Wednesday, March 30, 2011

Co-pays for home care

The Massachusetts Home Care Alliance hosted an event for members of the Massachusetts elected delegation and their staffs. I had an opportunity to address them. Here are my remarks:

Thank you for the coming to our luncheon today and for this opportunity to speak to you about home health care.

I am Rey Spadoni, the President of the Visiting Nurse Association of Boston... an organization that is celebrating, this year, our 125th anniversary as the very first home health care provider in the United States. In the late 1800s, a group of bold and visionary women took note of the unmet needs of the most vulnerable members of the Boston area community... the individuals who were falling through the cracks of the then emerging network of infirmaries, clinics and hospitals. We are most pleased to be able to say that their vision is alive and well in our organization a century plus later as we continue to fill in those gaps for those among us who are, in fact, the most vulnerable.

I begin my comments by expressing our gratitude for all that you, your colleagues and our entire elected delegation from Massachusetts have already done for these members of our community and the agencies such as the VNA of Boston who care for them. Thank you for making us in this room the envy of our colleagues from 49 other states.

I also want to acknowledge that in my almost 30 years of working in the health care industry, I've never seen it like this before. It's a time of great change... and great stress.

There's no doubt that every one of us in this room believes in the importance of ensuring high quality home care services. Services that are good, dependable and consistent. There's also little doubt that all here believe that it's important to ensure access for every single person in our community.... whether they are people of means or people who struggle. But now, the third leg of the stool, the cost of health care, is front and center. Reigning in the escalating costs of health care has emerged as critical to not only preserving the health care system, but also in helping to address the larger economic problems and even long-term fiscal viability of our nation.

We certainly get that.

In the years I've worked in this industry, I have come into this building... sometimes talking about the issues of the acute care hospital industry, sometimes post-acute hospitals and on one occasion, the needs of federally qualified community health centers. On each occasion, I offered perspectives... perspectives you are all very familiar with... that each segment of the industry I represented at that time had unique needs and that we were part of the solution, not part of the problem. The points I made were legitimate.

But as I come here today to talk about organizations such as the VNA of Boston, I would like to point out two important differences between home care and the other parts of this industry.

First, we keep people out of those institutions. We keep people where they want to be most of all... in their own homes... living as independently as they are able... keeping families together... and providing dignity.

In the home care industry, we don't talk about the fixed costs associated with brick and mortar construction projects and we don't need to recoup R&D dollars associated with new and costly diagnostic technologies. We keep people out of those settings and in their own homes.

The second point relates to the fact that patients are being discharged more quickly and sicker than ever before from the hospital. Across the United States, 29% of all home care patients are readmitted to the hospital because their medical condition has deteriorated. At the VNA of Boston, that figure is 25%. It's 25% because we invest in training for our staff, focus on medication reconciliation, and deploy remote technologies into homes so that we know right away when a patient's condition requires immediate follow-up care. That 4% difference spread to larger populations... that is... paying for home care services instead of hospital readmissions, is a critical component of cutting overall costs in the health care industry. It is also a vital component of the emerging Accountable Care Organization movement.

If you or your colleagues have never been on a home care visit, I would like to invite you to accompany one of our skilled nurses or therapists on one. I guarantee that it will be eye opening and that you will enjoy it.

If you have not been on a home visit, I would like to tell you about one I recently made.

Pat, a 20-year home health veteran nurse, and I traveled together out to perform an admission of a 59 year old man named Richard. Richard lives alone in a large apartment complex in Quincy, Massachusetts. I learned upon arriving in his small three room home that Richard was honorably discharged from active service in Viet Nam when he sustained a nearly life-ending injury serving this country. The reason for our visit was due to a recent orthopedic related hospitalization, but the home care admission process requires a very thorough examination of a whole variety of health related topics... and thank goodness for that for Richard.

I couldn't help but notice as we entered his apartment that there was visible evidence of great patriotism everywhere, as well as signs of a hobby constructing intricate small scale models of 18th century ships. I subsequently learned that this was a long past hobby due to the advancing arthritis in Richard's hands. I also could not help but notice the multitude of prescription bottles on the coffee table in front of us. Because of Richard's arthritis, he can't contend with child-proof caps and so all bottles were open, with several tipped over, leaving a multicolored array of pills before us.

As I said, it's a good thing that the home health admission process calls for a thorough evaluation on a number of issues because it was during that process that Pat discovered a significant discrepancy between the medications listed on his hospital discharge summary and the one his primary care doctor had given him just a few months earlier. When questioned, Richard appeared to be confused over exactly which set of prescriptions he should be following. Rather than spending 45 minutes in his home, Pat and I were there for nearly two hours. During that time, Pat contacted the hospital staff first and then the nurse practitioner at the medical practice where his doctor works. She sorted through the complex set of drugs, focusing mostly on the ones he takes for diabetes, and ultimately came up with not only a game plan but also secured an appointment for him very next morning with his physician.

As she was on the phone dealing with this, I learned more about Richard. I learned about the reasons he is now homebound, I learned about the challenges he faces... including financial... and I saw firsthand just how much he trusts the VNA.

As we walked out of his apartment, Pat told me that it was likely that Richard would have experienced a significant medical problem, diabetes related, within days caused by the medication confusion. That problem would have most assuredly resulted in an ambulance ride to the emergency room and a 2 or 3 day hospitalization. That trauma, those additional expenses, were all avoided. Matter of factly, Pat told me "it happens all the time" as we drove away.

It happens all the time.

And so, I wanted to tell you about a proposal to levy $150 co-payments per 60 day episode of care upon patients such as Richard. MEDPAC has suggested the institution of these co-pays as a way to control Medicare spending.

When our nurses, who care for patients in the poorest neighborhoods of Boston, hear about this suggestion... they roll their eyes and tell us that most... most... of their patients will not pay them. They will prioritize paying for their prescriptions, their rent and food before they will pay for home care services. For most of our patients, age 80 and above, they are already spending 30% of their limited incomes on uncovered medical care.

At the VNA of Boston, we support initiatives that foster a greater degree of engagement and participation in health care decisions and costs... which co-pays are designed to do. But we have evidence that they are not the answer in home health care... having been tried before and eliminated in the 1970s when they were found to increase inpatient spending.

A recent "New England Journal of Medicine" article profiled 900,000 Medicare Advantage beneficiaries and the impact of new ambulatory visit co-pays. They found that for every $7,000 saved through the adoption of the co-pays, inpatient costs increased $24,000. Patients avoided the ambulatory visits, their health status had worsened... and their care cost our system more. Not only do co-pays not work for this population, they backfire.

We need your active help in preventing this mistake from happening once again.

Co-payments are short-sighted. They are ineffective. And unfortunately, they are cruel.

Please join in our fight to prevent them.

Thank you...

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