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.

Progress will be tracked through February 2008 and publicly reported in May 2008.

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.

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.

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.