Author: Pat Kelleher

The House Republicans are putting forward a plan, drafted by Representative Paul Ryan, chairman of the House Budget Committee, to cut federal spending by $4 trillion over the next decade.

Central to that plan is a proposal to end traditional Medicare.  It would turn Medicare for those currently under 55 into a “premium support”  plan where beneficiaries would choose a private insurer and the government would provide vouchers to pay the premiums, about $15,000 a year, with bigger higher support for those who are poorer or sicker.

Writing on the New York Times “Room for Debate” blog, Princeton professor  Paul Starr says: “Privatizing Medicare would enable the federal government to wash its hands of all the vexations of health-care cost containment and leave the elderly to deal with those vexations on their own.”

The competing opinion is offered by James Capretta, a former associate director of the US Office of Management and Budget who sees vouchers as a positive step toward giving beneficiaries  “more control” over what they get:  “The key is that the government’s contribution is set independently of the choice made by any one beneficiary. If Medicare participants choose a somewhat more expensive option, they will pay higher premiums. If they choose less expensive options, perhaps through a more efficient delivery system, they will pay less.”

Is the public or the Congress ready for such a radical step? Would it hold down costs?  Or move Medicare from ” one size fits all” to a system of “haves” and “have nots,”  in which some can only afford a less generous plan?

This is a discussion we all – as providers and citizens – have a stake in.

Next week, Home Care Alliance members will be in Washington DC to make sure that our elected federal officials understand the role of home care in the health care delivery system and the strain on services being imposed by new federal rules, such as the face to face requirement.  We will also be seeking their help in carrying our message to those unelected federal officials who run the Medicare program for the Congress and the American people: the Centers for Medicare and Medicaid. With both enormous responsibility and authority, this federal agency can hugely influence who gets and who provides health care.

In advance of our meetings, the Home Care Alliance sent a letter to United States Secretary of Health and Human Services Kathleen Sibelius asking that she use her recently granted authority to at least temporary impose a “cooling off” period for new home health agencies in our states.   Included in the letter was the following:

• ” CMS has sufficient data to indicate that rapid increases in the number of home health
  agencies has led to increases in utilization and spending beyond that which would be
  indicated by payment changes, growth in enrollees, or policy actions. The National
  Association for Home Care and Hospice collected data indicating that from 2001-2006,
  Medicare spending grew 2.5 times more in states where the number of home health
  agencies (HHA’s) increased as compared to states where the number of providers
  remained the same or decreased.
• The proposed rules suggest that determining factors for moratoria include a trend of
  growth that is disproportionate relative to the number of beneficiaries or a rapid uptick
  in enrollment applications. The recent situation in Massachusetts satisfies both of those
  requirements. After virtually no growth between 2001 and 2006, our state has seen an
  increase of 27 certified agencies in the past four years – an increase of more than 20
  percent. This has occurred despite the fact that no area of the state is un-served or
  underserved.
• This recent growth is driven by that fact that Massachusetts is one of only a few states
  that has neither state licensure nor certificate of need rules for new home health care.
  This ability to “take all comers” was further exacerbated by a CMS decision a few years
  ago to allow state Survey agencies to transfer their responsibilities for new Medicare
  home health certification to private accreditation agencies. Our experience is that these
  private surveys are less rigorous and that it has become much too easy for new agencies
  to become established without a full understanding of the complexity of Medicare
  compliance. In fact, we believe that several agencies received Medicare deemed status
  in the past five years have either been decertified or in danger of being decertified once
  the state makes an initial survey. All of this adds costs and no value to our system.”

Our agenda also includes – thanks to one of our most responsive elected officials Congressman Jim McGovern – a meeting to try to bring some reasonableness to the federal/state “TPL” fight over paying for home care.

Please continue to share your thoughts on both our current industry challenges and what you see as needed fixes.  When we are in DC, we are speaking for you.

Congratulations go out to MetroWest Medical Center which, in collaboration with MetroWest HomeCare & Hospice, has been awarded the 2010 Betsy Lehman Patient Safety Recognition Award. The award honors leadership and innovation in patient safety and the development of systems-based solutions through the implementation of best practices. The theme for this year’s award focused on the importance of transitions in care across the healthcare continuum.  Jane Pike–Benton, Executive Director at MetroWest HomeCare & Hospice, presented their innovative approach at the most recent statewide STAAR Learning Session and sent this along to the Home Care Alliance:

“ At Metro-West, we implemented a multi-faceted approach to the transitioning of patients that was designed and implemented via a strong cross-continuum collaboration between the home health agency and the hospital. The model includes:

• the implementation of a ‘teach back tool’ for patients with heart failure both within the hospital and through their transition to home with home care services
• the development of a standardized Heart Failure Protocol with front loading of home care visits, the use of a standardized teaching tool based upon evidenced-based research, an increase focus on medications, and the integration of phone calls by the home care case managers on non visit days
• post hospital telephonic support via the use of a calling center in conjunction with the MetroWest HomeCare Nurse Specialist intervening for these patients when gaps in care are identified
• the implementation of a Transition Care Coach who is also a MetroWest HomeCare Nurse who meets with the patients bedside prior to discharge from the hospital
• the implementation of a Palliative Care Team with members from both MetroWest Hospice and MetroWest Medical Center

These initiatives demonstrate the importance of cross-continuum collaboration to our patients and to our health care system. Our entire team is committed to implementing new and innovative ways to provide care for our highest risk patients, and to demonstrate the value that home health care offers to hospitals and other health care partners.”

Among those sending congratulations to MetroWest HomeCare & Hospice and MetroWest Medical Center on their innovative approach to patient care across the continuum was HHS Secretary Judy Ann Bigby, MD.  Her comments as to MetroWest as a “shining example” were posted on the Commonwealth Conversations Public Health Blog.

Thank you to Jane and her team for demonstrating leadership in this crucial area of care transitions and readmission reduction.

Today , Governor Patrick released proposed legislation “Improving the Quality of Health Care and Controlling Costs by Reforming Health Systems and Payments.” The bill calls for  “Encouraging the formation of integrated care organizations, commonly referred to as accountable care organizations, comprised of connected or integrated groups of health care providers that achieve improved health outcomes and lower the costs of care.

The bill does not explicitly define provides and services that must be encompassed in an ACO instead defining an ACO as “an entity comprised of provider groups which operates as a single integrated organization that accepts at least shared responsibility for the cost and primary responsibility for the quality of care delivered to a specific population of patients cared for by the groups’ clinicians; which operates consistent with principles of a patient centered medical home and satisfies the other requirements of this chapter; which has a formal legal structure to receive and distribute savings;  The bill does anticipate that “certain providers that are not primary care providers may be ACO network providers in more than one ACO, as set forth in regulation by the division.”    The “division” which has authority to draft authorizing regulations is the Division of Health Care Finance & Policy.

The bill calls for greater transparency in payment arrangements and requires that by March 31, 2012, the “Division will “document, categorize and publish all current payment arrangements in the commonwealth between payers and providers.”   Medicaid participation in the ACO model is envisioned by 2014.

The Alliance will be reviewing this legislation with the Legislative and Policy Committee and the Board of Directors and welcomes member feedback. as to whether home health’s role should be more explicit in this legislation.

Return to www.thinkhomecare.org.