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: , , , , , ,
Jun 28, 2012

Implications of SCOTUS Decision on Medicaid Funding of PA/LTC

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Before I get to the heart of this post (the Medicaid story), please allow me to share some additional thoughts up front.

Dewey Wins Moment
First, as was announced this morning, the Supreme Court has found the Affordable Care Act is constitutional in its entirety (noted exception regarding Medicaid expansion).  I was following the announcement on the SCOTUS blog this morning (where it was shared that the Individual Mandate was upheld), and so I had a very hearty laugh listening to John King of CNN go on for nearly five minutes about the implications of the Individual Mandate being struck down.  Apparently, a reporter in the Court read the opinion passage that, “the individual mandate thus cannot be sustained under Congress’s power to ‘regulate Commerce’ ” and failed to keep reading.  Ah, the risks of wanting to be first.

Maintaining Political Perspective
Second, a modest word of caution.  As I have written here and shared with industry peers and constituencies in various other formats, this is another step along the path of Healthcare Reform.  The next challenge the Affordable Care Act faces is the fall elections.  And I would not be the least bit surprised – or really, at all disappointed – to know that Republican strategists are in a back door way pleased with this decision because they can now use it to energize their voting base.  It will be a rallying cry to get the vote (and donations) out.  Democrats will have to redouble their efforts (if not their campaign fund raising) if they want the ACA to survive in tact beyond the 113th Congress.

But, it will be very difficult now to rescind the entire Act regardless of what Messrs. Romney, Boehner, McConnell, et al would like us to believe.  First, there is the political reality of having to not only win the Presidency but to maintain a majority in the House and take back control of the Senate.  I think retaking the Senate will actually be a longer shot than Romney defeating Obama.  Second, by the time any new legislation could be drafted, vetted and passed, the ACA will be well into implementation.  Trying to go backwards at that point would have devastating social and economic consequences that elected officials of any stripe are unlikely to want to be associated with.

There very well could – and I would expect, regardless of election outcomes, will – be some modest tinkering in the future.  We still have the economic realities of a very fragile world economy that keeps us teetering on the brink of another deep recession.  So I think it is likely the essential benefits definitions and actuarial soundness of insurance plans under standardization of coverage will be tightened up in ways that improve budget projections. 

Medicaid Expansion
To some, like me, this part of the decision was more of a surprise than the IM being found as constitutional – and there could, potentially, be rather significant implications for post-acute/long-term care providers.  I am not by a long stretch a legal scholar, but I will try to give you my best understanding.

Title II, Section 2001 of the Act – Medicaid Coverage for the Lowest Income Populations – expands coverage for individuals with incomes at or below 133 percent of the federal poverty level ($14,856 in 2012).  As a practical matter, this means expanding coverage for adults without children or disabilities.  According to a May 2010 Kaiser Family Foundation Report, it is estimated that an additional 15 million individuals will receive beneficial healthcare coverage under this provision by 2019 at an estimated cost of $465 billion.

According to 42 USC § 1396c – Operation of State plans, the Secretary of HHS has the ability to withhold federal funding of a state’s Medicaid program for failure to comply with federal requirements (this was existing code not altered by the ACA).  Thus, states not complying with provisions of Section 2001 of the ACA would be at risk of having all federal Medicaid funding cut off – not just funding of the Medicaid expansion.  In lieu of the ACA’s Medicaid expansion, the Court found that application of 1396c in such instance would be unconstitutional because states could not have anticipated such an onerous exercise of coercion when electing to participate in the original Medicaid program.

The remedy of this finding is that the Act must be amended such that 1396c would not apply to a state’s decision whether or not to participate in the Medicaid expansion under Section 2001.  So, in theory, states now have the option of whether they want to participate in the Medicaid expansion or not.

Now, given that the program’s design will initially provide 100% federal funding for newly eligible enrollees under the expansion program – declining to 93% by 2019 – I cannot imagine how any state would choose not to participate.  It would seem to be political suicide for an elected official to forgo federal funding to expand healthcare coverage to the poor when the relative impact on that state’s budget is, by comparison to federal spending, rather small.  And by not participating, that state would essentially be choosing to lose a portion of the taxes paid by its citizens that will benefit the poor in other states.

On the other hand, as we witnessed when several Republican governors chose not to accept economic stimulus funding, there is a very real possibility that some states may choose to opt out of the Medicaid expansion as objection or disagreement with the expansion (or the Affordable Care Act in general).  Add to that concern over the potential Medicaid Crowding Out effect, and you can see where some states may choose to opt out of Medicaid expansion.

In as much as many post-acute and long-term care providers are very dependent upon state Medicaid funding, the ripple effect of how this plays out in the months ahead will be something such organizations will want to watch closely.  And, of course, we will be actively monitoring such developments here in the Pub.  There could be significant state policy ramifications impacting the budgeting of Medicaid funding for post-acute and long-term care.

That’s what I think, anyway.  I would be very interested to know what you think.

  ~ Sparky

Filed Under: Affordable Care Act, Editorials & Opinions · Tagged: , , ,
Jun 26, 2012

Administration for Community Living

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Last week I posted an audio interview with colleague and industry thought leader, Rob Hilton, President & CEO of the A M McGregor Group.  It is my intention (or at least strong hope) that will be the first of many such informative Pub Chats in the future.  My goal is to post two-to-three interviews per month.

As a follow on to the topic Rob discussed with us – Affordable Housing Plus Services – I wanted to make sure patrons of the Policy Pub are aware of the new Administration for Community Living (ACL), as well as provide some general information and background on this new division within the Department of Health and Human Services.

In her April 16, 2012 news release, HHS Secretary Kathleen Sebelius shared the following statement:
The Administration for Community Living will bring together the Administration on Aging, the Office on Disability and the Administration on Developmental Disabilities into a single agency that supports both cross-cutting initiatives and efforts focused on the unique needs of individual groups, such as children with developmental disabilities or seniors with dementia. This new agency will work on increasing access to community supports and achieving full community participation for people with disabilities and seniors.

Key objectives of the ACL include:
1. Reduce the fragmentation that currently exists in
    Federal programs addressing the community living
    service and support needs of both the aging and
    disability populations.
2.  Enhance access to quality health care and long-term
     services and supports for all individuals.
3.  Promote consistency in community living policy across
     other areas of the Federal government.
4.  Complement the community infrastructure, as
      supported by both Medicaid and other Federal
      programs, in order to better respond to the full
      spectrum of needs of seniors and persons with
      disabilities.

At a conceptual level, these objectives should be supportive of new public policy efforts designed to integrate affordable housing, community-based services and healthcare: acute, post-acute and long-term.  Taken together, they represent a paradigm shift from a policy perspective that focuses on the “who” to the “what.”  Rather than a top down approach to providing for the variety of needs for distinct populations (e.g., elderly with chronic conditions, adults with behavioral health needs, children with disabilities), the ACL’s purpose is to transcend programmatic assistance across demographic characteristics.

If – and it is quite admittedly a very big if – the ACL can be successful in facilitating greater cooperation and improved communication by, between and among various federal, state and local agencies responsible for providing home and community based services (HCBS), the opportunities for the social integration of the populations served by those organizations is tremendous.  More importantly, the potential to develop local, community-based solutions that reflect a holistic view of individual health and wellness should – at least initially – merit our strong support, rather than a inclination to dismiss, “just another federal agency,” as I believe most of us have been prone to do.

But I will wager this: the ultimate success of the ACL will depend critically upon its ability to build productive knowledge exchanges with private sector organizations.  If successful in its mission, the ACL can help to knock down walls of bureaucratic obstruction that have historically impeded the efficient creation of community-based solutions that provide integrated services and care.  It will be the role of organizations having real world experience in planning, developing and providing HCBS, however, to work with the ACL in crafting public policy that aligns with and supports those solutions.

I think the Administration for Community Living has the potential to be a very positive step forward in addressing the tremendous challenges we face in providing affordable housing, community-based services and healthcare to our seniors.  I think it has the potential to create the type of excitement Rob Hilton shared with us in last week’s Pub Chat.  What do you think?

  ~ Sparky

Filed Under: Affordable Housing Plus Services, Regulatory Affairs · Tagged: , ,
Jun 22, 2012

Pub Chat No. 1: Rob Hilton ~ Affordable Housing Key to Long-Term Care

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In this premier edition of Pub Chat, Rob Hilton, the President & CEO of the A M McGregor Group in East Cleveland, Ohio, shares with us his knowledge, experience and insights on the importance of affordable housing when addressing public policy efforts regarding aging services and long-term care for the elderly.  Rob has been actively and passionately involved in the national dialogue on Affordable Housing Plus Services (AHPS) for over a decade.

Rob was gracious enough to stop by the Pub last week to discuss how during his tenure at McGregor he became interested in the potential for AHPS and the challenges we face as a society in combining affordable housing with aging services and long-term care policy solutions.  He also provided some great insights on where he sees opportunities – and risks – for other provider organizations interested in exploring AHPS.  Finally, he offered his thoughts on where the future of AHPS is headed from a provider and public policy perspective.

You can listen to my interview with Rob by clicking on the mic below:

          

As always, comments welcome and encouraged.

  ~ Sparky

Filed Under: Affordable Housing Plus Services, Audio Interviews · Tagged: , , , ,
Jun 19, 2012

Consumer-Driven Senior Care

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In a recent article published in Beckers Hospital Review:   6 Trends in an Era of Consumer-Driven Healthcare, hospital executives were provided with the strategic implications of current and emerging trends in consumerism.  These same trends will undoubtedly impact organizations that provide senior housing, aging services and post-acute/long-term care.  Understanding, analyzing and developing strategies to address the challenges and benefits from opportunities presented by/offered as the Baby Boomer generation begins to hold sway over the healthcare delivery system will be important for both providers, as well as policymakers.  So I thought it might be useful to try and interpret the key themes presented in that article from the perspective of senior housing and care (SHC) organizations.

Key Trend 1: Transparency
The Affordable Care Act specifically focuses on two areas of transparency: the gathering, assembly, analysis and reporting of clinical and operational data by healthcare providers (e.g., provisions found in the Elder Justice Act ~ Sec. 6703 of the Affordable Care Act); and the assimilation of comparative cost/benefit – i.e., value – information and analysis, particularly relating to provider charges and third-party reimbursement of same (e.g., Health Insurance Exchanges).

With or without the constitutionality of the Affordable Care Act, the message here for SHC providers is quite simple: get used to it.  Nay, if you want to be around in another decade, embrace it.  We are accelerating toward a period of time during which provider culture will be predominantly impacted by data-driven marketing, clinical performance, operational efficiency and financial reality.  And the watchdog enforcing voluntary compliance will not be CMS, state governments or private accreditation: it will be your own stakeholders and constituents.

Key Trend 2: Social Media
People talk – and, of course, people with more time on their hands talk more.  Evidenced by the well-documented social mobilization of the 1960s and 1970s – Boomers know how to communicate.  The intriguing, albeit sometimes almost depressing, realities of electronic social networking offer a challenging conundrum to SHC organizations.  Many, if not most, healthcare providers have embraced that reality in one form or another – whether that’s physicians communicating with patients via e-mail, hospitals using online YouTube videos to promote post-discharge wellness education or organizations like MorseLife in Florida developing an iPhone app (the MorseLife All) that connects seniors in its market to their campus.

Connecting in real time, however, carries with it a variety of challenges and opportunities.  The clinical side of healthcare (the side that can save your life) requires a keen sense of discipline and objectivity – two elements largely vacant in much of social media.  But there seems to be very little standing in the way of information – and misinformation – being haphazardly propagated as proxy for clinical expertise via such media.  Consumers recognize this risk, and that will offer an opportunity for SHC providers to be positioned within social media based upon their credibility, expertise and authority.  Recognizing this has important implications for brand management.

Key Trend 3: Consumer Empowerment
The underlying objective of increased transparency, access to comparative outcome analytics and evidence-based healthcare/medicine is, of course, to help position the healthcare consumer to be in a position to better advocate for their own healthcare. The benefits of such empowerment, however, will necessarily be tempered to the extent the targeted audience is unable to take full advantage. As we know, this is often true of a senior population that may face a variety of obstacles (e.g., mobility outside the home, effects of medication, propensity toward dementia). For good or ill, it will likely fall upon SHC organizations to play a proactive advocacy role for many disenfranchised seniors.

And this will put those providers in a potentially perilous position. Being an advocate usually necessitates having a healthy dose of skepticism. It is difficult, at best, to challenge and defend at the same time. It is sort of like playing a game against yourself: you will always win – and lose. But that is what innovation is all about – finding value-added solutions where none were thought to exist. Those organizations that develop innovative approaches to consumer advocacy for the senior population in ways that add value to all stakeholders will find huge competitive advantages in the future.

Key Trend 4: Consumer Expectations
Much has been written regarding the comparative demands of the Boomer Generation relative to previous generations, but demographically we have really only begun to see this manifested where product and service offerings target the 55 – 65 age cohort (e.g., Active Adult communities, age-defying miracle cures and, of course, Harleys).  But where those Boomer consumers have begun to make their mark the evidence of their purchasing sophistication and discernment is compelling.

Boomers demand value.  And as written in this space before, value in healthcare must be understood as providing better patient experiences and outcomes at an overall lower aggregate cost.  So while value is emerging as the driving force of third-party payer expectations (whether that is from employers, private insurers or Medicare/Medicaid), it will also be the driving force of the empowered consumer.  The message for SHC providers is clear: think value first, often and always.

Key Trend 5: Consumer Outreach
The proliferation of electronic communication media offers some very compelling opportunities for SHC providers to “connect” with their targeted markets.  In doing so, however, it is important to recognize how many other sources are competing for the attention of individuals in those markets.  While I recognized that at a theoretical level, this blog has been a firsthand experience of having to reconcile your individual perceptions on the value of content produced with the actual level of interest generated.

As I have been making the point in presentations on Healthcare Reform, if we get everything else right – increasing access, improving affordability, bending the cost curve, expanding the caregiving labor force – but fail to improve upon the overall health and wellness of our society, we will have failed miserably in creating a healthcare delivery system that is sustainable.  SHC providers are very uniquely positioned to leverage the benefits and advantages that electronic media can offer to help improve the overall health and wellness of the senior population in their communities.  And such efforts will find great synergy with other strategic efforts to develop integrated care and home and community-based delivery models.

I think SHC providers have more to gain than lose by being proactive in embracing Consumer-Driven Healthcare.  What do you think?

  ~ Sparky

Filed Under: Consumer-Driven Healthcare, In the News · Tagged: , , , , ,
Jun 15, 2012

SCOTUS Decision Day Approaches

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Okay, it’s prediction time.  We are about to head into the back half of June next week, and that means we have a two week period now during which the Supreme Court will hand down its decision in what is one of the most notorious cases that institution has ever deliberated.  No, it doesn’t rank up there with Marbury v. Madison, the Dred Scott Decision, Plessy v. Ferguson or Brown v. Board of Education – but it is likely to be remembered as the most impactful decision on future public policy since Roe v. Wade in 1973 for our generation.

So here is my prediction.  SCOTUS upholds the Affordable Care Act in its entirety.  Now, I have read more than I wanted to of the assessments, opinions, analysis – and the all-to-irritating opinions cloaked in very weak and self-serving analysis.   I have browsed through the transcripts of oral arguments presented before the Court.  I watched and listened to legal scholars, former judges and elected officials from every level of government.  And the one key takeaway I have from assimilating those hours of my life wasted is this: nobody at this point in history has any more inkling of how SCOTUS is going to decide than you or I. 

The legal arguments, particularly those that are based upon Constitutional Law and History, I found fascinating.  I wish I could believe that those arguments – on all sides of the issues before the Court – would carry the greatest weight to effecting a decision.  But Supreme Court Justices are human, after all, and subject to social influences – to what degree is the subject of some very interesting (if not quite useless) analysis.

And the Supreme Court’s standing in public opinion has taken a real beating. A recent opinion poll shows an approval rating of only 41%.  This has to carry some influence – regardless of the external rhetoric.    But while the logical consequence would be to assume such disfavor would weigh on the side of deciding against the ACA, I think the opposite will happen.  I think, in particular, Justices Roberts and Kennedy will not want to appear unduly influenced by public opinion and out of step with their historical vantage on previous decisions.  I also think they quite rightly understand that their decision – in either direction – will ultimately serve as the catalyst to energize the political party disappointed in that decision.  And so regardless of what they decide, the Affordable Care Act will de facto be sent back to Congress in one manner or another.

But please remember the SCOTUS decision is really a side show at this point to Healthcare Reform – particularly as reform will impact care provider organizations.  This holds true for the fall elections, as well, which will be the next round of political exchange impacting the reform effort however the Court decides.  At issue is when and how reform will be implemented – not the impact it will have on healthcare providers.

The underlying trends and drivers that brought us to this place in history will not abate because of a court decision or election.  The population will continue to age; people will continue to live longer and be sicker longer; the available caregiving labor force will continue to face challenges keeping up with demand; State budgets will continue to be under tremendous pressure; and the world economy will continue to influence the US economy in ways that are still very unpredictable.

But it’s fun to make predictions in any event, especially since this one has had such drama leading up to it.  So I’ve given you mine.  What’s yours?

  ~ Sparky

Filed Under: Affordable Care Act, Editorials & Opinions · Tagged: ,
Jun 12, 2012

Managed Care for Dually Eligible

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On another discussion venue in which I participate, a very learned and esteemed physician colleague in the San Francisco area shared with our group a recent brief from the California Medical Association (CMA Alert) regarding that state’s pilot project to move dually eligible individuals in Los Angeles, Orange, San Diego and San Mateo counties into a managed care plan.

Under the Medi-Cal 1115 Waiver, California is pursuing four pilot projects to redesign care for dually eligible seniors.  Similar pilot projects are being pursued in a number of other states as part of a national effort under the direction of the Center for Medicare & Medicaid Services’ (CMS) Center for Medicare and Medicaid Innovation (CMMI).  Of significance for this post, it was noted in the CMA Alert that, “if dual eligibles (sic) wish to remain in fee-for-service Medicare, they will have to actively choose to do so.”

In other words, they will be assigned to the new managed care pilot project by default.  Given what is the reasonably perceived inability of this aging population to necessarily advocate for themselves, at issue is whether such default can be interpreted as a back door mandate.  Are these individuals being deprived of their right to choose their healthcare provider? And who, by right, assumes the responsibility of advocating on their behalf?

This is certainly a moral dilemma, and I can appreciate CMA physician members’ concerns.  We are a nation and society with deep roots and political sensibilities to individual rights.  We are also a society, however, that is facing a potential national calamity in being unable to provide basic housing, services and care for an aging population that cannot afford to pay for such necessities.  From that vantage, I think an effective argument can be made that the potential to infringe upon such rights is outweighed by the urgent need to proactively develop innovative public policy solutions to address the aging tsunami that is building every day.

But setting aside for the moment the issue of the means by which the dual eligible population is enrolled, according to a Kaiser Family Foundation research paper, when compared to the non-dual eligible population dually eligible individuals are more likely to have chronic care needs, have a higher incidence of ADL needs, and be more than twice as likely to be both in fair or poor health – and suffer from a cognitive or mental impairment. This is a population for which the right to choose their own doctor is often not high on their list of priorities. This is also the very population where coordination of services and care across community-based programs, acute care, post-acute/long-term care and behavioral health services has the most promise of being beneficial to the individual because of the huge communication gaps that now exist between those areas.

So we are looking at a frail elderly population that isn’t able to pay for their own care – and likely in need of a host of complimentary/supplementary assistance (housing, ADL assistance, private duty, medication management, behavioral health – addiction in this population is scarily on the rise).  I do not wish to be ignorant of those individuals’ rights – but we are standing on the beach looking into the abyss of the looming demographic tsunami and understanding before a lot of others that such tradeoffs will have to be made.  They will be made.  The only thing at issue is when and how.  Wouldn’t it be better to plan for the flooding after the age wave hits?

These are the types of critically important public policy issues that senior housing, aging services and PA/LTC organizations should be aware of – and have active participation in their advocacy – whatever your views.

So, what do you think?

  ~ Sparky

Filed Under: Editorials & Opinions, Medicaid · Tagged: , , ,
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