Jul 30, 2012

Medicaid Coverage of Nursing Care in Tennessee: Prudent, Rationing or Inevitable Reality?

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In an article published yesterday in the Washington Post, Guy Gugliotta writes about a new Medicaid policy in Tennessee, which seeks more efficient alignment between reimbursement and cost settings (my interpretation). 

This is very likely an important bellwether of state Medicaid policy that will be repeated in some fashion or other in other states, and it has unsurprisingly been met with a fair amount of controversy and concern.

Operating under a Section 1115 waiver from CMS, TennCare is the State of Tennessee’s Medicaid program, providing health care for 1.2 million with an annual budget of $8 billion. TennCare utilizes a managed care model that extends coverage to additional populations who would not otherwise be Medicaid eligible, while seeking to maintain a consistent level of quality care.  Tennessee has one of the oldest Medicaid managed care programs in the country, having begun on January 1, 1994. It is the only program in the nation to enroll the entire state Medicaid population in managed care.

On June 20th of this year TennCare released a new Nursing Facility Level of Care Guide outlining programmatic changes to its CHOICES program, which, “are designed to target Nursing Facility services to persons with higher acuity of need, while simultaneously making Home and Community Based Services more broadly available.”  This is the subject of the above-referenced article.

With this initiative TennCare seeks to increase the Nursing Facility Level of Care criteria necessary for Medicaid eligibility to a level it believes to be more in line with criteria used in other states while providing a less costly benefit for those individuals who will no longer qualify under the new criteria.  The new criteria are being applied prospectively, so no one currently qualifying for nursing care will be affected.

Under the new eligibility criteria three groups are established:
Group 1: Individuals eligible to receive care in a nursing
                  facility (NF) and requesting care in a NF;
Group 2: Individuals eligible to receive care in a NF but
                   requesting home and community-based services
                   (HCBS) in lieu of receiving care in a NF; and
Group 3: Individuals not eligible to receive care in a NF,
                   but “at risk” of NF placement and requesting
                   HCBS in the TennCare CHOICES program.

Group 3 is the population of concern and being debated from a policy perspective.  These are individuals that may have qualified for nursing care coverage under previous criteria and been eligible for HCBS cost coverage at a level commensurate with the cost of coverage in a NF.  Now the annual benefits available to this population will be $15,000.

From a consumer advocacy perspective the concern is that many individuals in Group 3 will not receive adequate services and care because the $15,000 benefit is not sufficient.  From a state policy perspective the concern is trying to allocate finite resources in a fashion where those individuals with the greatest need are afforded the ability to receive care that meets those needs.  In short, pub patrons, welcome to Healthcare Public Policy in the 21st Century.

From a pragmatic vantage, the initiative in Tennessee has very important ramifications for providers of community-based services and post-acute/long-term care.  This is an initiative that is certain to hasten the trend toward HCBS and away from care in institutional settings.  It is a threat to projected demand for long-term care in NF settings – and it is a threat to projected reimbursement levels available to HCBS providers under Medicaid.

It seems to me that any healthcare provider wishing to include the Medicaid population in its targeted market in the future look now at how to integrate BOTH NF-based care AND HCBS in its care continuum if it wishes to be economically viable and sustainable.  What do you think?

Cheers, 
~ Sparky

Filed Under: In the News, Medicaid · Tagged: , , , ,
Jul 26, 2012

Pub Chat # 4: Community-based Care Transitions Program

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In this edition of Pub Chat I interview Lori Peterson, founder and Principal of Collaborative Consulting.  Lori has been directly involved in helping to facilitate several successful Community-based Care Transition program applications, and she shares with us her insights about what it takes to put together a quality CCTP application.

For more information on the Community-based Care Transitions Program visit the Center for Medicare and Medicaid Innovation web site.  To contact Lori directly, e-mail here at Lori@collaborativeconsulting.net or call 866.332.3923.

Click on Larry’s mike below to hear this interview:

Cheers,
     Sparky

Filed Under: Audio Interviews, Community Based Care Transitions Program · Tagged:
Jul 23, 2012

Healthcare Reform Depends on Home Healthcare

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As shared in this space last week, the Council of State Home Care Associations recently completed a five-month project that was designed to gain a better understanding of how well home healthcare and hospice agencies are prepared for Healthcare Reform.  Artower Advisory Services published the summary findings and observations of that report here.  Note that throughout this post I refer to, “home healthcare” without intending to be ignorant regarding the variation in terminology and services and care provided by agencies of different types (e.g., home care, skilled home health, private duty, hospice, etc.).

Now that the survey is over and results published, I wanted to take a moment and share some background behind my passion for working with and supporting the Council’s efforts and, more generally, the home healthcare industry.  In a nutshell, I believe that if the goals of Healthcare Reform are to be achieved, there are two areas where success will be most important: Wellness and Prevention – and Home & Community-Based Services.

The former because finite resources simply cannot afford to save people from themselves forever, and the latter because the age wave will require a more efficient and effective consolidation of services and care in non-institutional settings.  And, promisingly, I believe there are great opportunities where home and community-based services can be effective in promoting and facilitating wellness and prevention – across all age cohorts.

Shortly after the March 2010 passage of the Affordable Care Act I created a reference document that summarized and organized the various programmatic funding opportunities available to organizations both directly and indirectly involved with healthcare delivery.  What struck me at the time – and does to this day – was the number of instances where home healthcare was specifically identified as a potential recipient of funding pursuant to its role in helping to facilitate the intended benefit of such initiatives.

And what also struck me at the time was the hugely important role that home healthcare must play in the evolution of care delivery models under Healthcare Reform.  There are several compelling reasons in support of this belief.  There are also significant obstacles in the way of realizing the potential of these opportunities.  I will discuss each, in turn, below.

Compelling Reasons Underscoring the Importance of Home Healthcare

Policy Advancements
First, and perhaps most important, is the continued public policy advancement that is moving US healthcare delivery away from institutional settings to individuals’ homes.  Driven by a confluence of consumer preferences (i.e., especially of the Baby Boomer Generation), desire to reduce unsustainable capital costs and recognition of the health benefits home-based care can offer, policy initiatives at both the state and federal levels have steadily been moving toward a redistribution of public funding toward home-based care, and this is certainly reinforced in the Affordable Care Act.

Valuable Positioning
Second is the existing knowledgebase that home healthcare providers possess.  They already have established business models, market intelligence, operational capabilities and the clinical acumen necessary to identify, plan and implement integrated care delivery models that bring services and care into the home.  This “ahead-of-the-curve” positioning can offer substantial advantages to home healthcare agencies as they seek to become  a valuable conduit between acute care providers and patients as part of integrated care delivery models.

Alignment with Community-Based Solutions
Third, they are quite naturally already community-based.  One of the most highly attractive programs thus far in the implementation of the Affordable Care Act has been the Community-Based Care Transitions Program.  While other healthcare provider types are in the community, home healthcare agencies very much are the community.  They are ideally situated to leverage the knowledge and awareness gained from caring for individuals in the very homes that are the foundational elements of those communities.

Ability to Transcend Care Delivery
Finally, taken together, private duty, home care, skilled home healthcare and hospice agencies represent a wider transcendence of individual service and care than any other provider type.  From providing the occasional, and as-needed, personal care services (i.e., assistance with various activities of daily living) to intensive, ‘round-the-clock medical care, home healthcare agencies are excellently positioned to facilitate holistic and integrated care delivery.

Industry Challenges

But as the ORASI© survey identified, there are substantial challenges that must be overcome if home healthcare agencies are to successfully take advantage of the opportunities presented.  Some of these challenges are within the purview of organizations to develop strategies for overcoming, while others represent exogenous considerations beyond their direct control.  Thus, to a significant degree, the latter represent important future public policy considerations that must be addressed if the desired benefits from home healthcare are to be realized.

Challenge: Fraud & Abuse
The home healthcare industry has been its own worst enemy for nearly a generation now.  The inability to self police perceptually damaging fraud and abuse has resulted in a giant target on the industry’s back that has been manifested in burdensome regulations, which have often appeared to be throwing the baby out with the bathwater.  Although widely accepted that the isolated actions of a few have resulted in broad brush castigation, perception is reality: and the reality is this is a daunting challenge the industry must address square on before it can hope to be strong participants in integrated care delivery models.

Challenge: Producing the Necessary Labor force
Home healthcare is quite obviously a very labor-intensive business.  Unfortunately, the dichotomy of projected future demand for caregivers and cost constraints holding down the ability to gain a competitive advantage through wage differential is likely to get worse before it gets better.  This phenomenon will likely be the greatest driver of industry consolidation in the near future.  Organizations that are better able to recruit, train and educate and then retain the highest quality caregiving staff will ultimately have success over competitors.

Challenge: Over Reliance on Technology
Not unique to home healthcare is the belief (hope) that technology – both care-oriented (e.g. supportive, remote monitoring,  tele-health) and information (e.g., electronic medical records, communication, operational functionality) will provide great opportunities to increase productivity and efficiency.  This is a belief that I fear will end up costing a lot of agencies their businesses.  While technology certainly offers great promise, successful agencies will recognize it for what it is: an enabler of people and processes.  If the requisite investments are not made in the latter two, expenditures on technology will only hasten the burden of financial unsustainability under Healthcare Reform.

Challenge: Non Home Healthcare Provider Acceptance
In order for home healthcare agencies to be effective participants in a world of integrated care delivery they must be able to partner with other healthcare providers in ways that add value to both those organizations – and, more importantly, their patients.  Healthcare in the US for far too long has been dominated by silos of care segmentation.  Getting different provider types to work together and across disciplines is going to require a tremendous amount of personal discomfort on the part of healthcare providers – and it is going to require a major leap of trust, particularly in the sharing of patient information.  For better or worse, the burden of building that trust rests largely on the home healthcare industry.

Policy Considerations

The home healthcare stands at the precipice of a tremendous opportunity to be the primary facilitator of innovation and the catalyst of sustainable change in how healthcare is delivered in the United States.  It is strategically better positioned than any other care provider type to embrace the underlying concepts of Healthcare Reform embodied in the Affordable Care Act.  It is also functionally and pragmatically better positioned than any other provider type to implement the several programmatic integrated care delivery initiatives of the Act.

But as identified above, the industry faces substantial challenges.  Without being able to make the requisite investments in infrastructure, knowledgebase, technology and – most importantly – caregivers, the industry will not be equipped to fulfill these expectations.  Thus, it is vital that future public policy recognize the importance of providing adequate funding necessary to develop the industry into the national care delivery network required for success.  Not only does the home healthcare industry’s success depend upon it – but the successful implementation of Healthcare Reform under the Affordable Care Act depends upon it.

  ~ Sparky

 

Filed Under: Editorials & Opinions, Home Healthcare & Hospice · Tagged: , , , ,
Jul 19, 2012

Pub Chat # 3 ~ Marcia Tetterton

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This edition of Pub Chat coincides with the release of a new report published by Artower Advisory Services, which summarizes findings and observations from the recently completed Organizational Readiness Assessment Survey Instrument (ORASI©).  For more information, please click on the links below: 

   ORASI© Press Release         2012 ORASI© Summary Report

With the recent decision handed down by the Supreme Court regarding the constitutionality of the Patient Protection and Affordable Care Act, the probability has increased substantially that healthcare providers will have to implement significant changes in the way they do business. To assist providers of home healthcare and hospice in determining their organizational readiness for Healthcare Reform, the Council of State Home Care Associations commissioned the adaptation of an organizational readiness self-assessment survey developed by Artower Advisory Services for use by member agencies.

Over 940 participants from member agencies of 26 state associations took part in the survey during the period April 3, 2012 through July 3, 2012. The primary purpose of this effort was to help those agencies and the state associations to which they belong better understand the areas where attention, focus and training are necessary to help prepare home healthcare and hospice agencies be successful under Healthcare Reform.

You can listen to my interview with Marcia by clicking on Larry’s microphone, below:

~ Sparky

Filed Under: Home Healthcare & Hospice, In the News · Tagged: , , , , , , ,
Jul 11, 2012

IOM Report on Mental Health & Substance Use in Older Adults

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The Institute of Medicine yesterday issued a new report, The Mental Health and Substance Use Workforce for Older Adults.  It provides the results of a study commissioned by the Department of Health and Human Services, as directed by Congress, examining the emerging and projected crisis our nation faces as a result of an insufficient geriatric healthcare workforce – specifically the capacity of that workforce to address caregiving needs resulting from behavioral/mental health conditions and substance abuse in the senior population.

It is estimated that one in five older adults in this country have one or more mental health/substance use (MH/SU) conditions.  And these conditions typically exist in individuals that also have other health problems, making diagnoses, treatment and long-term care all the more challenging.  The most common of these conditions include depressive disorders and dementia-related behavioral and psychiatric symptoms.

But substance abuse is a substantial and growing problem as well.  According to a 2009 report from the National Survey on Drug Use and Health – published by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA) – it has been predicted that by the year 2020, the number of persons needing treatment for a substance abuse disorder will double among persons aged 50 and older.  Unfortunately, that growth is above the linear projection owing simply to aging demographics.

Currently, however, the number of direct caregivers at varying levels of experience and responsibilities reflect the lack of historical investment in Geriatric MH/SU training and education.  As identified in the IOM report based upon their research, future caregivers will need to have expertise in the following areas:
     systematic outreach and diagnosis,
     patient and family education and self-management
       support,
     provider accountability for outcomes and
     close follow-up and monitoring to prevent relapse.

The report was also resoundingly critical of several federal agencies.  The Centers of Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), SAMHSA and the National Institutes of Health (NIH) were all criticized for their failure to use their public policy influence to encourage and direct investments in workforce training in this critically underserved area.

The IOM encouraged Congress (which includes the Republican held House that again today apparently had nothing better to do than vote – what is it now, the 31st time? – to symbolically repeal the Affordable Care Act) to fund the National Health Care Workforce Commission established under that Act.  The report noted that under the Affordable Care Act, the Commission is authorized, “to serve as a national resource that focuses on evaluating and meeting the need for health care workers . . . and to build a workforce that reflects the diversity of the older adult population that it serves.”

And finally, the report provided five recommendations that together are designed to focus policy making efforts on the need for leadership, agency coordination and the accelerated development of education and training that reflects the unique needs of a senior population in need of MH/SU services and care.  In addition, the IOM believes such efforts should be directed in thematic alignment with the Affordable Care Act (i.e., being able to evidence the relative value of investments in this area of need).

What will come of this? Well, we know it’s certainly not an ideal environment to be lobbying for new expenditures, even when/if those investments were theoretically already initiated through the Affordable Care Act.  And pragmatically, it seems reasonable to assume that the House is not likely to fund the National Health Care Workforce Commission any time soon.  And we also know that as 32 million new Americans come on line with healthcare coverage (whether through Medicaid expansion or insurance exchanges) the demands of the primary care workforce will grow substantially.

But the senior population in need of MH/SU caregiving have several distinct advantages over the younger generation driving primary care investments: namely, a great deal more wealth, better insurance and a dominant voting bloc.  So while in the short run governmental funding of workforce investments may not be able to meet the projected demand for MH/SU services and care, private investment – whether from nonprofit or for profit organizations – could be richly rewarded.

And as a practical reality, those organizations that provide post-acute and long-term care to seniors are already sharply aware of the need for MH/SU as a core element of their overall approach to achieving better outcomes.  As we continue along the path toward integrated care delivery models, the inclusion of MH/SU will have to be developed and provided as a matter of necessity to achieve relatively better outcomes than competitive providers.  Knowing (accepting) that reality should be sufficient incentive to drive private investment in workforce training and education, irrespective of public policy initiatives.  The challenge will be in figuring out how to do it in a way that achieves the requisite return on investment.

  ~ Sparky

Filed Under: Behavioral Health and Substance Abuse, In the News · Tagged: , , , , ,
Jul 6, 2012

Coming to a State House Near You: Medicaid Wars

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Did the June 28th Supreme Court decision disallowing the federal government to coerce state participation in the Affordable Care Act’s Medicaid expansion kick a hornet’s nest or just lay it bare for more to see? Currently at issue is whether individual states will now “opt out” of participation in providing Medicaid coverage to an estimated 15 million individuals across the country by 2019 under Section 2001 of the ACA.

This past week one of the most vocal opponents of the ACA, Florida Governor Rick Scott, was out and visible at numerous media outlets willing to give him a bully pulpit to reinforce his position – that not only will Florida opt out of Medicaid expansion, but will also refuse to implement Health Insurance Exchanges as well.  Whether he follows through (he is not up for reelection until 2014) will be another matter.

In fact, the political challenge for him and the 28 other Republican governors who have to mull over that decision is a choice between increasing already tapped out Medicaid budgets or foregoing billions of dollars of federal funding available to the states that do not choose to opt out.  Since the cost sharing is initially 100% federal funding, stepping down to 93% by 2019, opting out might be economically prudent but very difficult to sell politically.  There are only three Republican governors running for reelection this fall: Jack Dalrymple (North Dakota), Gary Herbert (Utah)  and Luis Fortuño (Puerto Rico).  So expect more chest thumping bravado before some very difficult choices have to be made going into the fall of next year.

Complicating matters, the SCOTUS decision has caused an unforeseen wrinkle, or  donut hole as it were – a new potential coverage gap in the decades’ long protraction to bring this country politically kicking and screaming into the 20th Century by providing universal healthcare coverage to its citizens.  The math (actually the overlapping regulations) gets very tricky, so I won’t begin to try and explain what I haven’t been able to completely understand myself.

The up shoot is that individuals living in states that opt out of the expansion with incomes above those states’ Medicaid income eligibility but below 100% FPL will neither receive coverage under the ACA Medicaid expansion, nor be eligible for subsidies to help purchase health insurance in the new exchanges.  It should be noted this does represent a reduction in current benefits to this population – but the assistance that had planned to be available under the ACA now would not in states that opt out.  In any event, it would seem to have the makings of a political sword that could be used quite effectively in the future against any of the Republican governors choosing the opt out.

Underlying this whole discussion, of course, are even more challenging issues – issues that Pub patrons should be very interested in monitoring.  In states that really do end up opting out of the expansion, will that leave additional state budget dollars for long-term care coverage? <insert your favorite political sarcasm here>  In states that don’t opt out (which I expect will eventually be just about all) how will future efforts to negotiate FMAP rates for cost sharing of long-term care be impacted by the new coverage benefit (i.e., will federal lawmakers be pressured to reduce their share in lieu of Medicaid expansion)?

What we have shaping up – and has been in the making for the past twenty years – is a fierce generational conflict: as the aging demographics demand a greater share of public assistance for needs of the elderly it will become more and more difficult to maintain assistance for the non-elderly indigent and disabled.  Lack of a cohesive and widely accepted policy on immigration will serve as a catalyst to intensify that conflict, and the battleground will be state capitals.

At a practical level what this means for providers of senior housing, aging services and post-acute/long-term care is being caught between the lines: a labor force sympathetic to the economic struggles of their generation providing care to a powerful demographic that will, in the aggregate, carry dominating influence in how public funds are allocated.  My immediate reaction to this is to recognize now how incredibly valuable brand positioning and brand awareness will be in the future – and how critically important brand management must become for those providers wishing to survive this coming policy maelstrom.

   ~ Sparky

Filed Under: Editorials & Opinions, Medicaid · Tagged: , ,
Jul 1, 2012

Pub Chat No. 2: Mark Testa ~ The Data-Driven Future of Healthcare

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In this second installment of Pub Chat I am posting an interview with Mark Testa, the Vice President of Quality & Analytics at Catholic Health Services in Miami, Florida.  Mark is a Six Sigma Master Black Belt trained at Motorola and now responsible for planning, designing and implementing quality and process improvement strategies at CHS.

With or without last week’s SCOTUS decision to uphold the Affordable Care Act the healthcare industry – including post-acute/long-term care providers – has been steadily seeking to make greater use of Lean and Six Sigma methodologies in quality and performance improvement.  There are a lot of talking heads out there running around promoting the future of, “Data-Driven Healthcare.” Frankly, I don’t think many of them understand what that really means – and this is an area where having a little bit of knowledge may be more detrimental than continued ignorance if bad resource investment choices are made.

So I thought it would be helpful to provide some basic understanding of these concepts, as well as several suggested resources where you can learn more about quality and performance improvement in healthcare.  I hope you enjoy the interview, which you can listen to by clicking on Larry’s microphone, below:

  ~ Sparky

Recommended resources to learn more about Quality, Performance Improvement and the applicability of Six Sigma principles to Healthcare:
ASQ ~ Lean and Lean Six Sigma in Healthcare
Quality Digest
Lean-Six Sigma for Healthcare: A … Guide to Improving Cost and Throughput
Six Sigma in Healthcare: Today and Tomorrow (HIMSS)

Filed Under: Audio Interviews, Performance Improvement · Tagged: , , , , , ,