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.

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?

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."

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.

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.

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.

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:

• 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.