't know if you can talk about that a little bit as how the it's a system now, instead of what we're hoping for.

Rick Mountcastle:

One thing that Susie said was the she was lamenting that in dealing with health care providers, in regard to her mother's situation, she's had to become the bad person or the bad guy, that is the person who is raising a ruckus, questioning the health care providers, maybe even having to raise her voice, be somebody that she is not does not want to be and is not naturally, but in order to make sure our mother is properly cared for, she's got to turn into this other person who might be viewed as mean and nasty way on people on the receiving end, let me just comment about that, and the need to do that. You know, she's having to do that. And many of the people listening to your podcast, who are this podcast where caregivers end up having to do that, because they are fighting, not that individual health care provider, not that nurse, not that doctor. But basically a system that is in place that is not designed to provide care on an individualized basis. It is designed to provide care on a mass base basis. And your particular loved one who you are there to care for, is not viewed on an individual basis. And so all of those people that you're having to deal with are part of this system. They have pressures coming from the system, for example, nurses, and CNAs and LPNs, that are in direct care in a skilled nursing facility, also, we call the nursing home, we have pressures to get things done with a limited amount of staff. And so they are they're responding to that pressure as part of this system that is designed to basically turn your loved one into just a spreadsheet, a spreadsheet number, okay. And so when you find yourself and I say this to all the listeners, turning into someone that you wouldn't necessarily like because you have to be loud and maybe aggressive. And sometimes even me recognize that you're having to do that, because of the system, not because of the oftentimes understaffed and individually beleaguered healthcare provider.

Susie Singer Carter:

That's such a good, that's a that's a really important point. Because I and I know that and even though I know that and I've said it to the staff, and I've said I know you're understaffed and just bear with me, I'm trying the best to be, you know, to help you help me. And, and still, you know, when when emotions run high, you just think, come on does. Am I the only one that sees this, you know, and is anyone going to say anything, and it's hard because you've My heart breaks for them? It really does. But then you're in survival in a way so you're you're stuck between a rock and a hard place. So you said that just right. You know?

Rick Mountcastle:

You have to do it. You have to do what you have to do.

John Peirce:

You know the reality is you have to do this

Susie Singer Carter:

Yeah. because I think what we're dealing with in the system is you have by the time the resource gets down To the level of the caregiver, that resource goes to a lot of parameters that are set by sex and Tara. And once you have at the time the resource gets down to the application level, in the nursing home, the care being given to the patient, those caregivers is that personalized level are basically in most cases, not given enough resource to meet the needs, that's there, through no fault, largely, and a lot of the time, it's no fault of their own. So because the resource has been limited along the way, now your exposition where it's being delivered in the resource is just not there, it's insufficient. And a lot of the reason behind that is the money angle, the profit angle, decisions are made higher up to to maximize profits. And that impacts directly on the amount of resource care that is delivered to the people down at the ground level. So like Rick said, you know, we see a lot of the problem begins higher, it's not all occurring down here on the ground. So that that that is, is part of the problem in the system. It is and it's confusing, because there are, it can be at the bottom level, at that level, it can be on the what you know, and and we can't, so it's hard because you can't dismiss one for the other, although most of it is coming from the top down. And I have seen that, you know, I witnessed it just recently in terms of just this poor woman, this poor young nurse being thrown out on her own to take care of my mom on the floor at night and making a huge mistake. And basically, she she was it was she was so she was so frazzled, she it was her first time alone on the floor. And she said, I, I don't know what I'm doing. And when I brought it up to her supervisors, and the end the organization, it was like, it's a training problem, your mom's Okay, we got it under control. Thank you for pointing it out.

Rick Mountcastle:

So, you know, we used to be able to rely on physicians and other health care providers because they have the knowledge, right? They know how to treat patients what's we think what's in the best interest of your, your loved one. But I think that the profit motive, the money aspect of it, especially now has changed things quite a bit. Alright. So for example, if a year you have a loved one that is living in a skilled nursing facility, and there's a change in medicine, okay. And because there's some issue that's come up with them, they're given a specific medicine. And if you as a as the loved one, the person who's looking out for, for your loved one, go and ask, why are they getting this particular medicine? But in your example, Susie, why have you prescribed Depakote? The answer you're probably going to get is the answer from the system, which is, the doctor has determined that this is the best medicine for this problem for your loved one. And you as a layperson would tend to, I think, go along with that. Because hey, the doctor knows past well, that I don't think is is how you can approach these things nowadays because of the system in place. One of the one of the things that is out there in almost every nursing home, is that they have a what's called a drug formulary. And so they have a certain list of drugs that they prescribe for that they say this is our formulary, these drugs are what we're going to get for whatever particular elements there are, that those drugs are assigned to. And that's yet okay. And the reason they that many of those facilities have those drugs on their formularies is because the pharmaceutical company and or the in house pharmacy used to be the two big ones are on Medicare and pharmerica. There are more nowadays and are there there's a rebate system where if they put the nursing home puts that drug on the formulary, the pharmaceutical company and or and the pharmacy are going to exchange money and there's going to be a rebate and the nursing home they get a rebate, right so what you have to be able to error of when dealing with healthcare providers in a skilled nursing situation that we're prescribing drugs is you have to be aware that that prescription, or that drug might be getting dispensed to your loved one, not because it's in their best interest, but because it's on the formulary. And it is financially profitable for that nursing home to use that drug off of its formulary because they're getting a rebate from a pharmaceutical company or a pharmacy. So, the what, but what else is normal, lay people who don't have medical training, we're thinking, Oh, the doctor is going to make where that nursing home is going to make that decision based on what's best for my loved one, not necessarily the case. Now, I'm not going to say that they're going to do it in all situations. But you have to understand that part of the system is this financial pressure to get rebates from the the pharmaceutical chain from the pharmaceutical company and or the pharmacy to prescribe certain drugs to your loved one, whether or not it's best for them? Right. That's what we talked about the system. That's what we're talking about. There's this financial system in place. That steers how healthcare is provided.

Susie Singer Carter:

Can you go through the roles of that system? Yeah, cuz you you were sharing that with us in our pre interview and well, you think how is one person how is Susie Singer Carter going to go up against this? And, you know, I'm now looking over my shoulder everywhere I go now, because I after watching Dopesick, I'm like, is that person following me?

Rick Mountcastle:

So let's, let's start at the top, you know, we've got the FDA, Food and Drug Administration that we all believe, is this is the government agency that's making sure that the drugs that are approved to be prescribed are safe and effective, that they're watchdogging, how the pharmaceutical company, pharmaceutical companies are marketing those drugs, they're going to make sure that they market in a correct way. And they don't necessarily do everything that they're portrayed to be able to do. Okay. So there's pressure. Well, you know, even in dope sick, there's pressure on individuals in the FDA, who are employed to review and approve drugs to make sure that they are safe and effective, and that their labeling is proper before they are just this disseminated to patients. They have pressure to cater to the pharmaceutical companies because they want to go work for him at some point. Okay. And just like in the Purdue case, Curtiss Wright approved Oxycontin, as safe and effective, and he approved some pretty, I'm gonna call it lethal language and the package insert that enabled the company to say, hey, the FDA agrees with us that it is that oxycontin is less addictive and less abusable. And courage right after you prove that, shortly thereafter, went to work for Purdue. And there's nothing illegal about that. Okay. That is the system, the system that allows this sort of closing up between the FTAs individuals who work they're cozying up to the drug companies, because they want to go work and make lots more money and they're getting paid at the FDA. And that's part of the CIPA system in place that is financially driven, and not patient driven. The pharmaceutical companies are out there, and they're trying to make as much money as they can offer their drugs. And they're looking for ways to cut corners operate in the gray area, as they did in the Abbott case where they began marketing, Depakote for something that was not approved and not determined to be safe and effective. That is for agitation and elderly dementia patients confined to nursing homes. They did that the FDA is out there. And Abbott was able to do do this illegal marketing for at least eight or maybe more years. Okay, before our office before John and Harold caught up to them. All right, yeah. So where's the FDA for eight to 10 years? Well, not only do they have this financial pressure on some of the individuals to cozy up to the pharmaceutical companies, but they're also understaffed in terms of how they A reviewing the the marketing by drug companies. I mean, they have an office of about 50 or 60 employees who basically are responsible for looking at more than 30,000 marketing pieces per year and impossible task.

Susie Singer Carter:

How? Oh, my goodness.

Rosanne Corcoran:

How is that allowed? How, who thought that was a good idea?

Rick Mountcastle:

Well, you know, Congress is the Congress, which is part of this system, are the ones that appropriate money for the FDA. So it's, it's not necessarily who thought it was a good idea is part of the system. Right? Okay. So, of course, the insurance companies are out there, and they're gonna pay. They're gonna reimburse for what, you know, for certain categories of drugs. And doctors in nursing homes. You know, and I'm not gonna say that this is 100%. But many of the ones that I've looked at, are doctors who are doing the nursing home rounds, as a side job as an expert, that's not their main job. They've got an office where they're seeing patients that are paying them a lot of money. nursing home patients, by and large are, you know, there are some that are self pay, at some point they get their money gets used up and they become Medicaid patients, and Medicaid doesn't pay doctors that well, right. So this is sort of a side gig for now. So they're not necessarily paying a lot of attention to your loved one who was confined to a skilled nursing facility. In fact, many of them probably don't see your loved one more than once or twice a year. And they're either a nurse or a nurse practitioner practitioner is actually the person that is seeing your loved one. Okay?

Susie Singer Carter:

He's saying the truth, you guys. I mean, I'm going through right now. Absolutely. Absolutely.

Rosanne Corcoran:

It's exactly how Rick is saying it.

Rick Mountcastle:

That's part of this system, because it's part of the financial system, because it's not financially profitable for the physician, the doctor to spend a lot of time with your loved one in the nursing home, right. Of course, we've already talked about how the drug companies pay rebates to get their drugs on the formulary, the nursing home wants to make sure that they prescribe the drugs on the formulary because it's cheaper for them. They're getting rebated and incentivized by the drug companies and the pharmacies that that serve the nursing home. So all of these financial pressures, which include the government, are working together to form a system that you as a loved one who was trying to look after, you know, your mom, or your grandma, or your grandpa in a nursing home. That's the system you're having to fight. And so you have to be very much of a mean person, a questioning person, a skeptical person, and not take the Well, the doctor thinks that this is the best thing, right. You might have was this, are you prescribing this? Because it's on your formula? Is that why you're prescribing this drug instead of this other drug, which my mother was on?

Susie Singer Carter:

Right?

Rick Mountcastle:

Previously, that worked? Well,

Susie Singer Carter:

right. When my mom went into hospice, suddenly, she was taken off a couple of drugs. And I said, Without asking me and I said, Why are you doing that? I mean, I thought that's going to keep her comfortable. I'm wondering if it was because they weren't on the formulary? Because I had to fight to keep her on the Blood thinner? Yeah,

Rick Mountcastle:

And we don't know. But you have to question that you have to make sure that you're factoring that fact, into a process, you know, using that to process what they're telling you. Okay.

Susie Singer Carter:

Right.

Rick Mountcastle:

And maybe you have to ask that pointed question. Well, is, you know, is drug A, the one you're given to her giving tour? Now, is that on the formulary? And what about drug B, the one that you didn't get that you stopped? Is that on your formulary or not? Right, since you're what the truth is about, right?

Susie Singer Carter:

And can they go outside of the formulary, or it's just advantageous, or they have to stick to the formulary?

Rick Mountcastle:

Corporate policy probably tells them, You have to stick to the formula? Gotcha. The actual what you can and can't do is they can go outside the formulary, but it's going to cost them it's gonna cost them it's not, it's not cut into the bottom line.

Susie Singer Carter:

it makes so much sense, makes so much sense.

Rick Mountcastle:

So, corporate managers are probably telling them, you cannot go outside the formulary. And then they've got to go get permission to line I think, to do that. And go and so again, part of the system is they go through those folks that are you're talking to that have to go and ask. Well, you know, Susie has come and she wants her mother on drug B which is not a formulary, they have to go through you know, basically people or people don't like conflict, well, now they're in a conflict with their boss and the boss's boss. Right? They want her boss to take the path of least resistance nature. And you're forcing them into some kind of conflict, which they don't like,

Susie Singer Carter:

I get it. And I don't like it either. I don't like it. And you're so right, I'm just going to keep validating everything you guys say. So I can put a face on it and just say, you know, my mom has been in desperate need of a wound Doctor specialist to come in. And they kept when, when she got back to the place that she's at, and they said, Yes, we're going to do that. And then it took three weeks to get a nurse practitioner, who they told me was better than the doctor. And only once, and only once. And now my mom is back in the hospital because of this gigantic, horrible thing on her back. And it's awful. And so, yeah, and you know, so you can't you you cannot, unfortunately, you trust, anything that said to you, if you if you smell something's wrong, believe it. Right, right, John? Exactly, I see you shaking your head,

John Peirce:

You have to understand that it gets back a little bit to what I was talking about a little earlier is a limited resource in a nursing home. So they may take the resource away from your mother and put it over here, they move them around, unfortunately, because there's not enough resources to take care of all the needs. So they move them around. And they do that to create the, the easiest scenario for the nursing home. So if they get a Susie that comes in and out becomes somewhat disruptive, my mom's getting this. And you know, I've got a problem with it. And I'm gonna be back tomorrow if you don't fix this. So you become the bad person, like he, like you said, you become the bad person. Now you get the attention, and prompts them to move the resource back to your mother. So that's kind of what you're faced with, you already know this. But again, it's it's the profit motive is reducing the amount of resources getting down to the ground, is because we're looking to maximize profit, not maximize quality of service. So the amount of service is getting down has been minimized, because the money has been taken off in another place in the chain. It's like Rick said, that's, that's the way the system works.

Susie Singer Carter:

Quality of Service, thus quality of life.

John Peirce:

Exactly.

Susie Singer Carter:

Right?

Rosanne Corcoran:

II's amazing, though, because, okay, so it's the system and the pharmaceutical company, FDA, the insurance company, the skilled nursing, okay, so it's the circle, well, how much money that they're making, that the resources aren't being, you know, pushed to the people, which is who they're they're supposed to be serving. But yet, they're compiling this massive profit. So when is it enough? It's, I mean, they keep running to to make this profit, that's great. Well, is is a million dollar profit enough? Is $4 million profit enough? In the meantime, the people that you're serving are suffering every day. So how does that how does those scales get back into balance? Because they're horribly out of balance right now? What can be done to get them back into balance?

Susie Singer Carter:

That's a huge question. Oh, boy.

Rosanne Corcoran:

I know, I know. But you know, I mean, really?

Susie Singer Carter:

Well, it comes down to how rich can people be like nobody needs really billions of dollars. It's dangerous to have that much money, I think, but that's another another topic.

Rosanne Corcoran:

But, but Is that is that it? Is that it? It's it's it's an I don't want to say it's as simple as its profit. But is that what it really all of this? All of this? The way it's set up? Is that really, the bottom line here is just it's just profit?

Rick Mountcastle:

If you're asking me, I'd say the answer is yes. The way that nursing homes have been run and has changed has evolved over the years, you know, went from being sort of a local community place where the community was involved in it. their loved ones were this nursing home, their people from the community work in nursing home and people from the community made financial decisions for that nursing home. So there was a lot more person it was more personal, right. You know, the CEO of that nursing home, you know, their their kids went to school with the kids of someone who has a loved one there. So it's all that has now changed to where these nursing homes are now being. They're owned and operated by investors. Okay, one or more investors. because we don't live in a community who, you know, put together a group of nursing homes as an investment, they maybe get some other investors in who are have no relationship to that community. And now just becomes a balance sheet. And the, you know, and more of a corporate type of entity, or and the nursing home as part of that corporate group of nursing homes, and the people that are now making the decisions, they're not looking at quality of care. That's not one of the factors. They don't get briefed on quality character monthly meetings, they're getting briefed on profit, return on investment. And if it's a corporation, what's the share price? And the briefing also is has a discussion on it? And how can we increase each one of those things? What do we need to do to increase them? But never on any kind of those agendas? My opinion, will you find item number four? How do we improve care?

Susie Singer Carter:

Right? And would you say that they're also motivated, because I'm feeling this by you know, that that they make a lot of decisions based on their fear of liability. So they take the path of least resistance in terms of Let's do everything not to be liable for, you know, any kind of misconduct? I've heard from nurses saying, I can't do that. I don't want to get fired. We're not allowed to do that, because we could be liable.

Rick Mountcastle:

You might have your, again, your folks who are the employees, who are the hands on people that are worried about getting fired, but I think our experienced hires up in terms of worried about liability. John, what do you think that the the CEOs, the owners of a nursing home? How much do you think they're worried about liability, or being caught doing something?

John Peirce:

Well, what we've seen, they've established policies that possibly are being carried out, but what we've seen in the investigation, we've had people at the upper corporate levels, tend to tend to feel assured in the levels of insulation that they have, that they are not walking the halls every day, that they are not taking the complaints from the ground level that they're, you know, states away, they're making decisions, possibly, okay, we're gonna, we're gonna put money into this, we're gonna put money into this not gonna put money into this. They transmit that down to the people on the ground who are making the decisions that could place a liability issues, whereas the corporate people feel like, well, you know, we didn't try that now. We're here making these decisions. So what we've seen is, is typically, the higher levels, they tend to feel partly well insulated. They don't like Greg says they don't they don't seem to worry a lot about that kind of liability,

Susie Singer Carter:

Really? So like, even if they're caught of misconduct or or like wrongful death or anything like that they're not driven by that, or they're insulated is what you're saying. Did I just did I, did I say something wrong?

Rosanne Corcoran:

You did.

Susie Singer Carter:

Did I go right there?

John Peirce:

If you have an incident of abuse or an incident of lack of care that takes place at the local level? Are the nurse or CNA tracing the responsibility for that, back through three, four layers of corporate management, to executive vice president or vice president who may be sitting three, four states away, who has not been in that facility, maybe never. Right? So establishing that connection sufficiently to seek any kind of criminal charge is a pretty high burden. And that's, of course what we did. That's what our job was and it can be done. But it can be a difficult task.

Susie Singer Carter:

Gotcha. For the average, not for not as sleuth as investigator and a, and a and a fabulous Assistant Attorney General.

Rick Mountcastle:

Well, yeah, well, I don't know about that. But just like say, you know, and maybe this is a topic for another podcast because we did. John is alluding to a case we did after the advocates involved in nursing home and trying to hold the corporate CEO owner who is in Florida liable. It was very difficult. And, you know, it may be something we could talk about in another podcast, because it's a whole story unto itself. But the other part of going back to the theme of the system, okay. I will also say this, my personal opinion is that the Department of Justice, who I worked for for 32 years, and I enjoyed every minute of that job as a federal prosecutor, but the Department of Justice is part of that system as well. Okay. And as came out in the Purdue case, when the folks on the ground wanted to prosecute, you know, executives at Purdue for serious felonies to Department of Justice, you know, system when the demotion they prevented us from doing that. And I believe that the Department of Justice also prevents not only that case, but many other cases where you there are laws in place federal laws in place, a federal law in place where you could hold executives respond personally accountable criminally for the conduct of their corporation that violates federal law, and spent and that department justice for some reason, and I have spoken about that to them, when I was an Assistant US Attorney, are reluctant to use that law. And I think that is also part of the problem, part of the systemic problem, in terms of making sure that there's corporate personal corporate responsibility on the part of CEOs,

Susie Singer Carter:

Wow.

Rick Mountcastle:

...and other executives making decisions.

Susie Singer Carter:

So wow, this is, this is daunting, because it's like, if they're not worried about any kind of liability, and they're, they're sufficiently insulated, and they feel very cocky about it, then what power do we have as caregivers to other than just being immensely annoying? You know, just to get the get you off their back? That's it? I mean, other than that, like we do we have any recourse?

Rick Mountcastle:

That's a tough question. In part one of this podcast, and there's not a good answer, because the caregivers who are facing that system, you've got to fight tooth and nail, you have got to use just about all of your energy, and resources, just to make sure that your loved one individually gets the care that they need. That doesn't leave much space to go out there and try to change a system that is weighted heavily, heavily against any kind of change, you're talking about. A system where you, you'd have to get Congress to act, and they're very much dependent on money from the nursing home lobby, the pharmaceutical company lobby, the physicians lobby, you know, you have all of this money coming into them. And to that, that, again, part of the system that skews against changing it, okay. And so I'd be very hesitant, because I know how much you're, the folks listening to this podcast are going through personally, how much energy how much it takes out of you to just take care of your loved one, especially if they have Alzheimer's. But then on top of that, you're trying to find a system just to get the care that your loved one basic care that they need. There's nothing left in the tank for those folks. I mean, I don't know how you can then say, Okay, now let's take on the system that is so stacked against you,

Rosanne Corcoran:

What can you do, Rick and John? Is it? Is it the physical being present there? Is that what it is? Is that the they have to see you so they know that somebody is there is is that the best approach? Because it sounds like otherwise, there's no there's no going higher. So what you can do on a daily basis for the person that is in this facility in this community is to be there and show your face...

Susie Singer Carter:

Even then...

Rosanne Corcoran:

...and accountability. Well, I know but it's it's a something --

Susie Singer Carter:

It's a something --

Rosanne Corcoran:

...is that... Because it sounds like as far as the system is concerned. That's that's a whole nother quagmire. So then what can a caregiver do?

Susie Singer Carter:

John, you were there.

John Peirce:

I think... I think. That is without question. I mean, that's the best thing a caregiver can do. I mean, that's what we've seen. I think you've seen it. You've both seen it. We know that that's the case. You have to be there. You have to be persistent. You have to be a problem. If you want your loved one to get the care they deserve. Being there regularly not giving up asking questions, asking hard questions, refusing to take answers that are insufficient. Unfortunately, that is the name of the game. Beyond that, I know in Virginia, there are some resources available. There's some here in Virginia, we have a state office of ombudsman for long term care. That's, that's a legal resource. They also have local offices on Aging, I'm sure every state is different. This is strictly Virginia. These people by and large, we work with them to some degree, they're good people that, that know the problems and really have a desire to do something about it. They're somewhat limited at times, but that still resource, you may go there, you may make a complaint, nothing may come up. But then again, something may come up the departments of the Departments of Health in the state of Virginia, Virginia Department of Health regulates the nursing homes. That's, that's a, as another resource. You may go there, you might make a complaint, nothing comes of it. But it possibly could. So that's another layer beyond that. And this is all pat answers that you get go to your congressman, Gov, this go to that. Sometimes that actually has an impact, quite honestly, most of the time it does. Sometimes it may, okay. But it's to be brutally honest, you get back to what we've been talking about here, you're on the ground, you have to stand up for your love. You'd have to stand up for your loved one on the local level. And typically, the louder you are, the more persistent you are, the more successful you will be. But that, as you know, is a great drain upon yourself as a caregiver.

Susie Singer Carter:

It really is, it really is, it's, you know, it's not my nature to be that way. My nature is, you know, I have a disease to please and I want it, you know, and and it's been, it's been hard to walk into a facility and say, Good morning, and people go, literally grunted at you. Because you're the enemy.

Rosanne Corcoran:

Well, yeah. And there's, and it's fearful, because you're only there for that period of time, and then you're leaving, and they are there with your person. So, you know, you can't be adversarial because they are with your person. So there's a very fine line, to try to balance that.

Susie Singer Carter:

Don't go the same time. Go a different time. That's what I do. They never know when I'm coming. I don't know, it' just something I do.

Rick Mountcastle:

You know, maybe this is a crazy idea or answer to your question. Because it's not one that's easy. And it's not one that can happen overnight. But it's it's the communities need to just maybe take back those kinds of those facilities in our community. And I don't know how you do that. But I do know, as a fact that when nursing homes were locally owned, and you know, operated by people in a local community, there was more they're not saying there were perfect, I'm sure there were there were issues, but there was more of a feeling of service to the patient versus service to the financial well being a corporation. But I don't know how you do that. It, you know, it's it's money is what really talks these days and in terms of our society, everybody wants to be an investor and everybody that an investor wants to have a return on their investment. So, you know, I don't know how many if you own any kind of a stock portfolio, you may have stocks in nursing homes and and nursing homes or feeding your stock portfolio portfolio. So are you going to really complain that much about it? I don't know. But to me that seems to be in terms of a fix. How do we get people in the community to pull together their resources maybe and and say, We want to get this nursing home back and we want to make sure it's taken care of our love ones --

Susie Singer Carter:

Right.

Rick Mountcastle:

Because, if you live long enough. We're all going to be there.

Susie Singer Carter:

So they're all going to be there God willing, as my mom would say. But John, I have a question for you. Are the nursing homes not held to the same medical standard? as a as a hospital because I feel like why is that? Why are the hospitals seem to be? I'm not saying they're perfect either. But they seem to be more judicious about the kinds of steps that they take. And they seem to be very concerned about doing the right thing. It seems like there there's much more concern about liability, are there different standards that they have to satisfy as opposed to a nursing home?

John Peirce:

My thinking is that, at least in the state of Virginia, the amount of oversight and amount of regulation for nursing facilities may not lie at the same level as for a hospital, Rick may know more about this than I do. There is still an amount of oversight, they still are held to, to certain standards. Whether whether or not that is as closely monitored, as let's say, a hospital. I'm not, I'm not really that familiar. I do not think they're held to the same standards. I do not think they're regulated by the same bodies. Nor are they held to the same standard.

Susie Singer Carter:

That's a big chasm, especially in a skilled nursing home where they're working with Foley catheters and G tubes and massive wounds on people that are, you know, bedridden, those things are medical services that they are providing to our loved ones. And yet the standard is different. And that seems that seems that doesn't seem right, Rick?

Rick Mountcastle:

Yeah, I think the hospitals are probably on a higher standard, and they're probably some state licensing standards that they have to meet. They also have, they're doing procedures that are invasive a lot more. And so there's a higher degree of liability in terms of malpractice. There's a lot of regulation in hospitals do cut through the state agencies in terms of licensing all the staff in a hospital. Nursing homes, on the other hand, have their blood sugar regulation stem from a federal regulation under HHS, Health and Human Services. But the standards are very kind of vague. For example, as we talked about, in part one, there are no minimum staffing requirements for nurses and certified nursing assistants and alike in a in any of those regulations. There, the the insurance coverage on nursing homes is substantially different from hospitals, right hospitals are covered by large insurers like Blue Cross, and so there's a lot more money that hospitals can earn by providing more services, whereas nursing homes, you're either self pay or Medicaid, right. And nursing homes will go through a self pay patients resources pretty quick and turn them into a Medicaid patient. And Medicaid payments are limited. Okay. So there's less money to be made. In a nursing home setting, the standards and regulations are a lot more vague. And, you know, Jeff, basically, it's it's the language is sort of like to the tune of must provide care to sufficiently thrive. You know, what does all that mean? In terms of specifics, it doesn't run. Right. And we talked about, we're talking about one of the ways because understaffing seems to be the root of a lot of the problems in nursing homes, we talked about getting that the states really could solve that problem by imposing minimum staffing requirements. And I hear this story more and more, and it's ridiculous. When CNA is taking care of 50 patients on an overnight shift is ridiculous, but that is there's nothing that prevents that. Okay. That is that is not unusual. That's not contrary to regulation, but certainly insufficient. If you you know, you all know that just from observation. But it would be a whole different thing. If there was a requirement that the states each of the states imposed that said no, 50 patients, you got to have three or four whatever the number is that experts say should there should be that really, I think would, would go a long way. wouldn't solve everything completely, but would go along, but Yeah, huge step in making things better conditions better in nursing homes. So yeah, two different standards. The nursing homes are not regulated as much as hospitals, they're not at all their standards aren't as high as hospitals. They're the root of the problem. Those are understaffed. Everything goes back to that. You know if there's excess pressure sores, nine, not enough staff to turn patients adequately that aren't able to do it themselves enough patients to trip and night of staff to treat those those wounds, right? If there's if there's malnutrition, and if there's dehydration, not enough staff to adequately feed the residents, they can't feed themselves not have staff. That's that's the route, in my my personal opinion, that's the route of most of the problems

Susie Singer Carter:

Yeah. 100% 100%. And that, and also the fact that they're not held to the same standard because they are, they are, you know, providing medical services, right. And the reason why my mom was in the hospital, again, is because of a medical service that they weren't providing properly. And I kept saying it to them. Are you sure that should be in my mom had a catheter? You sure that should be in there that long? That was from the hospital? What made it easier on them? And and right, so she ended up hemorrhaging, because it was just in there too long. And that that's frightening.

Rosanne Corcoran:

Well, right. But in a nursing home, if most of the most of the people that live there are, are on Medicaid and Medicaid doesn't pay a lot, is... it sounds like it's rife for the deals with the pharmaceuticals to make that extra money to make up for the Medicaid not paying as much? And it's it sounds like that's just the cycle. That's the that's the wheel? Wouldn't it be? Because Medicaid only has so much they only have so many resources for each state for the number of people on Medicaid. So it's just that It's that continual? Well, how do we get more money? Well, if we get if the pharmaceutical company can pay us, and if the if we can alleviate some of the loss from the Medicaid payment or lack thereof, is that part of this system?

John Peirce:

Absolutely, I mean, when profit motive is what drives what drives the show, there's profit to be made on both sides of the coin, you bring in as much money as you can, that's why a lot of nursing homes, push for Medicare rehab patients, they like to get Medicare rehab patients in all their beds, because they get more money, right. So let's maximize the money that's coming in, get more Medicare rehab, not as many Medicaid patients that's for private pay more money. So you try to maximize on that side, bring in as much money as you can, then you go to the other side, try to minimize all the money that goes out, where are things that you can do that with? Well, instead of hiring 100 people per facility, you hire 50. So you cut your payroll. So what happened to the payroll, they went in, it went end up bottom line, they went in the bottom line, so then you manipulate other expense categories, you might be you instead of buying a doctor that says the quality a you you bow be be modest. Right patient stop getting the good doctor, but you save money, right? So you constantly got those manipulations, but leadership and these things to work the money and and often, of course, the results of all this is where is the patient is the resin is not getting what they need the resources finally, spit out ball this is insufficient. So now all of the staff is trying to allocate that limited resource,

Susie Singer Carter:

Right. But how is it done in the hospital? Like why can my mom go into a hospital with her Medicare and Medicaid? Why why is she Why does she get the better service there as opposed to in a nursing home?

Rick Mountcastle:

Patient mix. And I've heard this term used also patient mix is also part of the system. Right? So all of these facilities look at what is the what patient mix should we have to maximize profits? Well patient mix means how many private insurance patients do you have? How many Medicaid patients do you have? How many Medicare rehab patients do you have? That number that's your patient mix? Yeah, hospitals have their normal natural patient mix, I think is such that they have a lot more private insurance insurance. Unless you have long term care insurance, your typical Blue Cross and Aetna and all those don't pay for long term care in a nursing home. Now it's only Medicaid, Medicare rehab for up to 100 days only after that, you know no coverage and self pay. And then a few patients who managed to you know, buy Long Term Care Insurance which eventually all yourself any patients are turned into Medicaid patients.

Susie Singer Carter:

Yeah. And by the way, self does the long term insurance at least in California, there's no regulation on that people that I know that have bought it. At they the rules change when they go to use it. It's suddenly like, it's not for the rest of your life. It's for certain period--.

Rosanne Corcoran:

No! If the company is still in other companies still available, yeah.

Rick Mountcastle:

And then they'll become Medicaid patients. So really the patient mix in a nursing home, very much heavily Medicaid, which is lower reimbursement than in the hospital where, okay, your mom's a Medicaid patient, but she's only one out of you know, a nurse for her. There's there's 25 others that have private insurance or something else, so they don't have to,

Susie Singer Carter:

It offsets the loss..

Rick Mountcastle:

And think about this, what is the biggest cost in not only a nursing home, but pretty much any business these days.

Susie Singer Carter:

Employees.

Rick Mountcastle:

What's your biggest cost?

Rosanne Corcoran:

Health care, health care.

Rick Mountcastle:

But, but the health care is part of Employee Benefits.

Susie Singer Carter:

Its employees.

Rick Mountcastle:

Your personnel. Yeah, right. Right. Yeah, exactly biggest maximize your profit, you want to end you want to cut costs the most you cut people, you cut staff. That's just - and until there's a required minimum number of staff per patient in a nursing home, they're going to be chronically understaffed.

Susie Singer Carter:

And with COVID, there's not a part of our society that hasn't been affected by it. I mean, there was a whole story on on on KCRW yesterday about teachers, for special ed students, there's not enough teachers anymore, who are... so they're hiring people that aren't qualified, just to have bodies. And this is what's happening in nursing homes, their training as they go, which I saw that I witnessed that, and I understand it, but there needs to be some transparency to us. So that we know as as caregivers, and residents, what we're up against. So just give us a fair, you know, you know, because I think one of the things that you said that was very profound in our pre interview was that, you know, it doesn't matter how much you spend on your care, or how, and what the advertising says and how beautiful the brochure is, and the rating system on it, because they're all the same. I'm sorry to have such a depressing conversation, you guys. But let's get real, because, you know, I want to live a long time. And I don't want to end up like that. And I don't think you do. Sometimes I say it's a blessing my mom has Alzheimer's, because she doesn't really realize what a burden she seems to be to most people. You know what I mean? And that's sad, to me, that hurts my feelings. And I'm glad that she doesn't know that.

Rosanne Corcoran:

Well, it's also one of those things where people don't realize until they're in it, and then they get in it. And they're like, wait a minute, what is this? Is this how it is? And it's like, yeah, that's how it is. And that I don't know how you it needs to be more prevalent, we need to talk about it more. So people understand that this is this is the path, you can't keep up with these costs. There's no way you can, you can save enough money to pay for your care, as you age, they're just you're gonna run through it. And everybody winds up on Medicaid. And I don't think people realize that everybody winds up on Medicaid eventually, because you've run through you live long enough. There might be there might be a little there might be a small percentage of gazillionaires. That don't, but for the rest of us, eventually, that's what happens. And there has to be some sort of a better setup for that. I'm sorry, Rick, I started to speak and I cut you off, I believe.

Rick Mountcastle:

No, no, that's No, I I think you're right. And again, you know, to me, we're not going to change the system because it's been in place for so long. Congress is beholden to monies from nursing homeowners, you know, and other people in the health care industry from pharmaceutical companies, and they're not going to pass any kind of legislation that limits themselves from receiving that money. And then but but the one thing that seems that would make things better, not perfect, but better is to somehow get the state's regulatory, you know, the state legislatures to impose minimum staffing requirements. So, you know, and the problem Is this that I've had conversations with people about their loved one nursing home many times, and they talk about how well they're not, you know, people don't come and check on them in a timely basis. They're not taken to the bathroom, they're not changed when they wet, get wet, and all that kind of stuff on a timely basis. And unfortunately, I've gotten to a point where I say, You know what, unfortunately, that is just the way it is in every nursing home in the country, because they're understaffed. And I hate that I have that, that's my view. But unfortunately, I think it's the reality, and how do you fix that so that you're not going to make things go from being bad, to Now, hey, they're great, but you couldn't make it went from being bad to being better. If they had enough staff there to, you know, -- get people up and feed them that need that

Susie Singer Carter:

Right. need help and turn them so they don't get pressure stories and change them in a timely way. If they get they soil themselves and all that if they had enough people to do that in a timely basis. It wouldn't take a lot. But unfortunately, it would cut into corporate profits. So sorry to do that. But it would improve health care a huge amount. Right. But what can we do to in-- like, what would incentivize them to do that, then? Because they're like you said, it's bottom line? So what would what would be the incentive to do that, other than some kind of standard that they have to be held to? And what and the repercussions of not being held to that standard? It seems like other than that, we're just saying, be good guys. And, you know, like, I mean, where do we get our leverage from? I know, he's saying the system is tight, and it's really locked up. But what part of the system isn't? Is there any is there any hole on that system that I can fit through? I'm tiny, I go through it.

Rick Mountcastle:

You've got to get to your state legislature tours, the ones that pass the laws for the state and somehow convinced them that you don't have to be addicted to the money from nursing home lobby, you need to make, do something that's going to help our loved ones improve their lives and pass legislation that says nursing homes have to have a minimum staffing reform. That's my, that's the only thing I can think of. John, I don't know if you have any....

John Peirce:

No, I mean, I think that's in a nutshell. And you know, I hope I'm not speaking without a sufficient basis here. But I believe I have seen in the news that possibly, there has been some talk by the Biden administration about the need for staffing standards in nursing facilities. I don't think I'm wrong there. And I hesitate to admit that because I don't really know any of the details. Okay. But I do seem to remember that I have seen some something along those lines in the media. So the fact that government at some level is talking about this, to me is some hope, because that's how it starts. You have to talk about it, you have to acknowledge the need. And I think everybody in the industry knows this is the problem. And I think in America, our society, I won't say we got blindsided by this problem, but we we should have seen it coming and we didn't.

Susie Singer Carter:

Yep.

John Peirce:

But over the last several decades. We all know our elderly population has grown fairly substantially. Yes. So we, as a society didn't see this, maybe didn't acknowledge this, that, hey, people are living longer, we're getting more elderly people with the problems that go along with that. So all of a sudden, we have a demand on a system that probably wasn't up to handling it would have been a problem in and of itself. And then we throw in the fact that hey, guess what, these are just the gray area like a lot of money. Okay? The money that comes in is good. It's mostly coming from the government. So the money's pretty secure coming in and we can play around with what we're spending going out so we can make a lot of money here. So throw those two factors together. And I think that's given rise to where we are today. And, unfortunately, who's tried to burn the brunt of dealing with that it gets down to the people like you to on the ground, tried to make sure your your loved ones are getting some level of care, beginning government to at least acknowledge and talk about this, I think is the beginning of my career. says, you know, it's obviously an uphill battle getting as the legislature but hey, before Obamacare, there was no national health insurance.

Susie Singer Carter:

Oh, yeah, no. So it's got to start somewhere.

John Peirce:

Yeah, exactly. You got to start somewhere.

Rosanne Corcoran:

It's a whisper, to a conversation, to a yelling, to a, "let's fix this".

Susie Singer Carter:

Like, I think there's nothing better, more more important for me to do as I'm a filmmaker, but, you know, this will become a film. It has to, in and because I'm seeing too much. And, and, and it's deep. I mean, it's multi, like you said, you know, and on an on a human level, it becomes a journey that is, I mean, so massive that I, I'm obsessed with it right now, because I see, I feel like, I possibly have enough energy to do it. I don't, I don't know, I'll see. I feel, you know, I, I feel like I was blessed with a lot of energy. So I should make the best of it and see what I can do with that. And, and also, I'm extremely emotional. So, you know, I, I'm on both sides, I feel like I feel like, you know, maybe I have good tools to do at least make some noise and bang the drum and pots and pans, at least get some, you know, some ears and eyes on a situation that is, is probably the worst crisis we could have right now. Because it's a financial crisis. It's a it's an emotional crisis. And it's it's gotta be a universal crisis. We can't be the only country like this. I mean, this has got, you know, we are we have just marginal I know, ours is the worst, I'm going to tell us all put up, put myself on the line and say that, but we have marginalize the hell out of aging and see it as a, you know, a liability and an embarrassment as opposed to party in the celebration. So that's just crappy. It's just crappy. And I can't I mean, it's just the worst so. So anywhere in that system, I guess the, our, our best bet, as you said, I'm going to repeat, is to, is legislation. And to continue to... because I know people have

Rosanne Corcoran:

To re-- a revamping of the, of the nursing tried, and I know they get turned down. Wasn't there a big report that just came out a 600 page report Rosanne, that was like home system. And the last time it was revamped was in 1987. Which is insane or 83. It was, it's insane. Yeah.

Susie Singer Carter:

And it was dismissed.

Rosanne Corcoran:

It's got to make it through its system. It's got to make it up the chain. And I mean, we've heard we've heard why the resistance is there. And it makes perfect sense when you when you lay it out like that it makes perfect sense. And then it's just a matter of how we go forward with this.

Susie Singer Carter:

All right, back to the happy news. So John. Back to you. So I Okay, so here's John, what's the most egregious thing you you found? When you were boots on the ground? I'll tell you, my new you tell me yours.

John Peirce:

I would say, you know, in the Abbott Case, and there's obviously many facets to that investigation to that case, there was a lot of elements involved. All across the healthcare, industry, pharmaceuticals, medical, I think what what concerned me the most that I saw in that case was, you know, the pharmaceutical companies they operate pretty simply, they're, they're in business to make money. They're in business to develop products and sell them and make money. Okay, that's, that's why they operate the way they do. But I guess what would concern me the most is the ailments in the medical community. And I'm talking about researchers, I'm talking about medical doctors, practitioners, that seem to be more than willing to maybe not carry out their, their standards in what they did and how they, how they interpreted things and how they did their activities. Because to me, people in the medical community, they take an oath, they're held to a higher standard. That's right. So, you know, to say the most egregious thing I saw in that particular case, that that was an area of concern for me because I know at least in my parents generation, You know, if you were a doctor, what you said was gospel, right? Never challenged anything. Having no medical affiliation is like the. And of course, I don't think most of us nowadays are at that point. But I know at least at one point in America, Americans were, yeah, that's a lot of power. That's a lot of power right there. Just because someone has a medical degree or whatever hack for their name. So to me to see somebody in that position, then take that position, and turn it around and stored it somewhat for their own gain that was bothersome to me,

Susie Singer Carter:

I agree with you, I and I saw, I've seen that. I saw that personally, recently. And, you know, so much for the Hippocratic Oath. And, and, you know, and I think, again, going back to what you said, Rick, that even the doctors are understaffed, you know, so for so they're, they're doing, they're doing the minimal amount, because they don't feel big. I'm sure, like, one of the doctors I know, that's, you know, isn't is older, and I think tired. And, you know, and as up against the system, too, so it's better, it's easier to just go with the flow. And not, you know, not not fight for their patience, because they're just tired. And I get it. I get it. I'm not, you know, I can't even I don't, I don't really know, I only think we can blame what's like, you know, the fish smells at the head. Is that the same? I mean, I think that's the other one, I won't say because it's no ugly. But, you know, I, I do think that everybody is is is in the process is a victim of whoever's above them. And and then the lack of regulation that protects them as well as us. Right? Does that make sense?

Rosanne Corcoran:

Well, it sounds like the Abbott case, and the Purdue case ran the same course. In that, we're going to we're going to say that this provides this to my patients when really it was over here. And then it just kind of ran Is that pretty accurate? That Abbott kind of followed Purdue's playbook? Purdue with Oxycotin and Abbott with Depakote

Rick Mountcastle:

It's accurate in a general sense. So, in the Purdue case, it was basically just lying about the drugs, the dangers of Oxycontin, basically lying and saying that oxycontin was less than less prone to being abused, then other opioids than the competitor opioids. Similarly, what avid did was to well, they maybe even took it a step further, they took a drug that was approved for one set of uses epilepsy, bipolar mania prophylaxis for migraine headaches, and market it for something that was completely outside of those uses. That is treatment of agitation and regression and elderly dementia patients primarily in nursing homes. And the FDA had made it clear to them that they would not sign on to any kind of approval for that, that use, even if they did studies that were successful. So in some respects, he was they went completely outside the lane to promote that drug whereas Purdue they took a drug that was a pain, Dr promoted it for pain, but lie completely about whether it was addictive or abusable or not. And the result, of course, was much more clear and much more devastating. Because now we have the opioid crisis as a result of that, and 100,000 people a year are dying of opioid overdoses, but avid in similar fashion and many other form. You know, if you go and look at the Department of Justice's website at their press releases over the years beginning back into the mid to late 1990s Up to the present. There have been dozens of settlements with pharmaceutical companies for the unlawful and improper marketing of their particular drug. Dozens of dozens upon dozens and some companies have had it done to you know, they've been caught multiple times, always resulting in a large monetary fine and restitution and all that but and rarely have a involved holding a corporate decision maker and individual responsible. So it's the cost of doing business, basically. And Abbott Did you know they went about In a very blatant, and I think arrogant way, they set up a whole division within the company that was devoted to marketing it for an unapproved use, I mean, part of their organizational structure, a box for this long term care division to promote the drug for something that was blatantly not approved in that in that realm. Oh, my gosh, it was pretty arrogant. Yeah, and and then they used they use these clinical studies, which John can speak to probably in more detail, because he kind of focused in on that they took clinical studies that basically failed, that said, well, Depakote doesn't really do anything more than placebo, it doesn't really address that. And cherry picked language out of that to promote the use those promote the drug to doctors. And what they were doing was was trying to evade these, the obra 87 regulations of anti-psychotics. And they were saying that those regulations don't apply to us. If you have agitation or aggression in elderly, elderly, dementia patients, nursing homes, and doctors prescribing from nursing homes, if you prescribe Depakote then you don't have to worry about this script scrutiny would again if you prescribed an anti psychotic? John, if you want to add to that.

John Peirce:

Yeah, the whole thing with the clinical studies, as Rick said there was no approved use for this drug for agitation in dementia. So they were looking at a situation where this has been one of their flagship drugs, and they were about to lose their patent protection drug and after a long time. So you've got a limited amount of time left before you lose patent. So they, their theory was that hey, you know, based on research, we think that this drug actually is therapeutic to the the underlying disease here. Okay, the Depakote actually treats the ailment in the brain that causes dementia. So that was there thoery.

Susie Singer Carter:

Aye yi yi.

Rosanne Corcoran:

Oh, my goodness,

John Peirce:

A clinical trial that is going to show that. So they geared up to do this trial. Now, keep in mind, you know, Rick mentioned that they set up a whole sales division. So they they already set up the sales division, this sales, the salespeople are already going out there. Marketing this drug, you know, to treat dementia patients with agitation at the same time, now they're saying, Oh, we're going to do this study, to show that this works. So they care enough. And they started out and and it did very poorly. They shut it down pretty pretty soon after they started it. They started to revive it at a later time, but they never did. So they had no clinical studies, to take to the FDA, to show that this drug is actually a therapeutic airport needs, it needs to be approved for this use. All during this time period. They have salespeople out there marketing this drug to treat this condition. So the clinical trials was that was going to be that passed, let them get up there and do this, but they were doing it when they didn't even have a clue

Rosanne Corcoran:

Anyway.

John Peirce:

And their theory just it never, it just never held up. This drug was not therapeutic to the underlying condition.

Susie Singer Carter:

No.

John Peirce:

So, as Rick said, that's kind of a blatant operation when when you don't even have the trial, you're trying to set up a trial to cover what you're already doing.

Susie Singer Carter:

Because they're because they can be arrogant because because that system, they feel insulated, like you said, so there's this arrogance that and that, that could bleed over not just in our senior, you know, community but into all communities that that use medication and we don't we really are at the mercy of I mean, I don't even know what how do you trust anything like you know, I remember one of my, a friend of mine who's a nurse said, oh, you know, Metformin is really good for losing weight, which is like a diabetic drug. And she's like, all my friends are on it. Do you want some? It's like no, I don't. I don't want that. No, thank you.

Rosanne Corcoran:

So there's there's the drug How do you find out like legitimate information about the drugs, is it drugs.com? is are they Shadid? Like, how do you find this out? So that if if, if a doctor says, Okay, we're going to try this drug, I mean, I go to drugs.com I go to I go to the NIH, I look everything up. But then is that? Is that what you should do? Because in my mind, I think, well, if if somebody comes to the doctor and says, I have this pill, and it will treat this, doesn't the doctor look at that? Or do they just go by what's on that paper? Like, here? We have these clinical trials that we're lying to you about, but it says it does this, like how do you how do you maneuver through all that?

Rick Mountcastle:

With answer your question, as as ludicrous as it may sound doctors do listen to the non medical, retrained pharmaceutical rep that walks through their door, as they did in the, as they did in the case of Purdue and Oxycontin, much, much to my shock, than a physician's had been a medical school for, you know, four years plus, on top of their college education, they've done a residency for I don't know how many years two to four years after then somebody just out of college walks into their door with their history degree or whatever, not nothing. Well, history rates are the same. I do read business economics, they walk through the door and say, let me just tell you all about this drug and marketing pitch and the doctors, you know, they go along with it. It's easier. Again, path of least resistance easier for doctors spend two hours of their free time researching and reading power.

Susie Singer Carter:

They can't. They can't.

Rosanne Corcoran:

They can't, they can't. It's impossible.

Susie Singer Carter:

my brother? 900 milligrams of OxyContin a day? What he goes, Do you know that your brother had a laminectomy and a back surgery? I go, Yeah, I do. Because I had the same surgery. I had a laminectomy. I had a ruptured disc, I go, I know how bad it feels. And I said, Nope, nobody needs to be on that much oxycontin or pain medicine. I didn't even know what oxycontin was. I just knew it was pain medicine. I was like, why are you prescribing so much to him? And he said, Everybody's pain level is different. The end. That's what he told me.

Rick Mountcastle:

And that was the marketing spiel that he was parroting to you what the marketing discussion was that came out of Purdue.

Susie Singer Carter:

Yep. Yeah, it was horrible. So. So let's recap. You guys are great. I love you two bits,

Rosanne Corcoran:

You guys are great.

Susie Singer Carter:

Know your enemy. I'm quoting you, John, know your enemy. If you can. Go. Be there. Be present. If you can't be present, there's records you can ask for them. You can ask for what your loved one's on, ask them to give you a list of the drugs that they're on. And do your research. Go, whatever you can do go to drugs.com. Go to to the NIH go to the CDC, it's on us. We have to protect ourselves. And we have to be vocal. So did I miss anything else?

Rick Mountcastle:

I'll say one thing, I will say add to that list. It's okay to be a mean person when you're advocating for your loved one, especially in a nursing in the nursing home system. And that's because you're fighting a system you're not fighting those individuals. Keep that in mind.

Susie Singer Carter:

Beautifully said, that's that is that is

Rosanne Corcoran:

Yeah.

Susie Singer Carter:

So if you have stories, let's tell. let's good to know. And I get to remind myself all the time, tell the story. They're really powerful. I know that as a because I've literally walked in and said, I don't want to be this person, please stop making me be this person. You know, and, and I just the other night, one of the nurses walked out in the other nurse stayed behind and she said, "If I, if that was my mom, I do the same thing. You're doing a good thing". And I broke into tears because I was like, "Can I hug you? Thank you." Wow, I mean if these two people that this is what they do for our did for a living, it's like and say how hard it is can you only imagine for us. So, but of course there's power in numbers and it's gotta start somewhere. So needs to start. filmmaker, doing the film on my mom has really resonated and it makes a difference if you can tell a personal story dope sick that Hulu put on was that was a brave story to tell. And and it's it was important if you haven't seen it, watch it. It's hard to watch. Roseanne was like every she's like I can't watch anymore. It's I'm so frustrated. I'm so frustrated. I said, "You..."

Rosanne Corcoran:

Rick, I don't I don't know, man. I don't know how you did it, Rick. I don't know how you did it.

Rick Mountcastle:

Yeah, I think part as I look back part of how I was able to do that, or be in that case, and push through that case, was because it was from a really small office was because of people like, you know, in both the applications well, because of people like John Harold. And being in a small office was an advantage. Because, you know, John and I have worked together for over 30 years, Carol and I had worked together for even longer than that. And so by the time we got into these cases, you know, we we know each other, we had a personal relationship with each other. And you can do a lot more when you are working with people like that, that you know, that you have relationship with, that all are pulling towards the same goal that have no personal agendas, no monetary agendas other than trying to do the right thing. So, so that is, you know, I couldn't have done that by myself in a normal environment without people like John and Harrow, you know, being able to work with them and see them on a day to day basis and know that we were all about just getting doing the right thing and not having all these other agendas out there. And being able to withstand the the opposition that was presented. In those cases, you got to have a group of people that help you do that

Susie Singer Carter:

You really do. You got to find like minded people in any situation, that you're trying to get something done, and you have to find your tribe.

Rosanne Corcoran:

Thank you. And thank you, and thank you for all the work that you've done. That both of you have done.

Susie Singer Carter:

And Harrell. And Harrell.

Rosanne Corcoran:

And Harrell. Because it's it's it made a difference, and It made a huge difference. You're honest and honorable men that have integrity and are not afraid to stand up and I thank you at whatever personal cost, it may have cost you away from your families and away from anything else that you wanted to do in your life. But it was important and it was, it's you know,

Susie Singer Carter:

thank you. Yeah, thank you for being just such amazing men anyway, like, Rick knows I love you. And you've been so helpful with me just on a personal level, just supporting what I'm going through. And John, I, I just thank you so much to your delight. And I everybody just keep keep on keep on trying don't give up. We are strong together and follow Rosanne everywhere on on HeyRoe.com and on her wonderful podcast, Daughterhood the Podcast and and, and also, thank you for listening or watching us on love conquers all, and share our shows with other people that you think might need this information and especially this episode. And you know why you guys? Because--

Rosanne Corcoran:

Because you'll just keep going...

Susie Singer Carter:

I'm just gonna keep going. Because, as a matter of fact, here's why. Because love is powerful. Love is contagious. And Love Conquers Alz. And it really does