Through The Observation Stay Looking Glass…

The Senate Aging Committee admits that observation stays are a

The Senate Aging Committee admits that observation stays are a “crisis.”

Good morning, ProviderNation. Hope you’re recovered from your careful attention to the week’s most important news in history. Beyond the great news from Anaheim, the better news is that the next news will come from Chicago. Even if you don’t care for what one poet called “this combination of ballet and murder,” you owe it to yourself to watch the national anthem. It is an experience like no other. Trust your reporter: you’ll thank me later.

In other news, provider advocates are increasingly confident that there is (finally) momentum behind efforts to close Medicare’s observation stays loophole. In case you missed it, the Senate Aging committee on Wednesday took testimony from executive branch types on what the committee itself is calling a “crisis.”

“The financial consequences of these stays can be devastating for these patients and their families,” Aging Chair Sen. Susan Collins, R-Maine, said in her opening statement. “Many of these patients find themselves in a Medicare twilight zone.”

The hearing itself was something of a victory for advocates, who’ve been working for years to raise awareness of the thousands of people who are being denied Medicare benefits because of a loophole that allows hospitals to classify patients as being “under observation” instead of as, um, patients.  More than a few patients have found themselves through the looking glass here. (“‘When I use a word,’ Humpty Dumpty said in a rather scornful tone, ‘it means just what I choose it to mean—neither more nor less.’”)

On Wednesday, AHCA/NCAL’s Clif Porter II said he was glad to see the Senate committee focused on an ongoing (and growing) problem. “Millions are at risk for getting stuck with thousands of dollars in medical bills because of their classification status in the hospital,” he said in a statement.

The hearing comes just a week after the NOTICE Act, which would require hospitals at least to tell patients when they’re under observation, was introduced into the Senate. Collins is one of several senators who’ve signed on to additional bills that would count observation stays toward a patient’s skilled nursing benefit.

Beyond the hearing, though, advocates are feeling confident that Congress is inching closer to fixing the problem.

“We’re pleased the Senate recognizes the scale of the problem and appears poised to move on it,” says Neill Pruitt Jr., chairman and chief executive officer of UHS-Pruitt and a member of the congressionally appointed Long Term Care Commission. “We’re hopeful that movement comes quickly, and we’re ready to help in any way we can.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Bundles Of Joy…

"To prosper," Parkinson says, "providers will have to own their part of the bundle."

“To prosper,” Parkinson says, “providers will have to own their part of the bundle.”

Good morning, ProviderNation. Viva Las Bundled Payments: AHCA/NCAL honcho Mark Parkinson is keynoting a conference in Vegas on Monday, and he’s planning on telling them that—like it or not—bundled payments aren’t just coming, they’re here (and they’re staying).

Nothing says “Sin City” quite like the 2015 Healthcare Bundled Payments Congress, and Parkinson will take his audience through the latest in government plots to transcend the bad, old fee-for-service days. By 2016, the federal government wants at least 30 percent of Medicare payments to be made under alternative payment models. The percentage will rise to 50 by 2018, Parkinson will say.

“Our members and the association have been working hard to understand bundling and how it affects our profession,” Parkinson tells us in an emailed statement ahead of his speech. “Given the magnitude of this issue, and the slow but steady shifts toward bundling and other payment considerations, it’s important for us to take charge. I believe it will be vital for future success in the sector.”

Thousands of providers are already testing out new-fangled ways under the government’s Bundled Payments for Care Initiative, Parkinson says, and some of the results from the (admittedly small) samples are showing reductions in payments and lengths of stay.

Other models under the initiative have shown that the number of days in skilled nursing centers has dropped (from 21 to 16 days), as has the average Medicare payment to skilled nursing centers (from more than $12,000 per resident to less than $7,500).

What’s important, though, is that more than half of the providers who are in the initiative are only in Phase 1. Phase 2 of the project is when providers will have to start assuming risks (i.e., do good or be docked). Currently, there are only 61 skilled nursing centers in Phase 2, which means that the reality of the bundled payment future hasn’t really hit most providers.

As Parkinson sees it, there’s simply too much mass and energy behind bundled payments to stop its momentum (for instance, the Obama administration is barely two weeks out of taking a victory lap over its Pioneer accountable care organization model, which the government is now expanding on a national scale).

If all this sounds apocalyptic, cheer up. Parkinson says it’s unlikely that they’ll be any kind of comprehensive reform until after the IMPACT Act is fully implemented, in fiscal 2022. But he also says that providers have a real opportunity not to get ahead of the curve, but to shape it.

First, providers will have to join up with health networks and carve out the post-acute care niche, he says. “The key will be showing that you add value at low cost,” Parkinson says.

And, as things stand now, “hospitalizations are the hottest metric,” Parkinson says, which means that providers who can get their clients well, and quickly, will be in the proverbial catbird seat.

“To prosper,” Parkinson will tell his audience, “you’ll need to own your part of the bundle.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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The Fault In Their Stars…

CMS' fuzzy, Five Star math means that providers have to do the accounting for "low" quality.

CMS’ fuzzy, Five Star math means that providers have to do the accounting for “low” quality.


Hello, ProviderNation. Sorry to distract from the week’s most important event in history, but the fine folks at Kaiser have crunched the numbers, done the math, and added it all up. And they’re not happy. According to Kaiser’s analysis, nearly two out of every five skilled nursing center is lowly rated under the gummit’s Five Star Quality rating system.

Kaiser admits that another 45 percent of the nation’s centers have Four- or Five-Star ratings, but also finds that:

  • For-profit centers tend to have lower scores than nonprofit centers;
  • Smaller centers tend to have higher ratings than bigger centers;
  • Self-reported measures tend to be higher than measures “derived from state inspections;”
  • In 11 states, 40 percent of the centers tend to have low ratings, while in 22 other states (including the poor, benighted District of Columbia), at least 50 percent of the centers have four- or five-star ratings; and
  • States where the proportion of poor elders is higher tend to have lower-rated centers than states with more prosperous elders.

The Big Public, no doubt, will want to get into crash position. The problem, of course, is that it was my understanding that there would be no math here at the debates. (Excuse me again, my fellow Americans.)

You’ll recall that, earlier this year, the fine folks at CMS rebased their Five-Star system. By the stroke of a pen, nearly one in three of the nation’s care centers saw their quality rating fall, without quality actually falling. At the time, provider advocates worried that the CMS decision would make it even harder to tell hawk from handsaw; now, to their chagrin, they find themselves answering pointed questions that, to their way of thinking, is already more than a little question-begging.

“We worried about the Five-Star changes creating confusion, and now, unfortunately, it appears as though we were correct,” says Tom Coble, an Oklahoma provider and board vice chair of the American Health Care Association.

Gore Vidal, famously, said that “the four most beautiful words in common language” are “I told you so.” (The three most depressing words, Vidal added, were Joyce Carol Oates.) But something tells me that Coble and his friends take cold comfort from being right all along. Still, Coble tells me he’s trying to stay positive.

“Even so,” he says of the Five-Star debacle, “we’re proud that over half of all centers continue to be ranked at four stars or higher. What’s important, though, is the continuing commitment to quality care. We will never stop in that pursuit.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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What, Me Worry?

What, we worry?

Why America slept:’s findings are worrisome.

Good afternoon, ProviderNation.

The numbers are in, and they aren’t encouraging. The fine folks at crunched survey data and found that Americans are woefully under-prepared for their aging future. In separate surveys, 37 percent of respondents said they thought they would need long term care in the future; as it happens, though, 69 percent of Americans are actually expected to need long term care.

“It’s time for a senior care reality check,” says, in what may count as one of the understatements of our millennium.

More than half of Americans will spend at least some time in nursing homes, according to’s projections. Another 19 percent will use assisted living. Most people—86 percent—are predicted to use informal caregivers at some point (the numbers overlap).

But nearly three-quarters of people who need long term care will have to pay out-of-pocket, because Medicare will only cover about 12 percent of the nation’s long term care needs and only 30 percent of people qualify for Medicaid, reports.

If you think that’s bad, don’t worry, it gets worse. Because almost three-quarters of people surveyed haven’t bothered to have “The Talk” about long term care options with their loved ones, finds.

So what’s to be done? asked a few dozen professional thought leaders. AHCA/NCAL’s own Tom Burke urges families to take it slowly.

“Have several talks over time,” he says. “Avoid one-and-done scenarios. Go slow. Be patient with your mom or dad. Know that this is a scary topic.”

Dr. Bill Thomas, who is taking his show on the road as we speak, says the numbers speak to a larger problem with aging in our culture.

“We need to change the narrative surrounding aging in general,” he says. “Your topic is actually just one (very tangible) example of the toll we pay for living in a deeply ageist society. Fixing this problem requires us addressing ageism head on.”

Thomas puts the preparedness crisis bluntly. Age free, or—well, you know. “People who are prepared,” he says, “get to choose the kinds of care they will receive and who will deliver that care. People who are not prepared get care that is chosen by someone else.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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This Week In Sweeping Victories…

Parkinson is all smiles this week after a clean sweep of Capitol Hill, White House.

Parkinson is all smiles this week after a clean sweep of Capitol Hill, White House.

Good morning, ProviderNation.

What a week they’re having: The fine folks at AHCA/NCAL had barely sipped their celebratory bubbly after the doc fix vote when CMS announced a $500 million bouquet. That’s a 1.4 percent increase from fiscal 2015, which ends in October.

“The announcement today comes as somewhat of a surprise because CMS typically releases the rule just before May 1,” AHCA/NCAL honcho Mark Parkinson told his members on Wednesday, after the proposed rule came out. “Based on our initial analysis, however, the announcement is welcome news. Skilled nursing providers can expect to see a 1.4 percent increase in their reimbursements beginning October 1, 2015, representing $500 million for the profession. Additionally, there will be no changes to the therapy categories, cut points, or any of the other changes many expected to see.”

And, not that Parkinson wants to seem ungrateful, but the amount could have been even higher. CMS docked skilled nursing because of 0.6 percent “productivity adjustment” under Obamacare, and another 0.6 because of fiscal 2014’s “forecast error,” Parkinson says.

“It’s important to understand that the increases our sector have seen this year and in previous years are not automatic,” Parkinson adds. “Soon after the CMS rule is announced each spring, we begin working immediately on the next year’s rule, employing every resource we have at our disposal to ensure that we get the best outcome we can. This is a good win for our profession.”

Meanwhile, AHCA’s inestimable board chairman, Len Russ, took a star turn before the Health subcommittee of the House Energy & Commerce Committee on Thursday. Russ, a former newsman and current New Yorker, told the panel that he was in favor of post-acute care reform, but that he hoped that legislators would remember just how important his sector was to rehabbing patients.

“We believe PAC reform efforts in today’s health care environment are much more likely to succeed if they recognize the nature of skilled nursing facility patient and resident characteristics and service delivery which differentiate us from other PAC providers,” he testified.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Don’t Miss The Launch Of Provider’s LED Talks On ProviderTV


In her LED Talk, Ortigara tells the audience caretaking is “not work just anyone can do.”

Francis refuses to take her pills. George rages about how he was moved from his usual dining table. Eleanor screams for help while she is getting a shower.

Just another day in a nursing home? It doesn’t have to be, according to Anna Ortigara in her LED—Lead, Engage, Discover—Talk titled, “Power: Who Has It, Who Doesn’t, And Why It Matters.”

Ortigara’s talk, and eight other 18-minute Provider LED Talks featuring provocative, inspirational topics, are now available online on the video extension, ProviderTV. The LED Talks were held in conjunction with the recent AHCA/NCAL Quality Symposium in Texas.

Regarding caretakers and providers, “this is not work just anyone can do,” says Ortigara, who is an organizational change consultant for the Paraprofessional Health Institute in Bronx, N.Y. She calls for a second phase of the culture change movement, in which management personnel coach caretakers who work and have relationships with residents. “Power is when a person in a relationship … acknowledges the relationship and can make things different.”

In the cases above, Francis’ anger is validated, George is consulted before being moved, and Eleanor chooses when to take her shower.

Want to learn more about how to help yourself and your residents? Then watch one or all nine Talks. You may find something that sparks an idea!

Jackie Oberst is Provider’s managing editor. Email her at Follow her on Twitter, @ProviderMag.

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The Doc Fix Paddlin’ Machine…

The unresolved doc fix legislation has providers caught in a paddle machine of their own.

The unresolved doc fix legislation has providers caught in a paddle machine of their own.

Good morning, ProviderNation.

You know by now that the doc fix victory has been deferred, even if it hasn’t exactly been denied. Provider advocates we’re talking to are still upbeat: As they see it, the Senate simply didn’t have enough time to pass a permanent fix, but there was clearly overwhelming support for it. (One super-lobbyist we talked to, a Hill veteran, said that senators have referred to the annual doc fix drama as “the paddle machine,” and they are plumb tuckered out from all the paddlin’.)

Whatever happens with the doc fix April 13, when the Senate reconvenes, an unintended consequence of the stall is that providers and families find themselves facing a paddle machine of their own. Because the doc fix legislation expired, Medicare reverted to its old, bad therapy caps, starting Wednesday, April 1. Or as AHCA/NCAL’s inestimable Dan Ciolek puts it, “it puts beneficiaries and therapy providers in a very difficult position.”

CMS has reassured government and provider types that it can belay any automatic doc fix cuts at least until April 14, the day after the Senate comes back from its Easter recess. But the agency hasn’t said what it will do about $1,940 therapy caps that are automatically resumed by the expiration of the last doc fix patch.

I’ll let Ciolek explain:

“For providers, they can either do nothing different and continue to treat beneficiaries for services above the $1,940 cap threshold, and risk not being paid if the bill does not pass, or they can decide to issue an advance beneficiary notice (ABN) to the beneficiary indicating that if Medicare does not pay for the services above the cap threshold, then the beneficiary would be responsible for payment,” he says.

He adds: “For beneficiaries, they—or their caregivers—may need to make a difficult decision whether to continue needed therapy services while hoping the bill passes and Medicare will pay, or they may decide to forgo the needed therapy services until the law is enacted due to concerns that they could not afford it.

“While this unintended consequence may be temporary,” Ciolek says, “it could have a real impact on beneficiary access to needed therapy services until the legislative delay is resolved.”

Again, most observers are optimistic that the Senate not only will pass a permanent doc fix, but will make its action retroactive, meaning the caps won’t matter. But we’ve been close before, only to see the scenery collapse. It would be a real shame if, after all this work, providers were once again asked to assume the position.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.




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