Jan 10, 2013

Such is Hope

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Among the numerous provisions included in the Taxpayer Relief Act of 2012 impacting healthcare organizations was the establishment of a new Commission on Long-Term Care.  Now we can rest easy that the demographic tidal wave threatening to destroy our society has (or at least can now) be averted.  Excuse the sarcasm, but it seems I’ve been here before, haven’t you?

While there are specific expectations and deliverables outlined in creating this new commission (see below), vesting authority in 15 individuals to investigate and discuss the problems and then suggest what are sure to be already well-documented ideas offered as solutions doesn’t quite seem to have the legislative teeth one would expect if this effort were to be any more seriously supported than was CLASS.  Assigning yet another committee to tackle the fiscal realities of our nation’s future long-term care challenges is a bit like – well, like the way our elected leaders addressed the Fiscal Cliff.

As I predicted in my post on December 26th, what played out during the first few days of January in Washington was largely just another political fiasco of kicking the can down the road once again.  And if you have had any experience in long-term care you most likely consider that par for the public policy course, so from that vantage I guess the new Commission should be taken in stride.

Section 642 of the Taxpayer Relief Act permanently eliminated the CLASS Act, which was included as Title VIII of the Affordable Care Act.  CLASS (Community Living Assistance Services and Supports) was developed as a voluntary, government-administered program that would have provided a basic lifetime benefit of at least $50 a day (indexed for inflation) in the event of prolonged physical illness, disability, or severe cognitive impairment (e.g., Alzheimer’s disease).  At its core, CLASS was an attempt to provide individual savings incentives to defray the potential future costs of long-term care where private long-term care insurance has largely failed as an aggregate solution.

As may be recalled, in October of 2011 HHS informed Congress that it was unable to ensure the program’s financial solvency over the 75-year period that was statutorily required.  Shortly thereafter (as in the time it takes between a green light and the New York cabbie behind you to honk his horn crossing 42nd Street during rush hour), Secretary Sebelius and the White House quickly abandoned whatever support there may have been.  And thus, death be to CLASS.

The sad financial irony of this, of course, was that CLASS comprised roughly one-third of the projected $210 billion in savings the ACA was to garner between 2013 and 2019.  Indeed, substantial projected savings were verified by the CBO during the 10-year scoring window, but that did not account for the program’s benefit obligations over a 75-year period (i.e., the program would not limit the benefit duration and all future payouts had to be funded entirely by premiums paid by individual participants).

So in what can only be seen as a standard course of appeasement, Section 643 of the Taxpayer Relief Act created the Commission on Long-Term Care.  The Commission’s objective is to, 

“…develop a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services and supports for individuals in need of such services and supports, including elderly individuals, individuals with substantial cognitive or functional limitations, other individuals who require assistance to perform activities of daily living, and individuals desiring to plan for future long-term care needs”"

See, I told you you’d feel better.

The Commission is to consist of 15 members appointed not later than February 2nd by the President and majority and minority leadership from both Houses of Congress.  Further, it is to be comprised of individuals representing  consumers, older adults, individuals with cognitive or functional limitations, family caregivers, direct caregivers, private long-term insurance providers, employers, state insurance departments and State Medicaid agencies (all represented by 15 individuals mind you – what an eclectic group that will be).

In developing a plan to address future long-term care needs, the Commission is to provide recommendations that address where and how needed services and supports are currently provided for (or not) through existing governmental programs; improvements necessary in such programs to ensure future availability; and a variety of issues related to workforce adequacy, skills and capabilities (the most important element of this effort, in my opinion).

Then, no later than six months following appointment (i.e., early August of this year) the Commission is to provide (assuming it is in majority agreement) a comprehensive and detailed report, including any legislative or administrative action necessary to carry out its recommendations or proposals.  Subsequent to that (within 10 days) the “Commission bill” will be given to the President, the Vice President, the Speaker of the House of Representatives and the majority and minority Leaders of each House of Congress – and then subsequently introduced as proposed legislation into the House and Senate (by request).  The bill will also be made available to the general public at or around the same time.

I don’t know whether this new Commission holds out any greater promise of addressing the monumental challenges we face in trying to accommodate the future long-term care needs of an aging population without bankrupting this country.  My skepticism is not so thinly veiled in what I share above.

But I am more than willing to take the high road and give it my best shot.  I would like to think that readers stopping by the Policy Pub have a lot to offer in the way of input and ideas the Commission should consider.  To that end, I will do what I can in this space to track its formation and progress – and advise when and how those ideas might best be communicated collectively.

Until then, a quote from someone I know would have made a wonderful Pub patron:
”Such is hope, heaven’s own gift to struggling mortals, pervading, like some subtle essence from the skies, all things both good and bad – as universal as death, and more infectious than disease!”
  ~ Charles Dickens

Cheers,
  Sparky

Filed Under: Commission on Long-Term Care, In the News · Tagged: , , ,
Aug 2, 2012

Can Big Data Rescue Long-Term Care Providers?

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Big Challenge
Yesterday, the Alliance for Quality Nursing Home Care announced the release of a new study from Avalere Health, which projects a $65 billion cumulative reduction in Medicare funding of skilled nursing facility reimbursement over the next ten years. The cuts are projected to result from implementation of the Affordable Care Act’s productivity adjustment ($35.3 billion); the regulatory case-mix adjustment enacted in FY 2010 ($17.3 billion); a CMS forecast error adjustment in FY 2011 ($3.2 billion); and the sequestration provision of the Budget Control Act ($9.8 billion).

Several news sources have picked up the Alliance’s press release and noted those states with the highest levels of projected annual cuts, e.g., Florida ($370 million), California ($350 million), Texas ($240 million), Illinois ($240 million), New York ($220 million), Pennsylvania ($200 million) and Ohio ($200 million).  I don’t think the aggregate comparisons are necessarily very useful because there are a host of other considerations that should be included to truly understand the relative impact of these reductions on individual SNF providers in each of these states.  What is quite meaningful, however, is the stark reality the industry is facing: the decade ahead will see tremendous operational and economic challenges as providers try to accommodate the demographic realities of increasing demand at the very same time less resources are available to cover costs.

Big Data to the Rescue?
In the July 2012 issue of HealthLeaders Magazine Philip Betbeze writes about Healthcare’s Big Data Problem.  Well, it’s a problem in so much as substantial obstacles still stand in the way of being able to use healthcare data more effectively – and more pointedly, to the real time benefit of operational, financial and clinical decision making.

If I could sum up that challenge it would be this: how do you take an unparalleled amount of disparate  data (e.g., demographic, operational, financial, clinical) and meld it together into a warehouse of information, such that the various elements of that information can be combined, compared and contrasted in ways that reflect and then empower the distinctive thought processes of clinicians, managers and executive leadership of healthcare organizations?

As the article points out, some very encouraging progress is being made to overcome this challenge, including something called, “natural language processing technology,” which integrates clinician notes from the patient’s EMR into the aforementioned information warehouse.  This could be a huge step forward because it has the potential to address a major obstacle sited by many clinicians: i.e., the ability to effectively capture and later be able to quickly recall and share ad hoc note taking that is such a critical component of a patient’s record.

When looking at the path from data to actionable knowledge it is important to remember that data becomes information only after it has been collected, aggregated and organized.  Information becomes knowledge through analysis.  Knowledge becomes wisdom through synthesis.  Wisdom is the foundation of economically beneficial decision making.  Unfortunately, effectively navigating the winding path from raw data to informed decision making has a lot more to do with human nature and individual personalities than it does with the ability to store and manipulate binary data bits.

The Big Idea
So what does this have to do with post-acute and long-term care? As many providers are beginning to realize – and some I dare say, even accept – the economic future of healthcare delivery is going be built upon value-based incentives and risks.  Ultimately, the distinctive difference between financial sustainability and going out of business will depend on the ability of direct service and care workers – whether that is the medical director or the food service aide – to make real-time decisions that allocate the organization’s resources in ways that add value and minimize risk.

Empowering those individuals with the requisite knowledge (see above) to make those decisions more quickly, more confidently and more in alignment with the organization’s value-based mission will create competitive advantages that lead to comparatively stronger financial performance under value-based contracting and integrated care delivery models.  This is a critically important consideration to have in mind when beginning to explore potential relationships with other healthcare providers in your market. 

It is likely that many if not most post-acute/long-term care providers will have to link into and utilize the Big Data solutions of more formidable acute care organizations.  In doing so, PA/LTC organizations must be in a well-informed position so that they can clearly articulate how such solutions must serve them and their direct service and care workers as a prerequisite to their adding value to an integrated delivery network.  It fundamentally has to be a core element of the negotiating process.

So my advice to the leadership of PA/LTC organizations is straight forward: if you don’t yet realize and understand the impact that emerging Big Data solutions will have on how well you are strategically positioned to compete in a value-driven world of healthcare delivery and integrated models of care – learn quickly.  Or, as an alternative, find someone you trust who does – and listen to them.

That’s what I think, anyway.  Would love to hear what you think!

Cheers,
  ~ Sparky

Filed Under: In the News, Information Technology · 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 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 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: , , , , ,
May 27, 2012

Is Focus on Hospital Readmissions Misguided?

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In the April 2012 issue of the New England Journal of Medicine there was a Perspective’s article that is being circulated and discussed: Thirty-Day Readmissions – Truth and Consequence (you can download and read the article by clicking on it in my Dropbox™ account to the right).  In the article the authors argue, “that policymakers’ emphasis on 30-day readmissions is misguided.”

They present three reasons:
1. many of the variables inherent in driving readmissions are beyond the hospitals’ control (e.g., “patient-and community-level factors”), and they note that, “it is unclear whether readmissions always reflect poor quality”;
2. improved discharge planning and care coordination could be more effectively achieved by focusing on other metrics, rather than readmissions; and
3. resources committed to reducing readmissions may be better allocated to focus areas able to demonstrate a perceived higher ROI (e.g., patient safety and quality).

I think this misses the point as to why there is a focus on hospital readmissions.  In particular, noting that readmissions may not reflect poor quality seems like a fallacious assertion because I don’t think the argument is being made (at least by those who understand the issues and concerns) that readmissions necessarily do reflect poor quality.  At issue is whether the readmission could have been avoided with more effective care planning and transitioning – and thus equal or better care provided in a lower cost setting.  From listening to nursing staff at PA/LTC facilities, the evidence of opportunities for care transitioning improvement is overwhelming, albeit anecdotal from my frame of reference.

Admittedly, it is very difficult to study the true economic impact of hospital readmissions by attributing their causes.  Some patients should never have been discharged in the first place, and there are a host of reasons that drive premature hospital discharges.  Some patients are discharged to inappropriate settings – often because the patient and/or patient’s family intervenes over the recommendations of physicians and/or discharge planners.  Some patients are convinced they can follow a required post-discharge regimen and fall way short within the first 24 hours.  While some patients need just a little support (e.g., queuing, companionship, medication management), but they are in a situation where they have none.  And finally, some patients – particularly the elderly – are significantly impacted emotionally by care setting transitions, leading to adverse reactions that are very unpredictable.

But research has shown that education, coaching and timely intervention can be very effective in disease management.  We know that getting patients to change risky behaviors and become better self-managers of care can improve outcomes across a range of chronic illnesses.  We know that doctors have neither the training nor the time to engage in counseling on behavior change or to give self-management support. 

So it is inevitable that PA/LTC organizations will need to play a growing and critical role in designing, planning and implementing post-discharge care transitioning programs for patients in need of chronic disease management.  The sooner those organizations embrace the importance of this role and begin to build the requisite knowledgebase to be successful partners in integrated care delivery models, the better chance they will have of surviving in an era of Healthcare Reform.

A good place to begin for many of those organizations may be to become familiar with the work of Dr. Eric Coleman (University of CO Denver School of Medicine) and his colleagues on care transitions.  Many of the PA/LTC organizations that I work with now talk of the, “Coleman Model” and/or the “Coleman way” as an emerging standard bearer.  Here’s their web site:

http://caretransitions.org/

Have a Wonderful Memorial Day – and let’s all be very thankful to the brave men and women that have given so much to ensure we still have the ability to share ideas like I do here, open and freely!

  ~ Sparky

Filed Under: In the News, Transitional Care · Tagged: , , , , , , ,
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