America’s Housing Crisis

Warning-Challenges-aheadLast week the Joint Center for Housing Studies of Harvard University released a new report, Housing America’s Older Adults: Meeting the Needs of An Aging Population. Funded primarily from a grant provided by the AARP Foundation, it concisely and comprehensively depicts the fissure of disconnect characterizing the burgeoning need for affordable senior housing as contrasted against the nation’s ability to accommodate that need.

As reported on there, a myriad of overlapping demographic and socioeconomic components are advancing unabated to create a perfect storm in the form of a national housing crisis that represents one of the most vexing domestic policy issues we will face over the next two decades.  Despite the growing enthusiasm for home and community-based services as a more preferable and lower cost alternative to institutionally-based care, the stark reality is that individuals in need of services and support, as well as long-term care, need a physical location at which they receive that assistance – and a place to sleep to boot.

With all of the media attention that has been given to healthcare reform it’s not surprising that housing, services and support and long-term care for the elderly and disabled is characterized by those intimately familiar as a social time bomb, ticking away without the attention it needs or deserves. In good part this deference is also due to the political reality that it’s a minefield of tough choices, which upon further survey frightens even the most stalwart politician into a stasis of self-preservation (yes, more so than usual).

Friend and colleague, Rob Hilton, President & CEO of the A M McGregor Group in East Cleveland, Ohio has long held a personal and professional passion for addressing the affordability of housing, services and care for seniors. In June of 2012 I interviewed Rob for a Pub Chat: Affordable Housing Key to Long-Term Care. Rob was originally responsible for my getting interested in the concept of Affordable Housing Plus Services. LeadingAge’s Center of Applied Research headed by Dr. Robyn Stone has some very good resources on the background and research surrounding AHPS.

That interest spurred my thinking about how taking a holistic approach to the development process could result in more affordable product offerings. Real estate development is by its nature both a risky and capitally intensive endeavor. Being able to use a process that effectively manages that risk while reducing unproductive expenditures can – in the aggregate – have a major impact on affordability. The graphic below is one that we use at Artower to help explain key concepts of this approach.

chart_061914

I also wrote about this approach a few years back in a white paper on Mission-Driven Development that further describes some of the key concepts.

Depicted below is a strategic development planning matrix that was developed collaboratively by me and Rob Hilton over the past decade (i.e., many iterations reflecting our learning). In some fashion this represents the holistic, circular process shown above being flattened into a linear representation that can better accommodate process tracking and accountability. I realize this image is too small to read, but please contact me if you are interested learning more.


Visio-Affordable Housing101013-page-0

So while I don’t claim to have all of the answers to the housing crisis that is facing us, I have spent considerable time undaunted by the aforementioned policy minefield thinking about solutions. I would be more than happy to share what I have learned with others who are interested in tackling this challenge head on – while there is still time.

Cheers,
  ~ Sparky

Blog picture credit: Power By Choice, Colorado Springs, CO 80904

QAPI: A Steep Learning Curve for Many

Compliance Conceptual MeterI am becoming increasingly concerned that many, if not most, post-acute/long-term care organizations are poorly prepared to embrace the requirements of the looming Quality Assessment Performance Improvement (QAPI) reporting requirements mandated by the Affordable Care Act. I base that conviction on how much I have learned over the past few years working with my colleague, Nathan Ives, of Strategy Driven Enterprises, LLC.

A graduate of the United States Naval Academy, for over two decades Nathan has been immersed in the world of quality assessment, performance improvement and regulatory compliance as each has applied to the nuclear power industry. He has held several influential positions at the Institute of Nuclear Power Operations (INPO) and has led teams of nuclear operations professionals in the performance evaluation of over 24 nuclear electric generating stations from 20 utilities in the United States, Canada, and Japan. He also led the nuclear industry’s effort to redefine performance standards in the areas of organizational alignment, managerial decision-making, plant operations, and risk management.

For the past two years, Nathan has been working with my Artower colleague, Terri Williams, RN, on developing EviQual™, a turnkey regulatory compliance solution that PA/LTC organizations can use to create a QAPI program. Terri has nearly 30 years of experience as a practitioner, educator and advocate for quality improvement and patient safety at PA/LTC facilities. Now, as a I have neither an operational engineering nor clinical background, for me it has been a fascinating learning experience. And what I have learned primarily is that QAPI – as understood from how it has been applied in other industries – is an entirely different approach to outcome quality and patient safety than what most PA/LTC organizations are currently familiar with.

Whereas historically those organizations have focused a great deal of attention on observing, recording and diagnosing the cause(s) of adverse events, the whole point of a quality assessment program is to proactively diagnose existing practices, policies and performance to create an environment in which such events don’t happen in the first place. It is a paradigm shift in thinking and approach that for most organizations must be accompanied by changes in organizational culture.

That’s why in creating EviQual™ we have sought to leverage the already existing knowledgebase of what has been proven effective in improving quality and safety in an industry that has many parallels with healthcare. In fact, Nathan and I collaborated on a white paper  some time ago on the applicability of lessons learned in the nuclear power industry to aligning healthcare organizations via quality and performance improvement.

The Centers for Medicare and Medicaid Services has made available QAPI at a Glance, a step-by-step guide focusing on 12 core elements ranging from organizational sponsorship and leadership to tactical  program implementation. A very well written accompaniment to that guide was just recently completed as a series of articles for Long-Term Care Magazine by Nell Griffin, LPN, EdM. Both are wonderful resources if you are new to understanding QAPI and the important ramifications it will have on PA/LTC organizations.

The first step in the 12-step process for implementing a QAPI program focuses on leadership, responsibility and accountability. What this requires is the active and committed sponsorship of the QAPI process by senior executives and board members. So when I hear leadership teams at PA/LTC organizations say they are confident their clinical teams are proactively addressing the QAPI requirements, I can’t help but fear those organizations have already stumbled out of the gate.

Cheers,
  ~ Sparky

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Moving Away From Sick Care

There is a saying that goes, “America doesn’t have a healthcare system – we have a sick-care system.” I don’t know whether that quote is attributable to an individual or not, but the connotation is that what for decades has served as a healthcare delivery system belies the underlying premise that the individuals benefitting from that system’s value proposition are, indeed, healthy.

Of course, they are not – at least at the time service is required.  They are sick, ill or afflicted by a myriad of chronic diseases and conditions. Whatever we want to call it, a system that addresses the needs of these individuals is critically important. But the study in ironic contrast serves to raise awareness of the need to address population health as the best hope of reigning in the unabated march of healthcare’s gobbling up the nation’s GDP.

Last week a new Health Policy Brief, The Relative Contribution of Multiple Determinants of Health, was released by Health Affairs and the Robert Wood Johnson Foundation that looks at factors and considerations impacting individual and population health. These are commonly referred to as health determinants and can be summarized into five major categories: genetics, behavior, social circumstances, environmental and physical influences and medical care.

Researching and understanding how specific factors and considerations within these categories impact individual and population health is very challenging because of complex, interdependent, bidirectional relationships – and because the timeframe over which meaningful measurement must take place can often be decades. But if the US delivery system is to make a paradigm shift away from having a sick care system, efforts must continue to understand whether and how health policy interventions and choices, as well as the efficient use of limited resources, can achieve better outcomes.

This, in turn, requires the adoption of a more holistic understanding of health: the roles social and environmental (i.e., nonclinical) determinants play in impacting individual health. Human behavior, for example – a primary concern in understanding poor health outcomes – must be understood and assessed, “according to multiple dimensions and at various points of intervention.”

Despite the challenges, progress continues on understanding the role nonclinical determinants play in individual and population health outcomes. The continued advancements in Big Data should accelerate these efforts. The policy brief referenced above provides a nice overview of these efforts with resources that should be noted by healthcare providers wanting to better understand how their competitors are seeking to become strategically aligned with population health management.

There are currently a lot of major healthcare providers touting in the press their foray into population health, as if the opportunity for impact is ripe for harvesting. But having recently become more educated and aware of the myriad issues and complexity of population health, I do have to wonder if their strategies are too narrowly focused on how to creatively redeploy existing assets and resources – rather than making a candid and honest assessment whether either can be productively leveraged in the context of a holistic approach to healthcare.

Cheers,
  Sparky

Population Health Needs A Brand Positioning Strategy

Population Health (PH) is a term that has become ingrained in the Healthcare Reform lexicon over the past decade. It’s one of those politically gravitational conveniences that allow candidates from different parties to embrace a common goal with little risk of being criticized for holding beliefs different than their opponent. And that is precisely because it is difficult, if not impossible, to prove someone believes in something that does not have a consistent and agreed upon definition.

Just What is Population Health?
What PH enjoys in broad political support it lacks in definitional credibility. A good treatise on variations of contemporary definitions can be found in Academy Health’s Population Health in the Affordable Care Act Era by Michael Stoto, Ph.D. Without wanting to deliberately adulterate that work, Stoto highlights conceptual commonalities and differences in definitions from several sources that I will try and very briefly summarize below.

A focus on health outcomes – the subjectivity of which notwithstanding – and the distribution of outcomes (i.e., how do outcomes vary across comparative stratifications, such as geographic residence, ethnicity, age, etc.)

The impetus of achieving healthier outcomes is through encouraging healthier lifestyles, better nutrition, preventative care, avoiding behavioral risks, etc.

Measurement of health status indicators as well as the factors that are correlated with those indicators (e.g., socioeconomic conditions, physical environments, childhood development, etc.)

Utilization of data and analytics to develop a conceptual framework for understanding and explaining differences in population health indicators – and how that knowledge impacts research agendas, resource allocations and public policy.

Often discussed (or confused, depends on your perspective) with public health, though the latter also typically connotes a governmental influence of some type (e.g., a municipal health department).

Policy Perspectives
From a policy perspective, there are two ways to look at PH: altruistic and pragmatic. From an altruistic perspective policies that promise to improve population health are most often framed in cost—benefit analyses: the benefits, if achievable, are easy to agree upon (who doesn’t want to be healthier?). The ROI is the challenge and most often the subject of political contention.

From a pragmatic perspective – particularly as PH has been manifested in the Affordable Care Act – what we are really talking about is cost control. Healthier people demand less healthcare services. Individuals with chronic conditions that more effectively manage those conditions need less healthcare. Economics 101: if we can reduce demand while maintaining or increasing supply, costs should decrease.

Parallel to this latter perspective is the growing base of knowledge that indicates improving the quality of care can achieve both lower costs AND better care. So if population health is a vehicle through which quality can be improved, it benefits from that additional policy advocacy.

Population Health Perceptions
Population Health means different things to different people. A good part of that difference can be explained in the inherent subjectivity of the concept of health outcomes. Some other portion can be explained by academic exercises seeking to cut the Gordian Knot. Still another by political extrapolations that seek to gain favor by equating improved population health with an appreciative electorate.

Whatever the feasible explanation(s) may be, Population Health suffers from an identity crisis. Beyond just a definitional problem, however, it fundamentally lacks in having been able to achieve a shared understanding of its meaning and purpose at a level that resonates with the very “population” whose health is of concern. In short, PH could use a brand positioning strategy.

Perceptual Positioning of Population Health
One of my favorite books on branding is Brand: It Ain’t the Logo: It’s what people think of  you™ by Ted Matthews. Matthews argues that,

“a brand is the sum total impression and memory of every remarkable, every so-so and every negative experience with any and all pieces of an organization. A brand is the personality of [that organization] . . . and is judged and assessed a value by everyone it touches, whether inside the [organization] or outside. These perceptions of value may, or may not, be what you want them to be. Which suggests a fact that may surprise you: your brand isn’t really yours (emphasis added). You don’t own it – all the people thinking about you do.”

It’s not a leap to borrow or migrate these concepts of perceptual brand positioning to PH. Many proponents of PH take an interventional approach as a means to advocacy. Their focus is on modifying individual behaviors, inducing health screening, creating artificial employment incentives and imposing restrictions and/or impositions on environmental elements. This is not a sustainable approach to PH brand positioning simply because it fails to recognize that the perception of PH is owned by the individual – and not the advocate.

What to do Differently
When I was giving presentations across the country a few years back on the newly passed Affordable Care Act, I made it a point to say that I believed if we were somehow successful in increasing access to healthcare services, in improving quality, in lowering costs, in enhancing efficiency and productivity – that none of that would matter long-term because the forecasted demand from an aging demographic would atomize those gains.  The only escape from a tragic gap between demand for quality healthcare and the ability to meet that demand will come from lowering innate demand.

Population health, however one wants to define it, is therefore a critical component of any strategy that seeks to address the looming care gap. But the underlying concepts of what make improving population health mutually beneficial cannot be thrust upon individuals for their own good. Nobody ever bought a Macintosh computer because Steve Jobs told them they should. If you are an advocate of PH, then it’s time to start looking at how to perceptually position its brand benefits differently.

Look at the most valuable brands in the world, and look at how they were built: such as Apple, Microsoft, Coca-Cola, IBM, Google, Disney. Marketing and advertising played important roles, but it has ultimately been each organization’s ability to offer something of value to individuals that drove sustainable perceptions. What can be learned from the branding strategies of organizations like these that can turn the perceptual positioning of Population Health on its head to achieve the long-term benefits that we believe can be achieved?

Cheers,
  Sparky

Depression, Addiction & Mental Health Policy

Pic For BlogThe last time I remember feeling as badly about a celebrity passing has to be December 8, 1980. I remember exactly where I was and what I was doing when a radio disk jockey (people that used to play and broadcast what were known as records on electronic turntables) broke the news over a song that John Lennon had been shot. About two minutes later, the music was stopped – and the sad news announced that he had been shot – and killed.

Queue up round the clock Beatles music and millions of tears across the world.  The next day in the Rock n Roll capital was damp and dreary. A cold mist just seemed to hang in the air. One of those days where ironically it would feel warmer if it would have just snowed. There are a lot of days like that in early December in Cleveland, Ohio. But this one so fit the mood.

Nobody saw that one coming. Whereas we all know now what only a few knew all to well before Monday: that Robin Willams’ mental demons were probably always only a few steps behind. Shadowing him like the inescapable darkness of a night in the forest, depression is a disease that lurks, pounces, retreats and then stalks – taking in turn at random how it chooses to haunt its victims.

Addiction, on the other hand, despite the cultural shift in attitudes over the past few decades, is not a disease. Writing in the Psychology Today blog a couple of years back, Dr. Lance Dodes explains how addiction has little in common with other diseases and cannot be explained by any disease process. But as he also astutely points out, neither is it the purview of individuals lacking in discipline and morality,  just being selfish and self-centered.

But to understand addiction is to understand the mental state of an individual leading up to and perpetuating its hold on that person.  Dr. Lance writes, “addictive behavior is a readily understandable symptom, not a disease.” In Williams’ case the connection between depression and resulting behavior leading to addiction is something that should continue to build awareness and understanding.

I realize it’s a sensitive line here because the last thing we want to do is roll back the progress made fighting stigmatization and the barrier and obstacles that has created in affecting treatment access. On the other hand, from a public policy perspective it is crucial that we continue to dig deeper: to understand mental health – and mental illness – as a critically holistic element impacting all varieties of personal well being, not just as a precept to alcoholism and addiction.

Robin Williams’ wife has asked that we remember her husband by not focusing on his death, “but on the countless moments of joy and laughter he gave to millions.” As the emotional pain subsides I am certain we will be able to do that. Before we get to that place, however, it is natural to question and seek answers on how this tragedy might have been avoided.

For millions of Americans suffering from, or affected by a loved one suffering from, a mental illness, alcoholism or addiction, Robin Williams’ death is a painful reminder of the fear and vulnerability they live with every day. And they are right to be questioning what might be done to help address that suffering. Yesterday, Rep. Tim Murphy (R-Pa) noted that, “Williams’ greatest gift to us, if we choose to accept it, is a focused determination to help those with brain illness and finally take real action to stop the loss of one more precious life.”

In December of last year, in response to the 2012 elementary school shooting in Connecticut, Murphy – a clinical psychologist – introduced H.R. 3717, The Helping Families in Mental Health Crisis Act. One of the most important initiatives in the bill is to address the Institutions for Mental Disease (IMD) Exclusion, which limits Medicaid coverage for inpatient mental health and addiction treatment.

The bill is complex, comprehensive and has faced a significant amount of criticism. Good coverage of this can be found in a blog post from Gary Earles, LICSW, writing last year for the Morning Zen on the Children’s Mental Health Network. Very doubtful that even with this latest tragedy the bill will move anywhere before the next Congress is installed. But what might now happen is the debate will move from the purview of policy wonks, trade groups and special interests into the real world where those aforementioned suffering can have a voice. We can only hope.

Cheers,
  Sparky

Healthcare’s Disruptive Innovator

Disruptive Innovation is a term widely attributed to Harvard Business School professor, Clayton Christensen. Often used interchangeably with the term, disruptive technology, there is an important distinction: the former represents not just advancements in underlying technology but the innovative application of that technology.

Disruptive innovation is something that concurrently, though at varying speeds, creates a new market while disrupting an existing market in ways that essentially had not been anticipated. Examples frequently cited include the introduction of personal computers and the impact that had on mini and mainframe computers; cellular phones’ impact on fixed line telephony; the iPod’s impact on the music industry; and most recently – retail medical clinics’ impact on traditional physician offices.

Enter The Clinic at Walmart.

Writing in the Healthcare Finance News, Contributing Editor Anthony Brino writes how Walmart is now wading into physician territory. Having already opened over 100 walk-in clinics across the country that provide access to medical care through collaborative agreements with local hospitals and/or physicians, this latest move – directly employing nurse practitioners – is part of a longer term strategy for Walmart to be self sufficiently ingrained as a primary care provider.

And of course, it’s not just Walmart that is seeking to capitalize on the increasing demand for primary care coupled with the escalating cost of that care: according to a 2013 report from Accenture Research the number of retail health clinics is anticipated to double over the next three years from 1,400 to 2,800. The core value proposition is increased access and greater convenience at a substantially lower cost than a visit to a doctor’s office.

What we are really looking at here is the commoditization of Medicine. The underlying premise is that a wide swath of fundamental and routine aspects of primary care can be automated and standardized: treatment of simple acute conditions, preventative care (e.g., vaccinations), wellness screening, diagnostic testing, etc.

There are substantial reasons to be concerned with the promulgation of retail clinics, particularly where they serve in lieu of primary care physician relationships. For starters, nurse practitioners – which undoubtedly must be a critical element in expanding primary care – simply do not have the same level of training and experience as a board certified physician. Their ability to assess, decipher and act upon the nuances of a patient’s conditions are – in general – not going to be the same.

The historical relationship of a patient and his or her physician becomes over time an invaluable knowledgebase that the physician relies upon to identify changes in a patient’s condition that may warrant investigation. And convenience can be a double-edged sword. Being prescribed an antibiotic for a virus that someone then confidently carries with them to their work environment not only prevents that individual from staying home and getting needed rest – it unwittingly exposes coworkers to that virus, which the antibiotic does nothing to control (or treat).

But what disruptive innovation is without its unintended consequences? Look at how much time we now spend in front of computers instead of outside exercising. Cell phones migrated to smart phones that people now use to text their way to oblivion: in 2012 over 3,300 people were killed in distraction-related crashes. Whether the paradigm shift in the music industry is a positive or negative I think depends a lot on  your age – but as with all other such innovations, nothing will ever be the same.

That is true for the healthcare industry and the practice of medicine: nothing will ever be the same – except our resistance to change – that won’t change.

Cheers,
  Sparky

As the ACA Turns

So now what?

If the Affordable Care Act was a soap opera – and who’s to say it’s not – I think even Susan Lucci would have lost faith by now in the merits of a plot leading to any type of long-term resolution, clarity or certainty.

The U. S. Court of Appeals for the D.C. Circuit ruled today in the Halbig v. Burwell decision that the IRS had incorrectly allowed the subsidization of insurance premiums to millions of Americans covered under the Act’s health insurance exchanges. Then about an hour later, the U.S. Court of Appeals for the Fourth Circuit, in Richmond, argued that the IRS was within their legal power because the subsidies they provided were, “a permissible exercise of the agency’s discretion.”

Following along?

The Act provides that subsidies be provided to “state-run” exchanges, but whether through political objection or inability, 27 states opted to have the federal government establish and operate their exchanges while another 9 states opted to have their exchanges jointly ran by state and federal agencies. So by an interpretation of the letter of the law subsidies are unavailable to individuals living in those 36 states.

In writing the 2-to-1 majority opinion on the Halbig decision, Judge Thomas Griffith noted that, “we reach this conclusion, frankly, with reluctance.” Why? Because according to the Robert Wood Johnson Foundation an estimated 7.3 million people — about 62 percent of those expected to enroll in federal-run exchanges by 2016 — could lose out on $36.1 billion in insurance subsidies. Over 7 million individuals could be losing an average of $4,400 in annual subsidies (based on Congressional Budget Office estimates for the current year).

What each court had to wrestle with was whether it was Congress’ intent to provide expanded access to healthcare insurance through premium subsidization irrespective of whether the exchanges are ran by state or federal governments. Judge Griffith wrote that, “the fact is that the legislative record provides little indication one way or the other of congressional intent, but the statutory text does. Section 36B plainly makes subsidies available only on Exchanges established by states.”

And there’s the rub. Looking back to the summer of 2010, the legislative process leading to passage of the Affordable Care Act was ridiculously chaotic, incredibly politically charged and fraught with misinformation being spewed in all directions by nearly every stakeholder who could find a media outlet. All (as in both) parties being equally complicit in disinformation

John Earnest, White House press secretary noted, “you don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace. I think that is a pretty clear intent of the congressional law.”

I think he is wrong. It’s not clear because the legislative process leading up to and through passage was anything but. In fact, it can be effectively argued that lack of clarity was a direct result of favoring political expediency over legislative pragmatism. The Act is very poorly written and is fraught with these types of examples where implementation wasn’t very well thought through. But that lack of clarity – and legislative ambiguity in particular – is not grounds for overturning legislative intent.

Writing today in The New Republic, Brian Beutler argues that applying Supreme Court Justice Antonin Scalia’s concept of “overall statutory scheme,” that, “the words of a statute must be read in their context,” it is unambiguous that it was Congress’ intention through the ACA to provide insurance subsidies a priori of the means and mechanisms of the exchanges. Even if the argument could be made that it was ambiguous, Beutler notes that there is still the need to determine whether the law has been interpreted plausibly. In either case, it seems unlikely this latest attempt to derail the ACA will ultimately succeed.

But let’s assume that it does. I think it could easily be a case of be careful what you wish for because you might just get it for republicans. By the time this issue would make it through the Supreme Court there will be at least over 7 million individuals that are going to be told they will suddenly lose what then could reasonably be a $5,000 a year benefit. All that would be required to maintain the benefit would be an administrative language modification, which republicans could refuse as a plausible effort to cripple the Affordable Care Act. They would be in a politically very difficult spot – but then that seems to be a self-inflicted level of comfort they’ve grown accustomed to.

So stay tuned, as they say . . .

Cheers,
  Sparky

Picture credit: Time Magazine

The Lunacy of Our Mental Health Policy

MEDICAID1-master675An institution for mental diseases (or, “IMD”) is defined as, “a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment, or care of persons with mental illness, including medical attention, nursing care, and related services” (42 U.S.C. §1396d(i)).

Last week the New York Times ran an article addressing the infamous Medicaid IMD exclusion: the culmination of state and federal policies dating back to the 19th century up to and including the Medicare Catastrophic Act of 1988, in which an IMD was infamously defined as a facility with more than 16 beds.

The apparent intent at that time was to promote small, community-based group living arrangements as an alternative to large institutions. But what has resulted is that Medicaid covers mental health treatment for a large percentage of people with Medicaid, but that coverage is excluded for inpatient treatment of adults aged 21 to 64 in any acute or long-term care institutions with 17 or more beds that are primarily engaged in providing treatment for mental illnesses. This is what is known as the Medicaid IMD exclusion.

Another indirect consequential reality of the IMD exclusion is what’s known as psychiatric boarding. The 1986 Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals participating in the Medicare program to provide a medical screening examination of any person presenting to its emergency department regardless of the ability to pay.  For psychiatric emergencies, an individual expressing suicidal or homicidal thoughts or gestures, if determined to be dangerous to themselves or others, the hospital must either provide treatment until their condition is stabilized – or transfer that person to an inpatient facility where the person can be treated until the condition is stabilized.

But there’s the rub: since so many individuals with mental illness (and addiction is considered a mental illness) are Medicaid patients there are very often limited alternatives for transfer.  Thus those patients tend to stay in emergency departments longer than necessary – an expensive consequence because of the cost intensive nature of ED’s. Communities work hard to develop informal diversion relationships to try and address the issues and challenges this creates: but their time could be better spent – like on improving patient care.

Section 2707 of the Affordable Care Act, Medicaid Emergency Psychiatric Demonstration, is a three-year pilot program that permits non-government psychiatric hospitals with more than 16 beds to receive Medicaid payment for providing EMTALA-related emergency services to Medicaid recipients aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and who are determined to be dangerous to themselves or others.

But this only addresses specifically-defined crises and will take a long time to be tested, evaluated and debated. It does not address the epidemical crisis we face as a nation with heroin addiction. So even though 26 states have willingly or unwillingly embraced Medicaid expansion under the ACA, many of the individuals needing inpatient treatment for addiction will be unable to receive that treatment.

A recent study published by researchers at the Boston Medical Center in the JAMA Internal Medicine Journal  reaffirmed the importance of combining inpatient and outpatient treat of heroin addiction. From the NYT article: for many suffering with heroin addiction, “there is an undeniable and essential need for residential treatment,” said Allen Sandusky, the South Suburban Council’s chief executive in Chicago.

Study after study has demonstrated that substance abuse treatment and rehabilitation is less expensive than incarceration as an alternative to addressing individual addiction and alcoholism. At the same time, economies of scale driving greater efficiency and lower program costs in facilities that allocate overhead over a larger number of beds is just economically intuitive.

When all these considerations are taken together with the skyrocketing costs associated with increasing crime and the burden being placed on community first responders as a direct result of the heroin epidemic it would seem like the biggest no-brainer in the history of earth is to legislatively repeal the IMD exclusion. Thus be to the ignominious wasteland that is Washington, DC.

At a time when communities across the country are scrambling to address a heroin epidemic that is literally destroying those communities and the families living there Congress is focused on a lawsuit against the president (the House) and an irrationally urgent need to reverse the Supreme Court’s innocuous Hobby Lobby decision (Senate). Shameful, truly shameful. Even more so than usual.

Cheers,
  Sparky

Photo credit: Armando L. Sanchez for The New York Times

WARNING: Paradigm Shift Ahead

If you are responsible for leading a post-acute/long-term care organization, I believe you should take note of two recent regulatory and legislative initiatives that provide a rather clear vision of where the post-acute/long-term care industry is headed – and it’s going to be disruptive to traditional thinking (if you want to survive).

ITEM 1: VBP in Home Healthcare
Earlier this week, CMS issued propose rule,
CMS-1611-P, which proposed to update Medicare’s Home Health Prospective Payment System resulting in an over all 2.5% reduction in rates when consideration is given to rebasing adjustments and sequestration. Importantly, included with that rule was a solicitation of comments regarding a home healthcare value-based purchasing (HHVBP) model.

Section 3006(b)(1) of the Affordable Care Act directed the HHS Secretary to develop a plan for implementation of a HHVPB program for home health agencies and to issue an associated report to Congress. Key concepts of that report included building upon existing measurement tools and processes, the alignment with other Medicare programs and tying payment to performance.

As currently contemplated, beginning with CY 2016 in five to eight states participating in an initial demonstration, average Medicare payments would be increased or decreased in a rage of 5% to 8% based on quality performance as measured by both achievement and improvement across multiple quality measures. The belief is these incentives/disincentives would encourage better quality via improved planning, coordination, and management of care.

 

ITEM 2: Broad Spectrum Reform Targeted
Last week, leaders of the Senate Finance and House Ways and Means committees introduced bipartisan legislation (H.R. 4994, S. 2553) that would have the type of disruptive influence that Clayton Christiansen has researched and explained leads to
disruptive innovation. Being referred to as The Improving Medicare Post-Acute Care Transformation Act of 2014 (or, IMPACT Act of 2014), it would require data gathering and reporting standardization across different types of PA/LTC settings to facilitate better comparisons of quality and resource utilization among those settings and to improve hospital and post-acute care discharge planning.

The data collected and analyses completed would then be used to develop new payment system(s) that could be site-neutral and reflect various forms of bundling and/or at-risk capitation. Anticipated quality measures include functional status, skin integrity, medication reconciliation, major falls and patient preference. If enacted, SNFs, IRFs and LTACs would begin reporting some of these measures as early as October of 2016, with confidential feedback sent the following year and public reporting of the measures occurring in 2018.

Taken together, these two initiatives – even if neither is ultimately implemented – reflect the long anticipated but now swiftly emerging paradigm shift away from fee for service in the PA/LTC industry. They also reflect the migration toward a view of PA/LTC that encompasses the patient’s overall and entire experience after an acute care stay. Owning only a piece of the puzzle, without being able to seamlessly and economically integrate with healthcare providers holding the other pieces, will not represent a sustainable business model.

To reinforce this, simply look at the strategy of Kindred Healthcare. Writing in Forbes Magazine recently, colleague Howard Gleckman noted that,

“as recently as 2010, half of Kindred’s business was generated by its skilled nursing facilities. This year, only one-fifth of its revenues will come from its nursing and rehab centers. In a major strategic shift, Kindred is betting the company on in-home care, hospice, care management, and fully integrated care services.” [my emphasis added]

Ironically, PACE models – whose genesis dates back to the early 70s – are well ahead of the curve in successfully providing comprehensive, integrated services and care, though their positioning platform has primarily been a means of serving low income seniors. That road hasn’t been easy, as development and execution is fraught with financial, operational, clinical and regulatory challenges. But the overall long-term programmatic success demonstrates the value created from integrated care delivery under a fully capitated payment model (as in, see above).

So if you’re one of those individuals I referenced at the top of this post, what I would do if I were you is spend some time understanding the PACE model – and a crash course in organizational change management might not hurt either.

Cheers – and Happy Independence Day!!
  ~ Sparky

 

 

Changing Our Perspective on Mental Health

On Thursday I shared the post, Don’t Make Mental Health Policy About Stigma. Jessica Dawson, the brave woman who was one of several individuals featured in the USA Today article I reacted to in my post commented that she was, “discontented [her] photo is being used on [my blog] to discredit the impact which stigma has on government policies.”

I took that personally pretty hard as I had a sense I was betraying someone because of my ignorance on a subject that I am very passionate about and for which I have advocated here in the Pub. But I have to stick with what I wrote: not because I am sure I’m right – but because it’s what I wrote. In my response to Ms. Dawson I noted that I didn’t believe we had different goals but rather different beliefs in how to most effectively achieve those goals.

And then this morning I came across an article from earlier this week by Judith Solomon for the Center on Budget and Policy Priorities that is thematically consistent for what I was advocating: the pragmatic role that research and evidentiary support should play in advancing policies supportive of mental and behavioral health access and affordability – relative to (i.e., not exclusive of) the role fighting stigmatism can play in our current economic and political environment.

The article, The Truth About Health Reform’s Medicaid Expansion and People Leaving Jail, presents evidence that facilitating Medicaid enrollment in states participating in expansion under the Affordable Care Act, “can enable more of them to avoid returning to jail or prison by connecting them to needed mental health, substance abuse, or other treatment.  This is why many state corrections agencies and county governments are collaborating with state Medicaid agencies on projects designed to enroll low-income people being released from jails or prisons.”

On average, approximately 75% of the US prison population consists of nonviolent offenders, many of whom have a myriad of mental and behavioral health challenges and/or are fighting addiction. According to Solomon, “alcohol plays a role in over half of all incarcerations, and illicit drugs are involved in over 75 percent of jail stays.” But only 11 percent of inmates receive any type of treatment, while comorbid conditions are prevalent.

I haven’t taken the time to explore the cites and research that Solomon provides, so I want to be careful not to be advocating for something that obviously needs to be carefully considered, debated and vetted. My point is simply this: we should be investing more to determine – and evidence – whether and how this type of policy intervention can help achieve a stronger, more accessible, more effective mental health system.

We need to change our perspective on mental health. Fighting stigmatism – yes, important. I get that. But I believe we should be investing more heavily to educate the country about how intervention and treatment works – and how it can lower costs to families, communities and the country in the long run. There is a much better chance of redirecting funding from other sources than securing funding for new initiatives. That’s the political reality – like it or not.

Cheers,
  Sparky

Policy Prescriptions ®

The Evidence-Based Health Policy™ Experts

ChangingAging.org

By Dr. Bill Thomas

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