Friday, September 24, 2010

Taking Aim at the Middle: a DC Report

This blogger has carped on this theme before (here's an example), but this past week has certainly punctuated the point.  The Visiting Nurse Associations of America gathered in DC to consider a number of legislated and, in some cases, proposed changes to regulations governing the home care industry.  Here's the backdrop:

  • The recently enacted Patient Protection and Affordable Care Act significantly expands coverage and seeks to restrict the growth of health care expenditures.  Some of those latter changes are immediate (e.g., massive cuts to home care) and others are more gradual (e.g., creating pilot programs designed to test changes to how systems of care are reimbursed and creating quality-based provider incentives).  
  • The current political climate is stressing deficit reduction and the rightward-leaning agenda is gathering steam as we barrel toward mid-term elections.
  • Some opportunistic home care companies have been widely profiled (e.g., as in the referenced blog post above) for excesses and rule-bending gamesmanship that has, frankly, given much of the rest of the industry a black-eye.
  • Significant positive Medicare margins have given the Centers for Medicare & Medicaid Services (CMS) reason to consider systematic "corrections" to payment methodologies.
But, here's the rub: many organizations, such as the Visiting Nurse Association of Boston, have built a 125 year-old reputation for caring for all those in our service area without payer status prejudice.  We've also worked hard to differentiate ourselves on quality and outcomes measures.  An example: in the United States, 29 percent of all patients in home care are readmitted to the hospital.  That's not completely surprising because we care for sick patients who are increasingly discharged from hospitals still quite ill.  At the VNA of Boston, 25 percent of our patients are readmitted.  That difference does not happen by accident... and requires directed staff training, specific programs designed to cut unnecessary admissions (and trips to the ER), supporting systems, and a caring, dedicated staff of exceptional caregivers.  Clearly, home care is a far cheaper alternative to hospitalization and that 4 percent differential applied to a larger population adds up to a massive savings to the system.  Unfortunately, organizations such as ours will struggle to maintain investments in such programs when the cuts do hit.

Home care agencies who are selective in who they care for and who have been able to consistently attain 10 to 20 percent positive bottom lines can withstand a 5 percent cut.  Organizations who care for everyone and who routinely reinvest funds into programs for their patients (hence the much smaller profit margins) are not going to fare nearly as well.

In DC, we had an opportunity to meet with Congressional leaders (and their staff) from the Massachusetts delegation.  These include Congressmen McGovern, Markey, Capuano, and Lynch and Senators Kerry and Brown.  Their ongoing support of this industry is widely recognized and most appreciated.  Despite it, however, the policy direction in Washington is to aim for the middle of a lumped together pack, rather than to differentiate based on quality, performance and approach.

Ultimately, this fight is about compassion, quality and exceptional health care services for home bound and vulnerable patients.  It's about doing the right thing.  And... it is about dollars and cents.  However you slice it, though, aiming toward the middle just won't work.

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