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, December 31, 2007
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.
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
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%.
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.
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.
Wednesday, July 25, 2007
Why So Much?
The issue of the local cost of health care gets a good airing in the latest issue of Commmonwealth magazine available on newsstands and online. The article - Cost Unconsious - by David Denison rounds up the usual insurance, hospital and state government executives to agree that the current rate of cost escalation is unsutainable. To see who they blame and what they propose will require reading the article. Hint: there is little "physician heal thyself."
Monday, July 16, 2007
Test Your Health Care Reform Knowledge
If you think you know a lot about about Massachusetts' landmark health care reform legislataion, you may want to test your yourself by taking the health care reform quiz recently posted to WBUR's health care reform Blog CommonHealth. The blog itself is great reading as various parties on all sides in the ongoing debate about the law's intent and value weigh in on a daily basis. It is just what a blog should be - a conersation between interested parties - with an added benefit that we can all listen in.
And, BTW, there will be prizes for the most correct answers - and, I believe, for the best health reform haiku. So all you poets are welcome to play too!
And, BTW, there will be prizes for the most correct answers - and, I believe, for the best health reform haiku. So all you poets are welcome to play too!
Monday, July 2, 2007
Federal Budget Watch
Home health care once again has a lot at stake as elected officials in Washington debate the FY 08 Federal Budget and two Massachusetts representatives are front and center in the process. At stake is whether home health care will get a planned inflation increase in its Medicare rates - or whether this needed rate reflief will be sacrificed to pay for other Medicare and health insurance expansions, most notably a $50 billion increase for SCHIP - the state children's health insurance program.
Senator John Kerry is a member of the Senate Finance Committe that will be making these funding decisions over the next few weeks. Congressman James McGovern (D-Worcester) has been a primary sponsor of a Congressional Letter - now with more than 100 siganatures to preserve home health funding in this year's budget.
If you care about preserving home care, contact these elected officials and thank them for their support and ask them to hold steady.
Senator John Kerry is a member of the Senate Finance Committe that will be making these funding decisions over the next few weeks. Congressman James McGovern (D-Worcester) has been a primary sponsor of a Congressional Letter - now with more than 100 siganatures to preserve home health funding in this year's budget.
If you care about preserving home care, contact these elected officials and thank them for their support and ask them to hold steady.
Hospice Bad News/GoodNews
This week Brown University published their findings in a major study on patient satisfaction and the timing of referrals to hospice. Nationally, 11% of the more than 100,000 families surveyed said that they felt that referal for hospice care was "too late." (The figure was 12.4% for Massachusetts.) While the median length of service for hospice was 26 days in 2005, data from the National Hospice and Palliative Care Organization (NHCPO) indicates that 30 percent of people served by hospice in the U.S. dying in seven days or less.
More importantly, however, hospice usuage as covered by the federal Medicare program has grown tremednously in the past five years five years. In Massachusetts the number of patinets has increased by 49% between 2001 and 2005 - a good sign that families and most importantly physicians are seeing the benefits of this service - not only for the patients, but for the surviving families. (See work of Nicholas Christakis at Harvard Medical School on this.)
For families who need information about hospice care at End of Life NHCPO has developed a very informative website as a good place to start.
More importantly, however, hospice usuage as covered by the federal Medicare program has grown tremednously in the past five years five years. In Massachusetts the number of patinets has increased by 49% between 2001 and 2005 - a good sign that families and most importantly physicians are seeing the benefits of this service - not only for the patients, but for the surviving families. (See work of Nicholas Christakis at Harvard Medical School on this.)
For families who need information about hospice care at End of Life NHCPO has developed a very informative website as a good place to start.
Wednesday, June 13, 2007
We're Number 8
The Comonwealth Fund has handed Massachusetts a rank of Eighth in its new report Aiming Higher: Results from a State Scorecard on Health System Performance. Generally the areas in which our state scored the lowest are premium costs for employer sponsored insurance and "Avoidable Hospital Use and Costs." In the area of readmissions to hospitals during a home health episode. we were ranked 35, with a rate of 29.0, compared to a national rate of 26.9. Clearly this is not a problem specific to home care as in the category of overall readmisions for Medicare, 40 states did better than us.
Medicare has adopted reducing acute care hospital (ACH) admission from home care
as its national quality improvement goal for 2007. The goal for the campaign is to reduce the average ACH rate across all campaign participant home health agencies by a 5% relative improvement from baseline to the end of the campaign. The Home Care Alliance is a designated partner (a LANE) to the federal Medicare program in this QI effort and more than 75 local agencies have signed up as committed partners.
as its national quality improvement goal for 2007. The goal for the campaign is to reduce the average ACH rate across all campaign participant home health agencies by a 5% relative improvement from baseline to the end of the campaign. The Home Care Alliance is a designated partner (a LANE) to the federal Medicare program in this QI effort and more than 75 local agencies have signed up as committed partners. Progress will be tracked through February 2008 and publicly reported in May 2008.
Friday, May 25, 2007
NORC Anyone?
If you haven't read up on it, you might want to check out the new trend in supporting people who want to "age-in-place" without leaving their own home or community. NORCs - or Naturally Occurring Retirement Communities - are neighborhoods or buildings in which a large segment of the residents are older adults and in which a service structure is set up to meet varying degrees of needs. United Jewish Communities has been a leader in establishing NORCs nationally. The local model is Beacon Hill Village whose members are offered access "to social and cultural activities, exercise opportunities and household and home maintenance services, as well as medical care and assisted living at home."
Don't want to move to a retirement community? Consider starting one on your own.
Don't want to move to a retirement community? Consider starting one on your own.
Wednesday, May 16, 2007
A Whole New World - Maybe
Yesterday I testified at a Massachusetts legislative hearing in support of Senate Bill 680, which would allow home care agencies to use and get paid for monitoring frail, nursing home at-risk patients via telehealth and video visiting. The value of this technology to help patients living with diseases like congestive heart failure has been demonstrated in any number of studies. But it is hard sometimes for state programs like MassHealth in Massachusetts to embrace new approaches even as they contemplate - and seek permission from the federal government - for a new Community First strategy that attempts to reduce the state's reliance on nursing homes for long term care by expanding community program eligibility and offerings. Hopefully the legislature will prompt them by passing this bill.
Thursday, April 26, 2007
You Can't Have Everything. Where Would You Put It?
Having just returned from Washington DC seems a good time to be quoting from our a favorite philosopher comic Steven Wright who's observations always manage to be both spot on and funny. It so often seems that when it comes to getting something done in Washington, it's hard to get anything, even from the best intentioned officials. Because it's a zero sum proposition (government term: budget neutrality). When it came to talking about how we need our elected officials to stand up for home care and against cuts to a service area that has gone from about 9% of Medicare spending in the late 1990's to less than 4% today, even our best supporters need to identify who - or what other program - to "take the funds" from.
That having been said, I am proud to say that Massachusetts Congressman Jim McGovern, along with Rep Doug Petersen (R-PA), is taking the lead in the US House of Representatives in getting sponsors on a letter to the budget committee leadership in support of retaining the full funding update for home health required under current law.
Home care agencies have turned to Congressman McGovern before and he has always come through for us. We and our patients owe him our thanks.
More on this to come.
That having been said, I am proud to say that Massachusetts Congressman Jim McGovern, along with Rep Doug Petersen (R-PA), is taking the lead in the US House of Representatives in getting sponsors on a letter to the budget committee leadership in support of retaining the full funding update for home health required under current law.
Home care agencies have turned to Congressman McGovern before and he has always come through for us. We and our patients owe him our thanks.
More on this to come.
Tuesday, April 3, 2007
Eat Pray Love
Apropos of nothing too home care, just a post to highly recommend this book I just finished. Eat Pray Love One Woman's Search for Everything Across Italy, India and Indonesia is exactly what the title suggests: three very different experience in three very different countries. With a hefty book advance, the author was able to spend an extended period in each country. Far more than a travel memoir, this is a lovely, witty book with some universal themes about self discovery and recovery after a loss (in the author's case, a divorce). I had not read - or heard of - Elizabeth Gilbert before; but I may now check out her other works. Great beach reading - is it almost that time?
Monday, March 19, 2007
Health Care Costs and the Weather
Last week I attended an excellent forum on understanding and controlling health care costs in our state. As the presenters discussed the causes of health care costs from their various perspectives within the system, I couldn't help but think of a comment attributed widely, but not totally sourced to Mark Twain: "Everybody talks about the weather, but nobody does anything about it."
And so it often seems, health care costs like the weather are driven by forces beyond our control. Yet several at the meeting challenged this assumption. Many touted the big "Ts" - technology, transparency and treatment controls ("you can't always get what you want...") as possible solutions. But the real message was delivered in stark numbers by Emory University professor and researcher Ken Thorpe.
According to Thorpe, we are not victims of our own successes in doubling our life expectancy over the past hundred years with new and better medicines and diagnostics; rather we are victims of our own behaviors, what the experts call "modifiable popuation risk factors" such as obesity and smoking. Keneth Thorpe presented data that indicated that 30% - or one in three Americans - is now characterized as obese, up from 15% in the late 1970's. The cost of care attributed to diseases associated with this increase (diabetes, hypertension,etc) has risen from about 2% of total health care in 1987 to over 11 %. "Most of what is going on now to try to control health care spending is missing the target," Thorpe says. "Companies are tweaking co-pays and talking about health care savings accounts when really they need to redirect their focus to reduce the prevalence of obesity among children and workers."
To return to the cosmos metaphor... the fault "lies not in our stars, but in ourselves."
Last week I attended an excellent forum on understanding and controlling health care costs in our state. As the presenters discussed the causes of health care costs from their various perspectives within the system, I couldn't help but think of a comment attributed widely, but not totally sourced to Mark Twain: "Everybody talks about the weather, but nobody does anything about it."
And so it often seems, health care costs like the weather are driven by forces beyond our control. Yet several at the meeting challenged this assumption. Many touted the big "Ts" - technology, transparency and treatment controls ("you can't always get what you want...") as possible solutions. But the real message was delivered in stark numbers by Emory University professor and researcher Ken Thorpe.
According to Thorpe, we are not victims of our own successes in doubling our life expectancy over the past hundred years with new and better medicines and diagnostics; rather we are victims of our own behaviors, what the experts call "modifiable popuation risk factors" such as obesity and smoking. Keneth Thorpe presented data that indicated that 30% - or one in three Americans - is now characterized as obese, up from 15% in the late 1970's. The cost of care attributed to diseases associated with this increase (diabetes, hypertension,etc) has risen from about 2% of total health care in 1987 to over 11 %. "Most of what is going on now to try to control health care spending is missing the target," Thorpe says. "Companies are tweaking co-pays and talking about health care savings accounts when really they need to redirect their focus to reduce the prevalence of obesity among children and workers."
To return to the cosmos metaphor... the fault "lies not in our stars, but in ourselves."
Monday, March 5, 2007
All the News That's Fit To Print
Last week the nation's paper of record the New York Times ran an interesting front page piece exploring the homecare marketplace and the pros and cons of using so-called "full service" agencies versus hired friend and neighbors - what the Times labeled "gray market" freelance workers.
New Options (and Risks) in Home Care for Elderly took what I believe were a few unfair shots at agency offerings, including suggesting (in the words of one expert) that agencies offer little distinction over self-hireds, except for the ability to conduct criminal background checks. (Not true: Agencies not only screen, but they train, closely supervise, support, provide back-up and benefits to their aides.)
Worth pondering is the fact that demand for home-based help - of either type - is bound to exceed demand as the baby boomer bubble moves to the "elder" stage. The NY Times reports that home health aide wages nationally average $9.34 an hour; but here in Massachusetts our own wage and salary survey data indicate that the average hourly wage now exceeds $12.00. Still not a lot - but at least we are trying, with the resources we have to improve wages, and working conditions.
This could easily turn into a rant about how society in general undervalues the services of certain sectors (homecare workers, teachers, social workers) while excessively rewarding others (athletes, entertainers); but that's been done; and its dull, boring and unalterable.
So.. the question is posed: what do consumers value in a home care transaction? Agency directed care vs. self hired? Have you tried either? Both? And where will needed new workers come from?
The New Yorks Times just scratched the surface of this issue.
New Options (and Risks) in Home Care for Elderly took what I believe were a few unfair shots at agency offerings, including suggesting (in the words of one expert) that agencies offer little distinction over self-hireds, except for the ability to conduct criminal background checks. (Not true: Agencies not only screen, but they train, closely supervise, support, provide back-up and benefits to their aides.)
Worth pondering is the fact that demand for home-based help - of either type - is bound to exceed demand as the baby boomer bubble moves to the "elder" stage. The NY Times reports that home health aide wages nationally average $9.34 an hour; but here in Massachusetts our own wage and salary survey data indicate that the average hourly wage now exceeds $12.00. Still not a lot - but at least we are trying, with the resources we have to improve wages, and working conditions.
This could easily turn into a rant about how society in general undervalues the services of certain sectors (homecare workers, teachers, social workers) while excessively rewarding others (athletes, entertainers); but that's been done; and its dull, boring and unalterable.
So.. the question is posed: what do consumers value in a home care transaction? Agency directed care vs. self hired? Have you tried either? Both? And where will needed new workers come from?
The New Yorks Times just scratched the surface of this issue.
Wednesday, February 28, 2007
An Ounce of Prevention
Unless you are a caregiver for a frail friend, parent or grandparent, you might not spend a lot of time thinking about matters of balance and the cost and consequences of falls. But the numbers may surprise you. In the elderly, falls are the leading cause of injury-related deaths. They are more common than stroke (3 in 10 over seventy fall each year); cause over 90% of broken hips; and account for 16 percent of all Emergency Department visits and almost 7 percent of all hospitalizations.
In its 2006 Massachusetts State Injury Prevention Plan, the Mass. Department of Public Health reported that in 2004 Mass. hospitals reported more than 25,000 falls-related admissions. These 25,000 were more than 50% of all injury related discharges. By contrast, motor vehicle injuries requiring inpatient care totaled only 4,532. Total hospital charges for these fall-related injuries exceeded $300 million and Emergency Room care totaled more than $48 million. If you are in the health care delivery system - and whether your concern is ER back-ups, hospital bed availability, or escalating costs - you should be thinking about falls prevention.
Yes, prevention, because there is now evidence-based research that indicates that the causes of many falls are identifiable and the rates of falls can be lowered with appropriate risk assessment and intervention.
Home care agencies, which see primarily, home-bound, chronically-ill and frail elders, are increasingly becoming active in implementing falls prevention programs. This can mean assessing everything from a patient's muscle strength and home environment, to the medications they take and their impact on balance.
The Home Care Alliance will be supporting these efforts, including dissemination of best practices throught the industry, with the help of a grant from the Boston Foundation. Other resources supporting these efforts can be found on the Healthy Aging page of the National Council on Aging, which in 2005 launched a national Falls Free effort.
Can these efforts make a difference and actually bring those numbers down for Massachusetts? It's too soon to tell. But there is no doubt, the home care industry is dedicated to the effort.
In its 2006 Massachusetts State Injury Prevention Plan, the Mass. Department of Public Health reported that in 2004 Mass. hospitals reported more than 25,000 falls-related admissions. These 25,000 were more than 50% of all injury related discharges. By contrast, motor vehicle injuries requiring inpatient care totaled only 4,532. Total hospital charges for these fall-related injuries exceeded $300 million and Emergency Room care totaled more than $48 million. If you are in the health care delivery system - and whether your concern is ER back-ups, hospital bed availability, or escalating costs - you should be thinking about falls prevention.
Yes, prevention, because there is now evidence-based research that indicates that the causes of many falls are identifiable and the rates of falls can be lowered with appropriate risk assessment and intervention.
Home care agencies, which see primarily, home-bound, chronically-ill and frail elders, are increasingly becoming active in implementing falls prevention programs. This can mean assessing everything from a patient's muscle strength and home environment, to the medications they take and their impact on balance.
The Home Care Alliance will be supporting these efforts, including dissemination of best practices throught the industry, with the help of a grant from the Boston Foundation. Other resources supporting these efforts can be found on the Healthy Aging page of the National Council on Aging, which in 2005 launched a national Falls Free effort.
Can these efforts make a difference and actually bring those numbers down for Massachusetts? It's too soon to tell. But there is no doubt, the home care industry is dedicated to the effort.
Tuesday, February 13, 2007
Home Care Disconnect
Although I must confess to be one of those who are contributing to a steep decline in the percentage of the population watching a network nightly newscast, an NBC promo had me tuning in last night to see anchor Brian William's report on "Trading Places: When Kids Care for Aging Parents." http://dailynightly.msnbc.com/ William's piece was a moving account of his efforts to assure a dignified and quality life for his World War II veteran father, living by choice in a small one room efficiency in a New Jersey Assisted Living unit. Gordon Williams, now nearing 90 years of age, has survived not only his wife of 50 years and two of his children, but a "heart attack, cancer surgery, a broken hip and hip replacement."
Williams admits that he is fortunate to be able to financially care for his father - but physically - due to time and distance - he reports that he is dependent on some "angels" - namely the Visting Angels home care service. They do, he said, what he and so many others like him can not. And they do it quite well.
A few days before the NBC series began to air, the President proposed in his FY08 budget to freeze home care funding within the Medicare program, not only for the upcoming fiscal year, but for the next five years (FY08-FY12). The result would be a reduction over the five years of more than $9 billion nationally, and $302 million in Massachusetts. While many other services sustained cuts in the President's proposed budget, home health care's five year reduction is the most drastic.
Putting aside questions about budget sleight of hand that has the Executive Branch proposing cuts that will extend well past their tenure in office, the proposed cuts leave one wondering if indeed when it comes to care for aging relatives, we will soon be adding a "long term care divide" to our lexicon, along with "digital divide," "generation divide" and all of those other societal demarkations.
I am not saying that the government can or even should pick up the total tab for an aging population that is in large part an American success story: even those with chronic diseases can live longer and full lives due to great medical advances and great care.
But I am asking people to stop and think about Medicare and what it has meant for this country. Whether small government proponents like it or not, the fact is that Medicare remains the largest and I would argue probably the most succesful program our government has ever come up with. To allow benefits to be eroded as the President is proposing and at a time when they will be most needed seems at best short-sighted and at worse mean-spirited.
There is a small book I love called Really Important Stuff My Kids Have Taught Me." One of the sayings in it is the following: "If you want pancakes for breakfast, you got to help make help make them."
The message is if you have aging parents, you need to get off the sidelines and get into the long term care debate.
Williams admits that he is fortunate to be able to financially care for his father - but physically - due to time and distance - he reports that he is dependent on some "angels" - namely the Visting Angels home care service. They do, he said, what he and so many others like him can not. And they do it quite well.
A few days before the NBC series began to air, the President proposed in his FY08 budget to freeze home care funding within the Medicare program, not only for the upcoming fiscal year, but for the next five years (FY08-FY12). The result would be a reduction over the five years of more than $9 billion nationally, and $302 million in Massachusetts. While many other services sustained cuts in the President's proposed budget, home health care's five year reduction is the most drastic.
Putting aside questions about budget sleight of hand that has the Executive Branch proposing cuts that will extend well past their tenure in office, the proposed cuts leave one wondering if indeed when it comes to care for aging relatives, we will soon be adding a "long term care divide" to our lexicon, along with "digital divide," "generation divide" and all of those other societal demarkations.
I am not saying that the government can or even should pick up the total tab for an aging population that is in large part an American success story: even those with chronic diseases can live longer and full lives due to great medical advances and great care.
But I am asking people to stop and think about Medicare and what it has meant for this country. Whether small government proponents like it or not, the fact is that Medicare remains the largest and I would argue probably the most succesful program our government has ever come up with. To allow benefits to be eroded as the President is proposing and at a time when they will be most needed seems at best short-sighted and at worse mean-spirited.
There is a small book I love called Really Important Stuff My Kids Have Taught Me." One of the sayings in it is the following: "If you want pancakes for breakfast, you got to help make help make them."
The message is if you have aging parents, you need to get off the sidelines and get into the long term care debate.
Thursday, February 8, 2007
Universal Health Insurance
Yesterday, I attended a meeting of very committed and smart individuals dedicated to making Massachusetts Universal Health Insurance Reform Law work and work as intended - to provide access to health insurance to those in our state who are currently without it.
Health Care For All, which has been a major force in advocating for the consumer in this process, estimates that already the number of uninsured folks who have been enrolled in affordable and good quality health insurance plans since the law was signed 4/12/06 total more than 100,000: 58,000 new MassHealth enrollees since 7/1/06 and 47,000 enrollees in Commonwealth Care. (Commonwealth Care is a new state program that offers free or reduced cost insurance for adults 19 or older who meet certain income guidelines.)
But some big decisions loom, and what happens could greatly impact home care agencies. Home care agencies employ many paraprofessional workers (home health aides and homemakers) whose salaries are a product of what government payors (Medicare and Medicaid) will pay for a home visit. Although home care agencies almost universally offer health insurance to their workers, many aides and homemakers "opt out" because the premiums would consume too much in their weekly paycheck. (A $1200 a month family plan subsidized by the employer at 50% would costs the aide $600 a month.)
With the deadline for the individual mandate (at which point most citizens will be required to have insurance) fast approaching (July 1, 2007). decisions have to made. At this point, although many of these workers are income-qualified to access subsidized care through Commonwealth Care, they are at present excluded because their workplace offers insurance. The smart people referenced above, who are working to influence decision-making of the implementation body The Connector, are considering these issues with an eye toward possible changes. Nothing has officially been endorsed, however in the mix are:
Health Care For All, which has been a major force in advocating for the consumer in this process, estimates that already the number of uninsured folks who have been enrolled in affordable and good quality health insurance plans since the law was signed 4/12/06 total more than 100,000: 58,000 new MassHealth enrollees since 7/1/06 and 47,000 enrollees in Commonwealth Care. (Commonwealth Care is a new state program that offers free or reduced cost insurance for adults 19 or older who meet certain income guidelines.)
But some big decisions loom, and what happens could greatly impact home care agencies. Home care agencies employ many paraprofessional workers (home health aides and homemakers) whose salaries are a product of what government payors (Medicare and Medicaid) will pay for a home visit. Although home care agencies almost universally offer health insurance to their workers, many aides and homemakers "opt out" because the premiums would consume too much in their weekly paycheck. (A $1200 a month family plan subsidized by the employer at 50% would costs the aide $600 a month.)
With the deadline for the individual mandate (at which point most citizens will be required to have insurance) fast approaching (July 1, 2007). decisions have to made. At this point, although many of these workers are income-qualified to access subsidized care through Commonwealth Care, they are at present excluded because their workplace offers insurance. The smart people referenced above, who are working to influence decision-making of the implementation body The Connector, are considering these issues with an eye toward possible changes. Nothing has officially been endorsed, however in the mix are:
- a process to waive the exclusion from CC for certain workers in companies that offer insurance (if the insurance is too costly or does not meet "credible coverage" guidelines),
- advocating for premium support to help workers to afford to opt-in to an employer-sponsored plan,
- and, most drastically, delaying the insurance mandate for certain individuals (according to income, job status or other criteria).
All of these possible changes or mid-course corrections have domino consequences to the delicate balancing act that is health care reform. On the employer side, the mandate holds the possibility that workers who previously opted out (some in favor of higher hourly pay) now will seek coverage. (A good thing, many believe). But our home care agencies have little resources to find revenue to cover drastic increases in the employer cost of providing insurance. Government payors set our rates and we can't raise them at wil - even to cover new government mandates.
Which way all this will go is too early to say. The bottom line: our insurance system is costly and complex and so is the health reform act. That doesn't mean it wasn't a good thing, because it was. It's just going to take a lot of very smart and committed people to make it all work.
Monday, February 5, 2007
Baby, It's Cold Outside
Whether records were set today for temperature or not doesn't matter much, especially to people who have to work outside. It's cold and they know it. When the weather gets like this the media will often run a profile on cops or construction workers doing their jobs despite bone-chilling winds.
But I'd like to give my own shout-out to our home care nurses, aides and therapists who like the proverbial letter carriers are out there "in rain, in sleet and snow" and, of course, cold. Their clients depend on them and they deliver. Today, we estimate about 20,000 home care visits will be made in Massachusetts from sun-up to way past sundown. Medicines will be dispensed and bandages changed. Vital signs will be checked and limbs rehabilitated. Comfort and companionship just come with the service.
It was in 1957 that famous fictional nurse Cherry Ames had her assignment as a visitin
g nurse in New York City. Cherry worried about how she would be perceived - as "a stranger." Her supervisor corrected her: "It's hard to explain, but when you go to somebody's door and they light up and say 'thank goodness the nurse is here'.... well it's pretty wonderful."
A little warmth on a cold New England day.
But I'd like to give my own shout-out to our home care nurses, aides and therapists who like the proverbial letter carriers are out there "in rain, in sleet and snow" and, of course, cold. Their clients depend on them and they deliver. Today, we estimate about 20,000 home care visits will be made in Massachusetts from sun-up to way past sundown. Medicines will be dispensed and bandages changed. Vital signs will be checked and limbs rehabilitated. Comfort and companionship just come with the service.
It was in 1957 that famous fictional nurse Cherry Ames had her assignment as a visitin
g nurse in New York City. Cherry worried about how she would be perceived - as "a stranger." Her supervisor corrected her: "It's hard to explain, but when you go to somebody's door and they light up and say 'thank goodness the nurse is here'.... well it's pretty wonderful."A little warmth on a cold New England day.
Thursday, February 1, 2007
Formal and Informal caregivers
A Caregiver Survey that was just published in the Archives of Internal Medicine has me thinking about the roles of home care agencies and informal caregivers, defined as those who have taken a primary role of caring for a disabled or dying family member or friend. Some recent public policy initiatives on the state and federal levels that would compensate these caregivers for their efforts often seem to be positioned as at odds with professional or home care agency delivered care. But from where I sit, this seems hardly the case.
The survey revealed what many could intuit: Among the caregivers of adults in the last year of life, 41.5 percent were spouses and 39 percent were children; 75.1 percent were female (no surprise!). These caregivers had an average age of 64 years. They provided an average of 43 hours of care per week, and 84.4 percent of them provided daily assistance.
More than two-thirds of family and friends serving as informal caregivers to disabled older adults living in the community during their final year of life found their role rewarding despite providing more than 40 hours of care per week.
Interesting to me the authors concluded that these caregivers made "little use of caregiver-focused supportive services." Yet within the data was the fact that 37.2 percent used personal or nursing care services during the final caregiving year. To me this is significant. As I said in the opinion editorial that I submitted to papers for Thanksgiving 2006: "Professional caregivers - nurses, therapists and aides - are often best position to see the sacrifices family caregivers make for their loved ones. We know we can't replicate the love in the family caregiving relationship; but we can do our best to make their job easier."
To all the family caregivers out there, our industry acknowledges your effort and sacrifice. We need to also let you know that we are here to help if you need us.
Til next time.
The survey revealed what many could intuit: Among the caregivers of adults in the last year of life, 41.5 percent were spouses and 39 percent were children; 75.1 percent were female (no surprise!). These caregivers had an average age of 64 years. They provided an average of 43 hours of care per week, and 84.4 percent of them provided daily assistance.
More than two-thirds of family and friends serving as informal caregivers to disabled older adults living in the community during their final year of life found their role rewarding despite providing more than 40 hours of care per week.
Interesting to me the authors concluded that these caregivers made "little use of caregiver-focused supportive services." Yet within the data was the fact that 37.2 percent used personal or nursing care services during the final caregiving year. To me this is significant. As I said in the opinion editorial that I submitted to papers for Thanksgiving 2006: "Professional caregivers - nurses, therapists and aides - are often best position to see the sacrifices family caregivers make for their loved ones. We know we can't replicate the love in the family caregiving relationship; but we can do our best to make their job easier."
To all the family caregivers out there, our industry acknowledges your effort and sacrifice. We need to also let you know that we are here to help if you need us.
Til next time.
Tuesday, January 30, 2007
Welcome
After talking about it for what seems like years, I have decided to start thinking about home care in the form of my very own blog.
For a while I was torn about the idea. Mostly because it seemed so unseemly, self indulgent or just so 'next generation' to be posting my daily (okay, maybe weekly) musings for the world. But, whether it ego, love of writing, and/or I desire to be more "up with the times" (my kids just cringe at that), I am making a go of it.
Now that I am starting, the pressure is on ... what to write? And especially, what to write about for my first posting? Big thoughts on home care today? On the frequent lack of appreciate for its contribution in payment systems or outcome studies? Too much, too soon.
So I thought I would just post what seems to be good news. In today's Boston Globe a major front page story about computerization of medical records referenced that the community-wide effort in North Adams, Massachusetts includes the local visiting nurse association in its linkage efforts. Score one for homecare as a critical component in the care continuum!
Finally, the great Benjamin Zander addressed a gathering of home care executives in Boston this week on transforming their professional and personal lives through "The Art of Possibility." One of his central messages - everyone should declare or "reinvent" themselves as a contribution. Throw off traditional measures of progress and awake each day to the challenge of making a contribution, great or small.
A great reminder that not everything that counts can be counted, and not everything that can be counted counts.
'til next time.
For a while I was torn about the idea. Mostly because it seemed so unseemly, self indulgent or just so 'next generation' to be posting my daily (okay, maybe weekly) musings for the world. But, whether it ego, love of writing, and/or I desire to be more "up with the times" (my kids just cringe at that), I am making a go of it.
Now that I am starting, the pressure is on ... what to write? And especially, what to write about for my first posting? Big thoughts on home care today? On the frequent lack of appreciate for its contribution in payment systems or outcome studies? Too much, too soon.
So I thought I would just post what seems to be good news. In today's Boston Globe a major front page story about computerization of medical records referenced that the community-wide effort in North Adams, Massachusetts includes the local visiting nurse association in its linkage efforts. Score one for homecare as a critical component in the care continuum!
Finally, the great Benjamin Zander addressed a gathering of home care executives in Boston this week on transforming their professional and personal lives through "The Art of Possibility." One of his central messages - everyone should declare or "reinvent" themselves as a contribution. Throw off traditional measures of progress and awake each day to the challenge of making a contribution, great or small.
A great reminder that not everything that counts can be counted, and not everything that can be counted counts.
'til next time.
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