Thursday, June 19, 2008

A Matter of Balance

Earlier this week, the Home Care Alliance trained 29 local health care professionals to teach elders to reduce their risk of falling, using a program called "A Matter of Balance." A Matter of Balance was developed at the Roybal Center at Boston University, and has been nationally recognized for it successes in getting elders to overcome a fear of falling, which in and of itself can increase a person's risk of falling - when that fear leads to reduced activity.

The timeliness of this program can not be overstated. A new CDC Study published in this week's Boston Globe only reiterates what we already know: Falls are the most common cause of nonfatal injuries and hospital admissions for trauma among adults over 65. Within the next few weeks, a list of MOB trainers will be posted to the Alliance's website for local senior centers and church groups to schedule a training.

Monday, June 2, 2008

We've Only Just Begun

The Massachusetts Department of Revenue released an analysis of 2007 tax returns showng that 95 percent of 3.34 million adults filing health insurance information with their tax returns have health coverage. That is an impressive 'stat' and can make us all proud of the leadership role of our state. In our world of home care, I still remain a little concerned that many of our homemakers and home health aides remain uninsured, at least those who work full-time and find their agency's plan to be unaffordable. Should the MA Health Connector deliver on their promise on their website to develop affordable contributory plans for business, I am hoping that this issue too will have a solution. Kudos, all around.

Monday, December 31, 2007

Happy New Year

A new year on the way and new start to this blog! And a resolution to post more faithfully! It's hard to finish 2007/start 2008 with an issue that has run here before: the screening, qualifications and competencies of home care workers. Earlier this week, Newsweek Magazine ran a rather scathing piece ( Danger in Our Parents Homes) on home care transactions in which workers were spotlighted as at best "incompetent" and at worst thieves and "predators." The stories were heartbreaking and harmful to home care's reputation; but the conclusion that the industry is totally unregulated and "plagued" by corruption - I think went a bit to far - with little proof.

First off, much if not most of the home based health care provided in this
state - some $350 million last year - is provided by Medicare-certified entities that must meet fairly strict federal standards and that are audited and surveyed regularly. These entities must meet federal standards in all lines of business, including privately paid transactions. Second, Massachusetts requires criminal background checks of all workers going into homes to provide care. Yes, the system is flawed in that the data that agencies have access to is limited, but again agencies are by all accounts complying.

Most importantly, the systems in the state set up to handle complaints about quality of care ( the state Department of Public Health) or fraud (the Attronet General's office) handle very few home care cases, considering the amount of visits provided last year (more than 8 million) to about 1 in 10 Massachusetts elders.

Because of the isolated nature of home-based caregiving, home care workers have to be very carefully screened and trained. The story is not just the few cases where this sadly did not occur, it is also the hundred thousand satisfied customers who found the service to be invaluable to themselves and their families.

Monday, October 1, 2007

Clinicians Dealing With Death

A September 27th piece in the New England Journal of Medicine - The Code by Dr Katharine Treadway - has had clinicians talking. It's not necessarily new ground to cover, but Dr. Treadway writes pointedly about dealing with patient death and the coping skill of clinical detachment that comes early medical school training. "We learned to bury our fear of death in an avalanche of knowledge. We learned the trick of silencing the parts of our brain that didn't really want to be this close to death. And for good reason. We could not do what we do — take responsibility for the lives of our patients — if we were aware, minute to minute, of the true significance of what we were actually doing."

Through October 10th the Journal is inviting readers of the piece to share their perspectives on patient death and clinician response. If you have ever wondered about your own response - diassociated or not - get in on this important conversation.

Wednesday, August 29, 2007

Katrina - Two Years Out

On this two year anniversary of what has to be seen as the worst natural disaster in our nation's history, we all ought to pause and reflect. For those of us safe and warm and untouched by those waters that destroyed lives and livelihoods, we ought to think have we done enough to help. As it seems the benefit concerts and the spolight have moved elsewhere in the world, why not just do a small thing and buy a CD by a New Orleans artist or a compilation whose proceeds are going to hurricane relief. Better yet - if you love New Orleans and its music - make a donation to the Musicians Village - the Harry Connick, Jr., Branford and Ellis Marsalis project to build homes for in the Upper 9th Ward for musicians.

Laissez Les Bon Temps Roulez again for New Orleans, its people and its music

Tuesday, August 21, 2007

MedPAC: Is it Paranoia if They Really ARE Out to Get You?

The Medicare Payment Advisory Commission (MedPAC) – the independent federal body charged with advising Congress on Medicare payment policy – recently issued its 2007 “Databook on Health Care Spending and the Medicare Program.” The 208-page report is jam packed with charts and tables that analyze Medicare spending in more ways than any rational person could care about.

MedPAC submits a “Medicare Payment Policy” report to Congress every March. As just about anyone involved in Medicare home health knows, MedPAC has a more-or-less standing recommendation every year that Medicare payments to home health agencies should be frozen. The MedPAC “freeze home health” recommendation is one of those reliable signs of spring -- like the daffodils on Nantucket.

Given MedPAC’s position on home health rates, I thought it might be interesting to browse through the Databook and look at how home health compares to some of the other slices of the Medicare pie. I found some interesting tidbits to chew on:

Medicare pays for 38% of all home health services, more than any other type of health care. By comparison, Medicare pays for only 29% of hospital care, and just 16% of nursing home care.

Interpretation: home health agencies are far more susceptible to changes in Medicare payment policy than are other types of providers (Witness the fact that roughly 40% of all Medicare home health agencies went out of business when CMS implemented the disastrous “Interim Payment System” in 1997.) The major changes that CMS has proposed for the PPS case mix system for 2008 could conceivably have a similarly disruptive impact on the industry.

But the percentage of Medicare funds spent on home care has dropped dramatically in recent years: In 1996, home health accounted for 9% of the Medicare pie. By 2006, that percentage had plunged to just 3%.

Interpretation: Again, the impact of the IPS, from which the home health industry has yet to fully recover.

Overall Medicare spending on all post-acute care services (including home health, skilled nursing facilities, inpatient rehabilitation, and long-term care hospitals) grew by 68% between 1999 and 2005. But Medicare spending on home health grew by only 46% during that period; SNF and inpatient rehab spending grew by 70% and 67% respectively, while LTCH spending grew by a whopping 170%.

Interpretation: The transition from IPS to PPS did NOT result in runaway expansion of home health services. On the contrary, the Medicare program is increasingly relying on inpatient services for post-acute care. Given that home health services are far more cost-effective than inpatient care, CMS should be exploring incentive to expand Medicare home health utilization rather than try to restrict it.

Between 2002 and 2005, the percentage of SNF patients who were categorized into the “ultra-high” case-mix category nearly doubled, from just over 7% to 14%. Similarly, SNF patients in the “very high” category increased from 20% to 27%.

Thursday, August 2, 2007

Equal Choice Law Turns One

Mass Home Care reports that the Massachusetts Equal Choice in Long Term Care law passed its first anniversary on August 2. Celebrations were muted as progress has been slower than hoped for. The state did submit a Demonstration (1115) Waiver, which has yet to see federal action. The preadmission nursing home counseling has yet to be implemented.

Among the challenges to the state remaining are to: redirect long term care funds (in a budget neutral fashion) to community services; develop an expedited Medicaid authorization process for people needing home and community-based care; establish new community-based models that are not only efficient, but effective in nursing home diversion (the goal of the waiver effort); create a waiver assessment and quality assurance system. Not to mention, put together a rate structure that can help attract the workforce needed to serve a new group of clients.

Rebalancing Massachusetts long term care system is well overdue. Let's get to work. Together we can.