Archive for month: March, 2013

Want to Boost Revenues? Pay Every Employee a Commission

28 Mar
March 28, 2013


Particularly in the current economy, how can a small company safely and effectively grow? Much has been said recently about the impact of higher taxes — should the company postpone hiring? Rely more heavily on on part time or contingency staff?

Our company, Fishbowl, is sitting at approximately 100 employees. However, while our employee base has stayed relatively stable for the past two years, our revenues have soared by more than 60 percent year over year since 2007.

How have we accomplished it? Having an excellent product and hiring the right talent is key. However, much of our success is due to our highly unusual compensation strategy that motivates everybody in the business to help the company grow.

We put every member of the company — and we do mean everyone — on commission. In our opinion, every employee contributes to sales, so we pay everyone based on company revenues, instead of using a more traditional bonus or profit-sharing plan. The commission ratios vary from development to marketing to finance, administration, sales and customer support, and in the various areas are based on the metrics the individuals are most able to directly control. In some respect, every person’s compensation is configured as a base plus commission. Consider the advantages of this compensation plan:more, the commission is paid every month.

• Every employee is inherently motivated to help the company focus on creating revenue.

• Job security and company stability increases, as the company’s greatest cost — payroll — rises and falls automatically along with revenue creation.

• In a company that can’t offer stock options, this is a structure that acts like a stock dividend, motivating teams to pull together and to pull harder as they think of the company’s good.

• It closes the inherent gaps and divisions between departments by ensuring everyone is focused on revenue, profit, and savings, versus individual department agendas.

The commission structure encourages transparency and team participation. Everyone knows what the monthly operational “nut” is. Each day the employees get a report on how how far we are toward that revenue goal. Beyond the break-even sum, two-thirds of additional revenue goes to the commission pools for each department to share among its members. One-third goes to the company.

Yes, we are entrusting employees with sensitive and confidential information. But in our model, the team is highly engaged as compensation decisions act as an invisible “belt” to hold our decisions in check. Every team decides as a unit how to distribute their portion of profits. Do we need another programmer to meet a critical goal? As the developers look at the discretionary fund they’ll divide, they help to decide if the time is right for an additional programmer who can help to drive new features for future profit, or if they are able to “crunch it up” a little to keep the funds for themselves and accomplish the work on their own.

Towards the end of every month, we see individuals from every department offering extra resources and help to other divisions. A developer or member of a support team may go to the sales department, for example, to say, “I have an extra half hour. Is there anything I can do to help you finish a sale?”

Are there any disadvantages to this structure? Only a few:

• The commission plan is different for every role and for every department. Ratios range from 10 percent salary and 90 percent commission for salespeople to 80 percent salary and 20 percent commission for programmers and engineers. This can make for a complicated structure at times. We’re perpetually improving our ability to adjust and adapt.

• Is payroll difficult? In theory, it could be — but in practice, as long as we ensure the commission numbers are accurate, each department can submit its list of amounts within the payroll software and the automated payroll system takes care of the rest.

• Are there legal technicalities? Yes. It does require support from HR to build a program to ensure that we are compliant at all times with overtime pay requirements under the FLSA (Fair Labor Standards Act). We continually receive counsel from compensation professionals to ensure our programs are sound and correct.

• The structure of commission is so foreign to many employees that we’ve actually missed some prospective hires. Because of the commission structure, our base salaries are typically lower than average (by perhaps 20%), and in a very lean month there will perhaps be no commission at all. However, in fruitful months, the commission can increase employees’ income by as much as even 40-50%. Even so, there are admittedly some individuals who are unable to adapt to the prospect of compensation that may vary by as much as 50% every month.

Here are some specific examples to illustrate our structure. For a junior programmer who might make a market-rate salary of $60,000, we’d offer perhaps $48,000 plus commission. Then we would show them our revenue history, pointing toward the strong possibility that, based on this record, that they will actually make $65-75,000 per year. For an administrative employee, perhaps we would pay $10 an hour coupled with a 30-40% commission. In many months, the individual would make $15 an hour and even as much as $20 an hour, with commission actually matching their salary. (While skeptics might wonder how and admin can drive sales, in fact these employees have significant power to assist directly and indirectly in helping us close our company’s sales; they are often the ones that touch our customers the most.)

Overall, we pay more than market compensation through our commission model, by 20-50 percent. Yet in a lean month, we have sufficient revenue to cover the core expense “nut” without depleting savings or relying on borrowed operational funds.

On the whole, our employees have applauded our structure. In hindsight, we realize the hires who wouldn’t join Fishbowl due to their perception our compensation system seems risky probably aren’t as entrepreneurial and highly motivated as those who have joined us.

After a short while on this program, we have found the majority of our employees to be highly resistant to going away from this plan.

Interestingly, our structure has made it easier for potential stars to determine and to control their rising wages. We seldom need to change a base salary. Individuals who are ready for an increase are ready to build, sell, train and support to a greater degree (in other words, to produce more revenue). This means that the rise in income is something our team members can largely influence and control on their own. As a point of reference, as incomes for the majority of incomes actually decreased in 2011 and 2012, our employees’ incomes increased by an average of 19% in 2012. We considered it a profound achievement for us as a company, and for them.

If we ever considered changing our base-plus-commission plan, we suspect we’d have a mutiny on our hands. We believe this structure could benefit every small company in 2013 that is looking for an effective way to stay safe in the current economic climate while also accelerating their ability to grow.

More blog posts by David K. Williams and Mary Michelle Scott
More on: Compensation

David K. Williams and Mary Michelle Scott are CEO and President, respectively, the paired leadership team of Fishbowl, provider of Fishbowl Inventory Software, and one of Utah’s and America’s fastest growing companies. Fishbowl is based in Orem, Utah.



27 Mar
March 27, 2013





This is just wonderful.

March 26, 2013 at 9:29 a.m.REPLYRECOMMEND


L PierroNew York
Kudos Marty for stimulating this dialog on one of the defining issues of the next 50 years – the aging of the Baby-Boom generation. The comments show just how personal this issue is, and how it impacts all of us, uniting us in our desire for life until death. What some of those commenting don’t realize is that Marty’s eloquence masks the struggles he has faced, and conjures up images of a scholarly professor in an ivory tower. Nothing could be further from the truth.


Entering the long-term care world before age 50 is unimaginable for most, even worse with your mind fully in tact but your body ravaged by Parkinson’s. How ironic that it happened to someone who was already fully engaged in long-term care as a pioneer in the insurance industry, a twist worthy of Kafka. But Marty believed deeply in what he did, and bought a policy in his early 40’s. It has served him well, and we can all learn from that, too.


For me, assisted living was experienced through my mother, who had Alzheimer’s, and was lucky enough to find a good facility when living at home became impossible. And through Marty, who was not so lucky the first time around, but has found a place he can live comfortably in. We have been friends for 25 years, and I have learned a great deal from him, both before and after his illness. Now, his unique perspectives from inside the LTC world shine a light on the need for humanity to embrace the aging process, revere it, and give it the attention it deserves.
March 26, 2013 at



Berkeley BeeSan Francisco, CA
Mr. Bayne writes quite accurately, and with poignance, when he calls us all out as “This culture of people with tiny hearts who live on glaciers of ambition.” Sadly, on target. I will not forget this column or this phrase soon. Thank you, Mr. Bayne.
March 25, 2013 at 4:08 p.m.REPLYRECOMMEND1


rssteinAmherst, MA
My wife who suffers from Parkinson’s and is recovering from some broken bones from falls recently returned home from an Extended Care facility. The facility was excellent and, being retired, I could spend several hours a day with her and join her for lunch. Despite this being good, she enjoys being home where I and my daughters can provide caregiving, and we can afford to have people come in to help. Hoiwever, Medicare does not pay for such home help, even though it is cheaper than nurding home costs. We need better ways to make it possible for such people be at home where the environment is often more enjoyable and stimulating. I believe adequate home care, with necessary help is a better solution than intitutional care. As an 87 year old, I think of what I want in the future. I certainly would prefer to be at home. A saving grace is that I’m a “computer nerd” and enjoy keeping up with the world’s events and having electrtonic contact with friends. My hope is that I can continue doing this as long as possioble. I have met the famous physicist, Stephen Hawkings, who continu

es to produce and make important contributions despite a debilitating illness. His is a fortunate way to satisfy one’s needs.

March 25, 2013 at 8:25 a.m.REPLYRECOMMEND3


P.Ellen KChicago
With no disrespect to Mr Bayne, his Q&A responses are clueless at best and elitist – the product of a man who ran a successful business. Most people don’t fail in that category. If the gate keeping question to get into assisted living is whether and what your passion is at that time of your life, most would fail. The elderly in my acquaintance- my parents, my aunt and uncle, the friends of theirs I have known for more than 50 years have reached the point where any passion could be better described as an effort to not just slog through a day..


I get that he wants to live with people who are mentally vigorous, but by the time most people choose or have to go into assisted living, that is one more item that does not work very well any more. It is not the Little Old Lady chorus line of Mel Brooks out there


The majority of middle class/professional /formerly white collar people with whom I am acquainted struggle financially at life’s end. His criteria would have them pressing their faces to the glass while people like Bayne, who had money and some remaining energy and ability for social interaction “maximize their potential”.


Don’t forget t toss

them a piece of cake on your way out , Marie, er, Mr Bayne.

March 24, 2013 at 2:20 p.m.REPLYRECOMMEND1


mkbayneCenter Valley PA
Elitist? Why is it that the most vigorous challenges are always from those who have no solutions of their own? (and have never actually lived one day in an institutional aging facility.)
March 25, 2013 at 8:21 a.m.RECOMMEND2


Berkeley BeeSan Francisco, CA
I am delighted that Mr. Bayne has expressed himself so well AND, I am sure, he reflects the perspective of people of the 20th and 21 century as they age.


I know that I have heard many of the same comments from my mother who will turn 87 later this year. She did not have a high-powered career, but was a long-time administrative assistant (until the age of 72!), and a mom and a wife.


Mom still lives i

n the same house where all four of us kids grew up and it is becoming more of a “job” that an joy.

As we all start to look at options, she wants and needs to live in a place where she is challenged and there is a lot of stimulation. We want her to have that kind of environment, too!
March 25, 2013 at 4:08 p.m.RECOMMEND2


CaseySanta Ynez, CA
Mr. Bayne is speaking for himself and what would work for him. I’m sure there are many people who would benefit from implementing his ideas.


My mother lived in 2 assisted living places before she finally died last April. At the first one she had a small 1 bedroom apartment. She was quite ambulatory and enjoyed many activities, mostly Bridge which she played at least once a week. But I don’t think she would have liked doing small jobs in the community. She did do her own laundry for years and I think that was enough. Nor would she have wanted to participate in a group meeting every week to talk about how things were going. That was not her style. Maybe not her generation’s style.


When her health deteriorated she moved to an assisted living, special care facility She had her own room. There were many people at that place that were in similar circumstances. There was 1 woman who loved to help the care givers sort laundry. Others played bridge (my mom), played in a Bell Choir (my mom) and were involved in various other activities, depending on their

 abilities. Some were just content to stay in their rooms.


I don’t think a 1 size fits all approach will work for everyone. My suggestions: More caregivers, tasty food and a large private room. If some people want to have a “job” make that possible. But many enjoy the extra activities like bingo, art classes and making music, lectures etc.
March 23, 2013 at 6:03 p.m.REPLYRECOMMEND1


Is it feasible for 3-5 people to pool their resources, rent or buy a home and hire staff to assist them? Would government pay for part of all of this as it would be many times cheaper yet more humane than larger institutions?
March 23, 2013 at 10:11 a.m.REPLYRECOMMEND5


bebarEast Coast
No matter how good the facility is, the most important thing family can do to make life more bearable for any care-needing person is to visit , and touch, and listen, almost EVERY DAY. This means p

lacing the person in a nearby facility, of course. No one matters more than family.


Most people say they would prefer to stay home or live with relatives. But that is not always best or even practical. So plan ahead! Choose your own place. Based on what I have seen of various senior living arrangements among our family and friends, I can say that IF I live to be 80 I will be shopping for a facility for myself (near my kids) and move in before I am 85. From what have seen, one key is to move into a continuing care facility (one that offers independent living with some amenities, assisted living, rehab/nursing, dementia care, and hospice) when you are still active and well enough to make friends and join in the activities. Most people wait too long – until the issue is forced upon them.


Please don’t let money be the only thing that matters.
March 23, 2013 at 10:10 a.m.REPLYRECOMMEND3


MarinaSouthern Cal.
You are so very right and I hope to make sensible decisions around the same age you do.
In contrast, my in-laws clung to their single family home into their 90s, critically evaluating family members and friends who realized they were aging and needed to move to more suitable housing when they were younger (say, late 70s or early 80s.) So then, when my father-in-law died rather unexpectedly (after a very short and never really diagnosed illness), my nonagen

arian mother-in-law still figured she’d stay put. After awhile, thankfully, she did finally realize she was now A L O N E in a big house that she did not know how to take care of. After moving, however, into the local very nice CCRC (an an independent living resident) she lamented that she and her now-deceased husband should “probably” have moved sooner. No doubt about it, they should have, particularly because my father-in-law was by far the more gregarious of the two and would have facilitated their both making friends. Moreover, they were both physically agile in their 80s. Now, in her early 90s, my mother-in-law is far less mobile, though still remarkably healthy and mentally alert. And she is making a remarkable adjustment, but it is much harder than it would otherwise have been, and she’s having far less fun than she could be having if she had the chance to become more integrated when she could participate in more activities (especially off-site trips). At any rate, Bebar, it pays to plan ahead.

March 26, 2013 at 9:29 a.m.RECOMMEND


TrentonWashington, D.C.
“A good litmus test for when things really turn around will be when they stop paying sub-par wages to personal attendants, many of whom are women of color who work like crazy. That’s when we know there will be a change. Making sure that employees in these facilities are treated like human beings — like we would want to be treated. Until that happens, we’re going nowhere.”




March 23, 2013 at 10:07 a.m.REPLYRECOMMEND13


train rydernorth America
I spend almost 6 months of the year (in 4-5 week increments) in the “retirement home” where my Canadian partner lives full time.


For a while I was depressed because of the need and loneliness around me and the fact that I don’t “go home”.. I learned to connect by sitting, listening. As a female, I’m careful about touching men. altho, they DO need touch as much as the women do. I do as much as I have the energy to do. I still live my own life.. that’s very important. I remind some people of who they still are. I congratulate some people for just making it down the hall. the self-discipline and effort is equal to that of an athelete and I celebrate that.


The time will come when my William is gone. I’m beginning to search for my own solutions. The task of clearing out my home is already becoming overwhelming.
March 23, 2013 at 10:04 a.m.REPLYRECOMMEND2


My parents, at gre

at expense, were in assisted care before their deaths. I agree that the general staff are greatly underpaid and they are understaffed and the care is low level. Like many of our problems here in the US, it comes down to corporate greed. In addition, my complaints to the authorities in PA, the overseers of nursing homes, went unheard. Taxes paid by us go to these for profits and they should be made to use more funds for care. Bottom line, if your rich, you can have good medical care. And, for those of you think socialism is a bad thing, I suggest you investigate how the rest of the developed nations care for the elderly and compare. By the way, those countries also have national child care, enabling non-skilled workers to go work.

March 22, 2013 at 4:10 p.m.REPLYRECOMMEND4


BarbaraLong Island, New York
Could someone set up Martin Bayne on a YouTube video and help him broadcast his insights to a wider audience? And how about interviewing him for a TV special report on the needs of aging boomers? There are more and more of us everyday.
March 22, 2013 at 4:10 p.m.REPLYRECOMMEND15


mkbayneCenter Valley PA
Barbara, contact me at
March 25, 2013 at 8:



Tess HardingThe New York Globe
As Boomer begin to age out in staggering numbers, Mr. Bayne’s interview was a like the canary in the coal mine. Isn’t it about time we woke up to the next phase of life and what it could be if mindful people like Mr. Bayne can help guide us?
March 22, 2013 at 4:10 p.m.REPLYRECOMMEND4


mkbayneCenter Valley PA
I’m ready when you are
March 25, 2013 at 8:21 a.m.RECOMMEND1



, sc

I ‘m a group therapist in a geropsychiatric outpatient program and It’s amazing the curative power of the group in freeing members of pent up feelings and Breaking through their isolation. They all gain so much in sharing and. Connecting with others going thru the same things–anger, rage,helplessness, powerlessness. This man expresses it so well.
March 22, 2013 at 4:10 p.m.REPLYRECOMMEND2


My mother spent two-and-a-half years in a nursing home. She had me to visit every day and bring her new stacks of large print books, that she spent all day, every day, reading. Without that stimulation, I’m very afraid she would have sunk into the torpor and despair I saw overcoming most other residents.


There are so many problems with nursing homes, but the overwhelming one I saw was that well over half of the residents–I’d guess seventy to eighty percent of them–had dementia. Those still mobile were in locked wards, but once they were in a wheelchair, they were down in the regular wings.


This presence of huge numbers of patients with dementia exerts incredible influence on the care of everyone. Underpaid, poorly trained aides tend to treat all residents as if they were not mentally a

cute. There is little effort made to provide books. The administration left the air conditioning on well into the fall so they could be comfortable in their suits. Meanwhile, the residents were freezing at night. I had my mother dressed as if she were camping in Maine. But so many of the residents have not the capacity to understand or complain.


I don’t know the answer. I just know I am doing everything I can to ensure no one of my family ever has to suffer through that experience again.
March 22, 2013 at 8:53 a.m.REPLYRECOMMEND15


Judith E GrahamDenver
In our conversation, Martin Bayne recommended that people looking at assisted living centers and nursing homes find out what portion of the residents have dementia. This greatly influences the character of these facilities, as you’ve noted. If your older relative does not have dementia, it’s a good idea to think twice about putting him/her in a facility with a high number of residents who do have dementia.
March 22, 2013 at 4:10 p.m.RECOMMEND3


buffalogapBuffalo Ga

p, Virginia

Several years ago I met a lady from the AFL-CIO whose goal was to organize nursing home workers to press for better pay and basic benefits. It was very difficult, she said: “These women are so committed to their patients that they can’t imagine endangering them by opposing management.” She also said that I would be surprised to realize how very many of these women have disabled and/or needy family members at home…for whom they also care.
March 22, 2013 at 8:53 a.m.REPLYRECOMMEND11


In highly labour-intensive fields, unionization should be a snap as there is no way management can do the job. Go on strike for a day or two and let them try!
March 23, 2013 at 10:01 a.m.RECOMMEND1


Mary Shelley KleinFern Park, Florida
Mr. Bayne is performing a helpful service in telling what is expected in assisted living and how it might be improved. I’ve always wondered about the amount of sedation used since many of the patien

ts appear to be unresponsive. It would be wise for younger people to think about their futures before the unexpected hits them. We managed to keep my parents in their home and didn’t have money problems, but it was difficult and costly. I think we should just decide not to get old.

March 22, 2013 at 8:53 a.m.REPLYRECOMMEND3


Interesting comment, “decide not to get old”. My own elderly mother (and most of her cohort) constantly say they fear being dependent with dementia . . and yet they repeatedly seek medical intervention for every flutter, which pretty much guarantees they will end up dependent with dementia.


I myself live in a rural setting with limited access to health care. I used to think I should be responsible, and relocate to a better situation for health care as I age. Now, I think perhaps it would be wiser to just stay put, and die a more normal death when the time comes, without being saved time and again only to experience dependence with dementia.
March 22, 2013 at 4:10 p.m.RECOMMEND13


PDXPortland, OR
Assisted living is a little like an elephant being described by people wearing blindfolds: What it is differs depending on the perspective. Mr. Byrne describes more advanced assistance than what is typically available if he receives individual help several hours a day. Some facilities won’t accept people using wheelchairs, or who are incontinent.(I am not assuming that either is

 true for him.) If you need help dressing, bathing, transferring, receiving your medications, you pay more — fees get assessed piece by piece.

As for attitude, someone moving in may not be ready to “seize the day” immediately. He/she/they may be moving under pressure from family or because of a partner’s difficulties. Adjustment takes time. But I agree — attitude of the other residents and staff means everything. And the importance of not becoming a passive recipient of care/services cannot be overstated.
March 22, 2013 at 8:53 a.m.REPLYRECOMMEND4


Melo in OhioColumbus Ohio
When my late mother-in-law was at an assisted-living facility here in central Ohio, I used to spend a few minutes of each visit chatting with other residents in their rooms down the hall, and also came to lunch occasionally and engaged with her tablemates. It was fun for them and for me. If each visitor invests just a little time in the ‘community,’ it helps residents to keep connected with the larger world.
March 22, 2013 at 8:53 a.m.REPLYRECOMMEND11


Unhappy camperPlanet Earth
Perhaps the most i

mportant role that government could play is to keep private long term care insurers from ‘cherry-picking’ clients, as regular health insurance had previously done but will no longer be able to do beginning next year. My husband and I tried to get LTC insurance in our mid-50s. He succeeded, I did not.

March 22, 2013 at 8:53 a.m.REPLYRECOMMEND4


My own father spent time in 2 different nursing homes before he died of Alzheimers. The care in the first one was dismal, at best. Had my mother not gone each and every single day to feed him each and every single meal, the man would have starved to death. The second one was better, but a family member was still there every single day to ensure good care.


My husband and I are trying to make sound choices now to prepare for our elder years. We have been trying to buy a decent insurance policy to cover home health, assisted living, nursing home expenses. What we are finding is ridiculous. One particular sales rep went on and on about how her company wanted to help people stay in their own homes, so you could use the coverage for home health…BUT, the insurance would only pay 50% of the expenses.


When are we as a society going to address this issue? For most, there is not an acceptable answer for what to do with our seniors. Aging facilities and poorly educated and over-worked staffs are n

ot the answer. I do not have hope for the future as our population ages.

March 22, 2013 at 8:53 a.m.REPLYRECOMMEND15


Helen ElderWashington state
I am particularly enlightened today by Mr. Bayne’s answer to the question “What would you do if you were in charge?” Seems like many of your wonderful suggestions would not cost a dime to implement. So why is it so hard for management, in this enormously profitable business, to take charge of such simple and graceful ideas?
March 22, 2013 at 8:53 a.m.REPLYRECOMMEND13


C.Z.X.East Coast
If there were more of the supposedly exploited aides in these places and fewer administrators, that would already be an improvement.
March 21, 2013 at 10:57 a.m.REPLYRECOMMEND9


Carol A. PreeceWashington, DC
My daughter worked in one facility where she was assigned 25 patents. She was constantly running to get the basics covered. With 15 years of experience and multiple skills including phleboto

my she earns no more than a first year CNA(certified nursing assistant) Medicare hourly rate for CNA services is $20 ph: my daughter receives $10. from the nursing home that retains the other 50%. A national disgrace! Yes, but there are so many disgraces, and so many millionaires that need car elevators in their multiple mansions.

March 23, 2013 at 10:01 a.m.RECOMMEND3


Martin Bayne’s voice is very important. I’ve read him elsewhere and listened to him on NPR. We need him and others telling it like it is.
At the same time, what he shares doesn’t help me with the horrible guilt I feel in having placed Mom in one of those fancy assisted living centers that looks to be great but in all reality is just OK.
March 21, 2013 at 10:57 a.m.REPLYRECOMMEND8


BevNew York
A worker (a RN) at th

e place where my mother placed herself (good of her) told me she was leaving the assisted living facility to work with sick children. She said working with old people was depressing because you get attached to them and then they die. So in addition to working for aides to get a liveable wage we need to consider the emotional toll of this work.

March 22, 2013 at 8:53 a.m.RECOMMEND14


suzanneNew York, NY
I would like to know where Mr. Bayne resides and what the labor pool is in the area for assisted living facilities.


There is not one decent assisted living in the Washington DC area. Not one. It is a total disgrace. The wages are disgraceful. I especially enjoy knowing that HCR Manor Care is owned by the Carlyle Group, I’m sure they’re funnelling tons of money back into the facilities. Yeah, right.
March 21, 2013 at 10:57 a.m.REPLYRECOMMEND12




I live in Northern Virginia and am very familiar with many of the various assisted-care options here as a family member and volunteer. Like many states, Virginia has weak regulations concerning care in assisted living, unlike those for nursing homes and rehab units. As a result, quality varies termendously. But, yes, there are also decent facilities both here and in Montgomery County.


It’s fallen to consumers and family members to judge quality of life in a facility BEFORE entering a facility. Ask to see an actual activity calendar, not just a general description. What are the staffing ratios at various levels of care? How about staff turnover rates? When you observe the unit (not just on a tour with the marketers), how are the interactions between staff and residents? In talking to the residents, what do they like? dislike? What about their dining companions? Roommates, if any? Ask to see the library, check the hours, and its a

vailability to people in assisted living. Etc., etc., etc.


Check things like inspection reports, ombudsmen’s reports and follow-ups, etc. Many states make such info available on-line, just as they and private sources do for plumbers or roofing companies. has good info on nursing homes and home health agencies, as does your local Area Agency on Aging. So, too, do other health professionals in the community.


So, yes, good choices exist. They’re not cheap (understatement), and they don’t necessarily have the prettiest wallpaper.
March 22, 2013 at 4:10 p.m.RECOMMEND1


DNNorthern Virginia


To Gran: Nursi

ng and assisted living facilities can seemingly meet the various criteria you mention and still have very serious problems (that will not be caught by state inspections or dealt with by state regulations). The information from and other government sources only goes so far. I have dealt with the state regulatory agencies and what I have been

 told repeatedly is: “Your complaint is valid and important, but we are limited in what we can do by state regulations and statutes.” When I spoke with the ombudsman, she spent most of the time talking about how much worse her parents’ care facility in another state had been. I could go on but my point is that people should not presume that because a facility seemingly meets certain criteria that they have the full picture and that it must be a good choice.That was the mistake my mother made.

March 23, 2013 at 10:01 a.m.RECOMMEND3


suzanneNew York, NY


It’s really not quite that simple. Really. It’s a full time job doing what you suggest and not everyone has the luxury of doing things BEFOREHAND. Good for you. A lot of these places have devolved into places that are more like nursing homes than assisted living. They are so greedy just to get bodies in. No one should take care of the elderly for profiit and NO, there are not a lot of nonprofits. People are more particular about where they put their animals.
March 23, 2013 at 10:01 a.m.RECO


Telehealth Not Cost Effective for Long-Term Care, Study Says

23 Mar
March 23, 2013


Friday, March 22, 2013


Telehealth does not appear  to be a cost-effective way to treat patients with long-term illnesses, according to a study published Friday in the British Medical Journal, Reuters reports.   For the study, a team of British researchers evaluated 965 patients with heart failure, chronic obstructive pulmonary disease or diabetes over 12 months (Hirschler, Reuters, 3/21).

     Of the 965 patients, 534 were given telehealth equipment and support, while the remaining 431 received standard care.

The study is part of the larger Whole System Demonstrator Trial (Paddock, Medical News Today, 3/22).

Study Findings
The researchers found that the cost per quality adjusted life year — a standard measure of quantity and quality of life — for telehealth when added to standard care was about 92,000 pounds, or $139,200.
The authors noted that the QALY figure is far above the 30,000 pound benchmark used by Britain’s National Institute for Health and Clinical Excellence for assessing the value of various medical interventions

According to the study, the probability of cost effectiveness was 11%. The researchers noted that when the effects of equipment price reductions and increased working capacity of services were accounted for, the probability of cost effectiveness reached 61% (Medical News)

Researchers’ Comments

Martin Knapp — a lead author of the study and a professor of social policy at the London School of Economics — said the study’s findings demonstrate that telehealth needs to be better targeted.

He said, “We have got to find ways of better adjusting [telehealth] equipment to suit the circumstances of the individual patient.” He added that in some cases, smarter technology and a scaling up of programs could help improve cost effectiveness (Reuters, 3/21).

HOW DOCTORS DIE — It’s Not Like the Rest of Us, But It Should Be

18 Mar
March 18, 2013


iStock_000009487623MediumYears ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.


15 Mar
March 15, 2013


After watching my brother care for his wife through her 12 years of Alzheimer’s, I can well understand why many caregivers die before their charges do. He said to me at one point that he had not had a single uninterrupted night’s sleep in five years. He was in his 80s, and refused to put her in the local nursing home which is dirty and depressing. He died shortly after she did. He sacrificed his life for hers.

As an avid genealogist I have many death records of my ancestors. Looking at those records is very revealing. Many had a mild chronic illness for several years prior to death but the illnesses that incapacitated them and led to death were brief, from hours to days. The amount of intense bedside care they required was short.

We now have the ability to extend that period of incapacity to years, and people need care for long periods of time. Through modern medicine we’ve extended many lives without regard for the quality of that life, or the quality of the lives of those who must care for them.

This is analogous to inventing the 2013 Mercedes Benz without building a road system, or the jetliner without airports. Today’s 30-60 year old is going to have to work well into their 70s to finance their 80s and 90s. At the same time many are caring for both children and elderly, infirm parents. There are no landing strips able to handle the onslaught of infirm elders who are just beginning to circle the airports, and no ground crews waiting to handle the baggage of their frailty and extreme vulnerability. We are apparently a stupid people or we would have placed skilled elder care in pleasant environments as a priority.

The word has always been that things would change when the “Boomers” hit the demographic, but as far as I can see, and I am a “boomer”, we have no more sense than the generations before us. We are allowing even the pathetic system we have now to be dismantled by the tea-sharks in Congress. Twenty years from now families will look back at when they could put granny in a nursing home as “the good ole days”, as they are forced to shoulder the burden of care alone after the demise of Medicare and the theft of Social Security. Invalided elders, needing medication and nursing care that are unavailable to them, will die quickly (and very conveniently – cheaply) at home, cared for by their exhausted families.

There is nothing new under the sun.

Congress lumps home health aides in with casual babysitters under labor laws.

12 Mar
March 12, 2013


Home health aides are the fastest growing job in America, yet many are not protected by federal minimum wage and overtime laws.

That’s right, people can get away with paying grandma’s aide less than $7.25 an hour.

Why? Congress decided in 1974 to lump home health aides in with casual babysitters under labor laws.

President Obama has been trying to change this recently, but the industry is fighting back. The debate all comes down to the meaning of “companionship.”

“What they do is static, there’s not a lot of effort,” said Val Halamandaris, president of the National Association for Home Care & Hospice, referring specifically to companion workers.

“It’s in the same category as babysitters. We don’t think they should be subject to overtime,” he said.

According to the law, minimum wage and overtime are not required for companionship workers, who by definition, spend at least 80% of their workweek merely keeping a patient company. Playing chess or cards would classify as a companionship activity, for example.

Halamandaris said very few home health aide workers actually fit this mold. But a studyreleased by the National Domestic Workers Alliance shows nearly a quarter of home health aides earn below minimum wage.

Worker advocates say employers are exploiting the companionship law and getting away with it.

“It’s primarily an outdated, stereotypical idea of what a worker does. This is not the typical way they spend their time,” said Heidi Hartmann, president of the Institute for Women’s Policy Research.

Related: America’s fastest growing job pays poorly

Once aides spend more than 20% of their work week doing general household work, like cleaning or making a tuna sandwich, they are supposed to qualify for both minimum wage and overtime.

But are employers truly tracking their aides’ duties so accurately that they can make that distinction?

The large agencies say yes, and argue that they should not pay time-and-a-half to workers who often stay overnight with their patients. During that time, an aide may do little other than help a patient walk to the bathroom once or twice.

“There are many seniors that use our services throughout the night in sleepover situations,” said Paul Hogan, chairman of Home Instead Senior Care, which plans to hire 45,000 caregivers in North America this year. “This exemption allows us — to the benefit of seniors — to discount for those hours.”

As Hogan mentions, costs are a big part of the problem. The industry is pressured to keep prices down to accommodate elderly clients, many of whom are living on fixed incomes. Health care reform could also hurt the industry, as $39.5 billion in Medicare funding cuts through 2019 loom.

Home care providers argue that if they’re forced to raise wages and pay overtime, they’ll have to restrict workers to 40 hours a week to keep costs down. They also warn that if costs rise, seniors might turn to undocumented, unqualified workers instead.

But home care workers are already entitled to state minimum wages in 21 states, and businesses there are still growing. At least 15 of those states also require overtime pay for those who work more than 40 hours a week.

Meanwhile, recent case studies by the Paraprofessional Healthcare Institute show some companies have developed business models that allow for higher wages and overtime.

In New York, a group called the Cooperative Home Care Associates keeps overtime costs low by often splitting patients who need 24-7 care among four workers. The group is a worker-owned cooperative employing more than 2,000 people.

Addus Homecare (ADUS), a large Illinois-based company, doesn’t consider any of its aides as companion workers. So paying minimum wage and overtime are a requirement, not an option. The company uses scheduling software to distribute hours more efficiently and keep overtime costs low.

Darby Anderson, vice president of home and community services for Addus, said he thinks that as more older consumers demand health care at home, competitors will eventually need to rethink their stance on wages and overtime as well.

Related: Men in female-dominated jobs

Vilma Rozen, an aide working in Staten Island, gets paid more than the minimum wage. She said she realizes why it’s important to keep costs down. But she and her colleagues need to make a living.

“People don’t understand and they always have a complaint about how much they pay for us,” she said. “We need to do the best for the elderly, but we need the job too.”

She says many don’t recognize being a home health care aide as a legitimate career and wants to band together with other domestic workers to get the job the respect it deserves.

Grassroots movements have already taken off in some states, but with limited success. New York passed a domestic workers bill of rights in 2010, but when workers in California tried to do the same, Gov. Jerry Brown vetoed the legislation.

Six years ago, health care aide Evelyn Coke, a single mother of five and immigrant from Jamaica who was not paid minimum wage or overtime, took her case all the way to the U.S. Supreme Court.

Coke lost, with the court unanimously ruling that it was up to Congress or the Department of Labor to change the law. Coke died in 2009.

Now, the Labor Department is reviewing 26,000 public comments on the federal proposal. But it’s unclear when, if ever, a final rule will be released.


10 Mar
March 10, 2013

For me, there’s nothing as perverse and intolerable as a whiner.

Oh, for Heaven’s sake, you know who I mean; everybody knows at least one.

They go by a host of monikers:  bellyacher, grouser, fusspot, nit-picker, fussbudget.

Why my rant? Recently, I had a conversation with one of the administrators about an idea I had that would simultaneously improve the quality of life for residents while saving the lives of rescue animals. What makes it somewhat unique is that the animal (a “rescue” dog or cat) would only be delivered to those facilities with roughly a dozen residents willing to sign a binding Agreement that spells out in clear language the responsibilities of each resident involved with the animal’s care. Simple, right?

I mean, this is Bill Thomas 101.

Specifically, the agreement would define who is responsible for feeding, what is to be fed (that means stock control), what time they are fed and walked) . . .you get the picture.

We would even build into the system a series of redundancy controls — back-ups if something goes awry.

Well . . .after I had explained my program to the administrative director of my assisted living facility, her immediate reaction was to say, “But what if some of the residents are afraid of the animals or allergic to them?” .

Frustrated and disgusted, I said, ” . . .and what if a cat breaks into a refrigerator and makes off with an entire smoked whitefish?”

And for a second, I could actually see the wheels spinning in her head, conjuring up images of the skeleton of the fish, sans fillets.


Here’s the sad truth. Even if I were fortunate enough to sell this concept to the administrative director, then the real battle would begin . . .getting a dozen residents to commit a few minutes a day to the emotional, psychological and physical well-being of the entire community. Motivating residents — dragging them out of their rooms — is akin to nailing Jello to a tree.

So, how do I accurately convey the real problem in America’s Institutional Aging Community?

By telling the truth.

And that truth holds that it’s  not always the top-down management system at fault in the daily effort to move forward.

In fact, most of the time, it’s the residents themselves who are to blame for the systemic apathy and lack of inertia.

Martin Bayne


Mother Protects Son, Son Protects Mother

02 Mar
March 2, 2013



iStock_000015446505SmallI was recently asked by a friend, “What do people need to know when deciding upon assisted living?”

I thought about the question, and as I did, an image began to form. To be exact, there were two images: the first; my mother and I walking into a kindergarten classroom on the first day of school. My mother, intent on protecting me from anyone or anything that could threaten her first-born, and me, feeling awkward and self conscious in a room full of new faces.

But it was the second image that caught me off guard. I was simply unprepared for the emotional jack-hammer that dug up memories I was sure I had buried — like Chernobyl –under layers of concrete and steel.

These memories themselves were recent – the wounds still open sores. In this series of images, I hold my mother’s hand as we walk into an administrator’s office in a Lehigh County, Pennsylvania-run skilled nursing facility. Mom’s hand trembles. She is terrified.

When we leave the office, she pleads, “Please don’t put me in here,”she says. “Please, I beg you.”

NOTA BENE:  Before you draw any conclusions, you need to know the facts. My sister and her husband HAD CARED for my mother 24/7 for more than ten years after my mother’s stroke. They even built a lovely apartment attached to their home, so my mother could have the sensation of independent living when she chose to.

Everyone had done their best – no one was to blame. My mother had simply reached a point where TIAs and loneliness had created a psychotic break. She needed to be around people. She needed to be part of a community.

She has improved markedly since her move. And like her eight billion cohabitants on this planet: she has her good days and . . .well, you understand.

Our long-term care system has failed us. Not because there aren’t enough elegant buildings to house our elders, but because developers build impressive complexes — not communities. And what we need — desperately — are communities.