Tuesday, January 18, 2011

Penny wise, pound foolish

The home health industry is just now beginning to grapple with the devastating cuts to Medicare reimbursement and now talk of a $150 co-pay for home care services has resurfaced.  In some ways, the concept of co-pays makes complete sense.  Adding co-pays defrays the growing cost of health care to our Federal budget and helps empower individuals by making them more aware of the cost of their care.  The other side of the coin, however, must be considered.  Past experience suggests that cash strapped individuals will forego care altogether in order to avoid having to shell out the co-pay.  Sick patients often become sicker and then require far costlier visits to hospital ERs or even require inpatient stays instead.  Additionally, many of the patients that mission-driven organizations such as the VNA of Boston see simply do not have the resources to cover a co-pay.  Because we're mission-driven, we are faced with the dilemma: provide the care and lose the $150 revenue or walk away.  We don't walk away...

Our national association, the Visiting Nurse Associations of America, had this to say today:
(Washington, DC) – January 18, 2011 – The Visiting Nurse Associations of America (VNAA), which represents nonprofit home health and hospice patients, strongly opposes re-instatement of co-payments for the home health benefit as recommended at MedPAC’s January 13-14, meeting.

While the formal MedPAC recommendation does not mention a specific co-payment, the figure $150 per episode was discussed. Under the MedPAC plan, the co-payment would not be applicable for patients that are discharged from a hospital or other post-acute settings but would apply to all community-based admissions.

For those who are eligible for both Medicare and Medicaid, MedPAC presumes that Medicaid would pay for the co-payment for community-based admissions – but there was also a recognition that States are in financial crisis and Medicaid agencies might be unable or unwilling to make the co-payment for duals. In addition, many individuals who live just above the poverty level would be unable to make a co-payment.

"A co-payment would create a significant access barrier for Medicare beneficiaries who need medically necessary home healthcare per their doctor’s orders,” said Andy Carter, President and CEO of VNAA. "These patients are much more likely to end up back in the hospital or another institutional setting at much greater costs," said Carter.

Congress eliminated co-payments in 1972 to encourage use of less costly, non-institutional services. VNAA will fight against co-payments because they do not work and they increase overall Medicare costs.

VNAA will work with other national organizations including those that represent beneficiaries to oppose co-payment. In an economy where many seniors and families are struggling to make ends meet, a co-payment does not make sense.

VNAA Contact:

Emily Swanson

About VNAA: VNAA is a national association that supports, promotes and advocates for community-based nonprofit home health and hospice providers that care for all individuals regardless of complexity of condition or ability to pay. They provide comprehensive services for Medicare, Medicaid, uninsured, and privately insured patients. VNAAhttp://www.vnaa.org/ today.

Monday, January 17, 2011

How to shovel snow

One of our great occupational therapists forwarded this to our staff right after the last blizzard. 

I should have watched it...

Wednesday, January 12, 2011

The power of collaboration

A guest post from our Vice President of External Affairs, Janice Sullivan:

This blog has recounted the VNA of Boston’s continuing efforts to ensure our outcomes exceed both state and national benchmarks. Many of these outcome measurements (found on medicare.gov/HomeHealthCompare) are intended to improve care for chronic diseases and to keep people out of the emergency rooms and hospitals. One of the indicators we pay most attention to is the re-hospitalization rate for our patients and I’m proud to say we beat state and national benchmarks here.

Our referral partners at acute hospitals around the state also are diligently working on initiatives to prevent unnecessary hospital re-admissions. Not only is it better for the patient, but hospitals won’t be paid for these readmissions very shortly. It all ties back to providing value in the health care system. More efficient and high quality providers will be rewarded, the others…not so much.

Work on this initiative can range from improving the discharge process and paying attention to smooth transitions of care to implementing comprehensive clinical processes to insure better care for patients with certain chronic diseases. And, we’d contend, successful initiatives will have a strong home health care partner at the planning table to see real progress in reducing unnecessary readmissions. Our hospital partners are acknowledging this as well.

At a recent joint meeting regarding these initiatives at one of our acute care teaching hospitals, Dr. Eric Coleman, a national expert on care transitions, facilitated a discussion of a patient and the patient’s history of readmissions. The selected patient had received services from the VNA of Boston. The hospital discussed their perspective of the patient’s care and the VNAB team discussed it from their point of view.

There was a rich and thoughtful conversation with many on the hospital side of the table and Dr. Coleman expressing their admiration for the work being done by the VNAB to have kept the patient out of the hospital for as long as we did. They were also struck by the fact that we grounded our treatment plan not only on what was best clinically but what was best from the patient’s point of view. The meeting ended with more in-depth understanding and learning by both the hospital team and by the VNAB team…with commitments to follow up individually and as a group.

Bottom line, this type of collaboration will lead to value for the health care system, better processes to ensure smooth transitions and most importantly, better care for the patient. My congratulations to the VNAB team of clinicians. They have persevered to improve the health and well being of a patient who is facing a myriad of complex health challenges in a complex and fragmented health care system.

"A perfect ending to her life..."

Here's a nice letter sent by the family member of a recent patient at VNA Hospice Care.  With his permission, I'm including an image of his letter here.

It speaks to the difference that high quality, compassionate hospice care can make to the family members of a patient.  It also speaks volumes about our hospice staff and caregivers.

Tuesday, January 11, 2011

Punishing the Solution

A collection of thoughts regarding the recent cuts to home health services:

I met a brand new mother whose son had just been discharged a day or two earlier from a high tech hospital neonatal ICU. The infant, born prematurely, suffers from serious heart defects and respiratory problems and has survived three complicated operations already. His eager, loving mother gingerly and anxiously held her baby, unsure and worried. Then the nurse confidently and reassuringly took hold of the child and weighed him on the portable scale she brought into the home. She placed a small stethoscope that she had warmed with the palms of her hands over the child’s tiny thumping chest and carefully examined him with skill and poise. After a few minutes, she turned her attention to the mom. The visiting nurse instructed her on how to care for the child and then, before we left together, showed the mother how best to hold him, teaching her that holding him often was best.

And then there was the elderly man who lives alone in a third floor apartment building. He felt bewildered and overwhelmed when the hospital staffer read his complicated discharge instructions and asked him to sign the triplicate hospital forms. When we entered his home the next morning, the physical therapist I accompanied, before he did anything even remotely resembling physical therapy, reviewed the discharge papers and carefully and clearly explained them to the man. And when we left forty-five minutes later, I marveled at the transformation I had just witnessed - a transformation where despair and confusion gave way to anticipation and hope.

Not-for-profit home health agencies, such as the Visiting Nurse Association of Boston, do not construct sprawling medical complexes and we do not purchase multi-million dollar technological marvels. The wares of our trade are exceptional clinical skills and limitless compassion…. all brought to the one place most of us want to be – not a high cost institutional setting but our own homes.

The recently passed health reform law rightly focuses on improving access to care and curbing the high costs associated with providing that care. Unfortunately, the home health industry has experienced substantial reimbursement cuts in the process. The logic holds that there are home health corporations and agencies that have been able to generate vigorous financial margins, thus suggesting that the Federal Government has historically overpaid for services. But organizations such as the VNA of Boston have never been motivated by the quest for financial margins. We began 125 years ago on the waterfront in Boston, seeking only to provide care for those who require our assistance and today we are the largest provider of home health care services in the region for those in need regardless of ability to pay. The VNA of Boston does not turn anyone away and our 125-year track record of doing so will never help us to generate vigorous financial margins.

We are preparing for over $2 million of cuts to our reimbursement, challenging our ability to continue to meet our mission and to remain viable. More importantly, the reimbursement cutbacks pressure the one segment of the health care industry that can unquestionably demonstrate that we are the most efficient and best health care investment for taxpayers. A typical four-day hospital stay can cost over $20,000 while a typical three-week visit from a home care provider will cost far, far less. In Massachusetts, 28% of all home care patients will ultimately be readmitted to the hospital during their home care treatment. By investing in state-of-the-art information systems, creating intensive training programs for our staff, and developing clinical centers of excellence in diabetes and cardiopulmonary disease and others, VNA of Boston patients are readmitted at a rate of 25%. That three percent difference applied to large populations can result in billions of savings annually.

Recent Federal payment decisions have left us besieged and distressed. If organizations such as ours do not survive, patients will be forced into more costly settings. The infants, mothers and seniors we care for today will not fare better without skilled and compassionate home care.

Access to care and reducing medical costs are worthy goals. Visiting nurse associations have been devoted to these goals for decades and, in our case, for over a century. We have not been the problem… we have been the solution.

Clever, nested...

Photo by Dave Polette.  For insight into how this was done, see here.

Wednesday, January 5, 2011

Adele is Back!

Here's the first single.

New album due February 22nd.

Yes, I'm a fan.

Tuesday, January 4, 2011


We understand the problem, sir...

I was sent a clip from The Boston Herald this morning, quoting Dr. Domenic Paolini on the topic of forthcoming Massachusetts health care reform.  I don't know Dr. Paolini, but upon reading that he is a physician (heart surgeon, no less) and attorney, my interest was piqued.  Here is someone uniquely qualified to comment on the matter, I thought... offering perhaps not only a great perspective, but also some possible solutions as well.

Unfortunately, the piece offers the often repeated arguments against reform, but no real suggestions otherwise.  I've commented below on the specific elements of his case.
“When doctors lose money, patients lose lives, and limbs,” warned Paolini, a critic of the new health care payment plan state leaders will soon roll out.
That seems a bit dramatic.  He certainly has my attention, though.
“When doctors aren’t adequately compensated, they need to see more patients, and because there’s only so many hours in a day, they spend less time with patients, and less time preparing for patients, and that’s when accidents happen.”
I agree with the underlying concepts here.  Inefficiencies in our system, of which there are many, and shortages of key clinical personnel, which are well documented, do cause doctors to spend less time with patients.  The ever expanding paperwork requirements, which the home health industry is certainly also experiencing, also force clinicians to divert their attention and time away from the valuable skills they've acquired and toward less productive administrative tasks.  But... those tasks have been mandated by the need to standardize treatment protocols and to drive toward higher quality outcomes as well as the fact that some opportunistic providers and their agents have fraudulently billed for reimbursement.  Both have resulted in more demanding documentation requirements.  And more paperwork.

And for the record, doctors do need to be "adequately compensated".  The rigors of training and the personal sacrifices necessary to motivate college students through pre-medical programs and onto medical schools, residencies and advanced speciality training programs are real.  We want our top students to heed the calling to become physicians and to withstand the many challenges facing them as they pursue that goal.  Skimping on physician compensation is most decidedly not a viable solution to the perennial health care cost crisis.
By month’s end, Gov. Deval Patrick and the state’s most powerful legislators are expected to make national news, with a bill that aims to curb health care costs by changing how we pay for care.

If the bill becomes law, insurers will stop paying doctors for each test and office visit, and implement “global payments” and “accountable care organizations.”

All this means that in the future, insurers and the government will put doctors’ groups and hospitals on an annual per-patient health care budget, by giving them a lump sum of money to spend on care. Eventually, supporters say, doctors will stop treating a specific illness, and start treating the whole patient. And, they say, as our collective health improves, we’ll wind up paying less for health insurance.

It sounds great, but Paolini isn’t buying it. He’s skeptical because the architects of this plan claimed in 2006 that once everyone had health insurance, our premiums would nosedive, and that patently hasn’t happened.
Reaping the benefits of providing reasonable health coverage, including primary care services, will take far longer than four or five years to realize.  The investments in a person's health status when he or she is twenty years old may not prove out until a heart attack and complex cardiac surgery is averted thirty years later.

Additionally, we were paying for the uninsured population to receive care through the "Free Care Pool" and other even more obtuse funding systems.  And these costs were spiraling upward, causing premiums to rise.
Of this latest initiative, Paolini said, “We’ve already tried this, but back then it was called managed care, and that began when businessman decided to move money out of the health care system, and into their own pockets,” he added.

To make that happen, he said, the government and the insurers began slashing doctors’ pay.

“All the other money was going into the bureaucracy, the $2 million-a-year hospital administrators and the insurance companies,” he said, adding that they are the ones who have the governor’s and legislators’ ears. Take the money away from doctors, and watch the case loads and errors rise, Paolini said.
Even casual observers would conclude that in the recent health reform debate, physicians had "the governor's and legislator's ears", so I don't believe that lack of advocacy effectiveness is the real issue here.  Additionally, the "into their own pockets" argument is shallow at best.  Yes, some insurers and executives have benefited, but administrative costs are still a small fraction of total health system dollar outlays.  Additionally, the increasing complexity in the system driven by anti-fraud programs and the quest to develop better information systems and quality programs are expensive.  Payers, as well as providers, have had to bear those costs too.

Dr. Paolini does not talk about some of the other, perhaps bigger, problems.  These include:
  • The home health industry is currently experiencing very dramatic Medicare reimbursement cuts.  Yet... as has been argued in this blog, the cost associated with the provision of high quality home care services pales in comparison to the cost of institutional inpatient and emergency care.  For example, VNA of Boston clinicians are able to keep a higher proportion of patients out of the hospital than Massachusetts and U.S. averages suggest (25% readmission rate for VNA of Boston vs. 28% and 29% respectively).  Yet we are being cut at a disproportionately higher rate than other sectors.
  • Our aging population poses an ever increasing strain on our limited health care resources.  We're living longer and needing more operations, more diagnostic procedures, more medications and then, institutional care for longer periods of time.  I'm not arguing that we deny these services to these populations... only that we stop denying how much this all is costing us.
  • Palliative care is still viewed as "giving in" as we cling to life and hope for miraculous and intensive life saving cures.  There is nothing inherently wrong with this, but by the same token, we ought to recognize and encourage approaches that offer compassion and comfort when all professionals concur that the miracle cure isn't coming.

The health care cost and access conundrum isn't going away soon, despite the passage of Massachusetts and now National reform laws.  The problem is well understood, but simplified explanations involving fat cat insurance executives and threats of medical mistakes and death do little to promote dialogue and problem solving.