What Isn’t Happening In AL Regulation…

Our author, searching for evidence of things not seen...

Our author, wearing his Serious Face, searching for evidence of things not seen… (Photo courtesy Andrew Harnik.)

Bill Myers

Good morning, ProviderNation. Sorry to distract you from all the mesquite and margaritas down Texas way,* but the fine folks at the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services (say that 10 times, real fast) have done some thinking on state regulations of assisted living centers.

The short version seems to be: There’s a lot of them. The full report is here and the executive summary is here.

Most folks agree that the business of elder care is in its revolutionary age (and many assisted living advocates see their sector as the vanguard of that revolution), so it’s interesting to note what isn’t happening even as the profession grows.

Regulatory Certainty

In many other areas, as the businesses grow and diversify, it’s reasonable to expect that at least some of the bigger players advocate for federal regulations. The shibboleth here is, of course, “regulatory certainty,” in which bigger players argue simplifies political economy for everyone. Take whatever you like about the argument, what’s fascinating is the extent to which you just don’t see that kind of advocacy from assisted living providers.

Part of it, a Royal Smart Person tells me, is that, having taken a look a good look at what “regulatory certainty” means for their skilled nursing cousins, many assisted living providers offer a polite, “No, thanks.” (There’s also the fact that, however large assisted living companies have grown, no single player—or even combination of players—is big enough to warp the market.)

But part of it goes to the very revolutionary character of the profession, the smart person adds. Assisted living providers pride themselves on person-centered care, above all else. However you define person-centered care, the essence of it is flexibility. Therefore, any effort to govern from On High jeopardizes the very innovation, dynamism, and rapid-fire responsiveness that many advocates feel defines assisted living.

Alphabet Soup

Speaking of the alphabet soup of regulatory agencies, the good people of CMS and the National Coordinator for Health Information Technology have released final rules that backers say will “simplify requirements and add new flexibilities [cq] for providers to make electronic health information available when and where it matters most and for health care providers and consumers to be able to readily, safely, and securely exchange that information.”

CMS’ version of the rules is here and the coordinator’s rules are here.

*And, if you’re not following all of the white-hot, provider-on-provider action as reported by our Managing Editor, the Formidable Jackie Oberst, on Twitter, well,  you go to penalty box…

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

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Up To A Point, Lord Copper…

The second oldest profession... (Photo courtesy the fine folks at Wiki Media Commons.)

The second oldest profession… (Photo courtesy the fine folks at Wiki Media Commons.)

Bill Myers

Washington, D.C.—Hello, ProviderNation. One of the greatest minor characters in all of literature is Mr. Salter in Evelyn Waugh’s glorious “Scoop.”* So terrified is he of his terrifying, press baron boss that poor Salter can only answer in the affirmative by saying, “Definitely, Lord Copper” and in the negative by saying, “Up to a point, Lord Copper.”

But you’ll just have to forgive AHCA’s Dan Ciolek if, dealing with the media reaction to yesterday’s inspector general’s report on Medicare’s therapy margins, he feels that the Salter character is an outrage of his own copyright.

For the past 36 hours or so, Ciolek has had conversations that go something like this:

Reporter: The OIG says that skilled nursing centers made 29 percent profit margins on therapy in fiscal 2012, right?

Dan: Definitely, Lord Copper.

Reporter: The OIG also says that high RUG charges cost Medicare $1.1 billion in fiscal 2012 and 2013, right?

Dan: Definitely, Lord Copper.

Reporter: So we need across-the-board cuts to Medicare therapy rates, right?

Dan: Up to a point, Lord Copper.

As OIG itself noted, AHCA (in the form of Ciolek and others) has been up front in arguing that Medicare has to stop rewarding volume and start rewarding value. So it’s a little bit more than irritating to see some folks read the inspector general’s report—in essence, proof that volume-based payment is flawed—to argue that the only solution is to reduce the amount of payments, regardless of outcomes.

“We have been supportive of a shift away from the volume of service,” Ciolek tells me. “We want to be paid based on what we do in our centers, and in good outcomes. The challenge is to get data on quality and outcomes. That’s why we supported IMPACT and have been developing outcome measures as part of our quality initiative.”

The problem with OIG’s report is that “it doesn’t say whether the quality of the care or the outcomes were better, worse, or indifferent.”

“We care about outcomes,” Ciolek says. “The discussion should be, is the therapy valuable or not? We shouldn’t pay for what is done in rehab, we should pay for the results of rehab.”

Poor Ciolek is trying to thread a needle in the middle of a hurricane. He makes (or tries to make) the following points:

  • That, first, the far-famed Omnibus Budget Reconciliation Act of 1987 requires skilled nursing centers to help residents “attain and maintain [their] highest practicable physical, mental, and psychosocial well-being.”
  • That, second, federal regulators themselves have acknowledged, in the Jimmo settlement, that therapy services can’t arbitrarily be withheld for folks of any age of condition… “even when a chronic, progressive, degenerative, or terminal condition exists.”
  • That, third, regulators are already gathering the kind of data, under IMPACT, that will answer all sorts of questions about value and quality.
  • That, fourth, you can’t kinda be data-driven. If it emerges that Medicare is spending too much for therapy without demonstrating value, then the data will answer that definitively.
  • That, fifth, until the data comes in, any precipitous moves are also premature.

“The core issue is that beneficiaries need services to get stable, to get better, and to get home, quickly,” Ciolek says. “A lot of the focus is on the margins and the actuarial stuff. The system needs to get rid of minute-driven models. But don’t lose sight of the fact that these folks need care.”

So,  Ciolek’s measured, thoughtful approach will get the media to rewrite the standard-issue, hackneyed narrative about “nursing homes gaming the system,” right?

Up to a point, Lord Copper.

*Your Humble Correspondent, having served as a foreign correspondent, will take his oath that there is nothing satirical about “Scoop.” It is an understated work of pitiless realism.

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


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Land Of Stinkin’…

"Four score and seven years... wait, they've done what?" (Photo courtesy fine folks at Wiki Media Commons.)

“Four score and seven years… wait, they’ve done what?” Illinois’ politicians are having trouble listening to the better angels of their  natures. (Photo courtesy fine folks at Wiki Media Commons.)

Bill Myers

Good morning, ProviderNation. Poor Illinois. So close to Wisconsin, so far from God… The Land of Lincoln, already ranked dead last for fiscal health, seems to have overlooked that whole “we need a budget” thing. Governor Bruce Rauner, a newly elected Republican, is squaring off against the Democratic-controlled General Assembly, and the state has been without an operating budget since July 1.

Already, stories are trickling in, ranging from the silly to the sinister, but you’ll have to forgive Illinois providers if they don’t see the humor in it.

“The impasse in Illinois is going into its 14th week, which means the only services getting paid are those decreed by court consent decrees,” says Dave Voepel, executive director of the Illinois Health Care Association (and a man who easily has one of the most thankless jobs since the Maytag repairman hung up his cap). “There are almost 80 consent decrees in place over the years, and 10 of those are driving the expense dollars. The comptroller claims by the end of the year the state will have $8.5 billion in unpaid bills, and nursing centers will be part of that mix.”

Bad To Worse

It’s a problem so fierce that, even if a budget is ever passed, raising taxes won’t help, Voepel says.

“You can’t recover a year’s worth of revenue in that shortened time,” he says.

There is some silver lining: Voepel, at least, is a Cubs fan (nobody’s perfect).

UN: ‘Alarming Lack’ Of Elder Care

Meanwhile, the fine folks at the UN have taken a look at the globe’s aging population. Their findings are, um, not good.

Nearly 90 percent of African elders lack for care; 65 percent of Asian elders need help and can’t find any, the UN’s International Labor Organization finds. Asia alone is short by 8.2 million frontline caregivers, the report finds.

“If you compare rehabilitation services, which are needed both by younger and older persons, we find that older persons get much less,” study author Xenia Scheil-Adlung tells Voice of America.

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

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Managed Care Is Coming To Get You, Barbara…..

Managed care is coming to get you, Barbara... (Still, from Night of the Living Dead, courtesy Wiki Media Commons.)

(Still, from “Night of the Living Dead,” courtesy Wiki Media Commons.)


Bill Myers

Hello, ProviderNation. The fine folks at CMS have released their annual guide to Medicaid managed care rates. There are few surprises in it (as far as this English major can tell), but what continues to fascinate Your Humble Correspondent is the speed—and silence—with which managed care has steadily risen from its grave and crept up on mainstream health care.

Recall the pitchfork-and-torches that were gathered in the late 1990s, as HMOs were pilloried from the Hill to Hollywood and back again. Now, however, managed care isn’t just a trend—it’s the norm in most states, and it has the warm (and continuing) endorsement of folks like MedPAC.

That doesn’t mean that providers have taken things lying down. Recall that, just a month or so ago, the biggest huzzahs from Provider’s inaugural Ignite panel came when an audience member gave a full-throated “get thee behind me, managed care” speech.

Wicked Pahty…

In happier news, mad props to the good people of the Massachusetts Senior Care Foundation, who recently celebrated their group’s 30th anniversary—and who, oh, by the way, raised another $270,000 for the care of Massachusetts elders and adults with disabilities.

Since 1985, the foundation has handed out more than $2.7 million in 1,500 scholarships to long term care workers, sending them to (or back to) school to continue their educations.

Mark Parkinson, Alice Bonner, and Red Sox legend Luis Tiant were on hand, a reliable source tells me, and a good time was had by all.

NIC In Time…

Speaking of anniversaries and funky good times, the fine folks at NIC are hosting their 25th annual convention right here in the D.C. area this week. They’ll be gathering at National Harbor with the theme, “With Changes, Come Opportunity.”

Your Humble Correspondent will be checking out all the white-hot, analyst-on-analyst action, and maybe even the odd live Tweet. Hope to see you there.

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




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Of Writs And Regs…

Parkinson: New CMS regs

Parkinson: New CMS regs “simply too much.”

Bill Myers

Washington, D.C.—Hello, ProviderNation. Most of Washington, official and unofficial, is reveling in Pope-A-Palooza. Your Humble Correspondent devoutly wishes His Holiness could stay on, if only because his visit has created such unholy traffic that the National Staff Meeting Threat Assessment has been reduced to a mellow yellow.

(Borderline blasphemy aside, many thanks to the good people at CNN, who reminded us all that, while Pope Francis cancelled Wednesday events out of respect for Yom Kippur, the Pope is not, in fact, Jewish. News you can use.)

Parkinson: New Regs ‘Simply Too Much’

Speaking of writs from on high, AHCA/NCAL’s own Mark Parkinson has offered some thoughts on regulation. In a video to his association’s members, Parkinson urges providers to get off the bench, to remind CMS that proposals for sweeping new, “competence-based” rules “are simply too much.”

“When you add it all up, it’s just more and more regulation and nothing good for our residents,” he says.

CMS has already extended the comment period on its massive rulemaking. Parkinson and other advocates are hoping to make every second count.

Jimmo: Almost Famous

And speaking of the fine folks at AHCA/NCAL, Dan Ciolek and Mike Cheek (the “Butch Cassidy and the Sundance Kid” of that outfit) are updating folks about the status of the far-famed Jimmo case. Among their findings: The Jimmo case isn’t far-famed enough.

Recall that, under the settlement, the feds agreed to scrap the so-called “improvement standard.” It was a huge win for rehab patients and providers

Nearly half of survey respondents, for instance, said they weren’t even aware that federal regulators had engaged in a public education campaign after settling the Jimmo case in June 2013, Ciolek and Cheek report.

“Clearly, awareness and application of the Jimmo settlement are currently far from universal,” the Lads say. “There is more work to be done.”

‘Well-Funded Research’

“There is widespread agreement among respondents that further well-funded research will be key to efforts to implement the Jimmo settlement,” Ciolek and Cheek say. “Suggestions included pilot studies of maintenance care patients versus non-maintenance patients with similar code demographics, and use of home health records, as home health has had the ability to identify maintenance therapy since 2011. In addition, there is widespread concern about the understanding and application of Jimmo by Medicare administrative contractors. Many respondents also expressed concerns about the lack of clarity of guidelines for providers trying to document skilled maintenance care.”

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

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‘Age Is Not A Condom…’

“Human Immunodeficency Virus – stylized rendering” by Los Alamos National Laboratory (Courtesy the fine folks at Wikimedia Commons).

Bill Myers

Washington, DC—Good morning, ProviderNation. Exactly half of Americans living with HIV are now aged 50 or older, the fine folks at SAGE, the advocacy group for gay, lesbian, and transgender elders, say. By the end of the decade, more than 70 percent of HIV patients will be 50 or older.

It gets worse (as such things are bound to do). SAGE cites research showing that “older adults with HIV have higher rates of depression, struggle with more comorbidities, and lack robust support networks to enable them to age in place with dignity and respect.”

“Social isolation, higher rates of poverty, and a lack of access to culturally competent healthcare compound the problem,” the group adds. “What is most upsetting about these age-related disparities? HIV-positive older adults are more likely to be diagnosed later, too often when the virus has progressed to AIDS.”

Age Is Not A Condom

As you might expect, SAGE has its own thoughts on how to address the problem:

“(1) expand care, services, and support for older adults living with HIV/AIDS; (2) initiate new research; (3) revise testing guidelines; and (4) improve data collection. What are some concrete examples of actions the federal government can take? One easy example: the U.S. Preventive Services Task Force’s (USPSTF) recommendation on routine HIV testing, which currently cuts off at age 65. Testing has been shown to be life saving and cost-effective well beyond that age, and USPSTF should amend this policy to include individuals 65 and over. Another easy example: targeted prevention campaigns. ACRIA’s Age is Not a Condom campaign provides a great example of what the federal government could do. The Centers for Disease Control and Prevention (CDC) should develop prevention campaigns and other interventions targeting older adults.”

An Essential Challenge

This feels like an essential challenge to providers for three reasons. First, it’s not as though they already lack for comorbidities in their care centers. Second, we’ve still not rid ourselves of the cultural stigma of HIV/AIDS, and so work will obviously need to be done, not only with staff, but (crucially) with residents and families. Third, it’s very clear that an aging libido isn’t a dead one, and the collision of sexually transmitted diseases, a population of elders who came of age in “the post-pill paradise,” and dementia can get, um, messy.

In any case, SAGE is hosting a Webinar today at 3 p.m. EST. There’s no continuing ed credit, but it might be worth a listen.

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

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Keeping Up With Mrs. Jones…

A lifetime supply of whisky seems to do the trick. (Photo courtesy the fine folks at Wiki Media Commons.)

A lifetime supply of whiskey may be the key to a lifetime supply of life. (Photo courtesy the fine folks at Wikimedia Commons.)

Bill Myers

Good morning, ProviderNation. The feline has come screeching out of the bag. Asked the key to her longevity, Mrs. Grace Jones, 109, of Worcestershire, England, admits, “a little drop of whiskey every night” does the trick.

Your Humble Correspondent (who now expects to live to be 356), was not, of course, surprised by the irrefutable, ironclad, scientific evidence Mrs. Jones proffered. Having done his book learnin’ in the Gaeltacht, he knew that the Old Irish phrase uisce beatha means “water of life.”

So a hearty slàinte to you, ProviderNation. We must mind our elders, after all.


Speaking of minding our elders, mad props (and many, many thanks) to the fine folks at Brookdale Living and Good Samaritan for their incredibly thoughtful work on #ProviderChats  earlier this week. They led a talk on nourishing mind, body, and spirit in assisted living. If you missed it, you stupide, just some English pig with no brains, you know.

We did crazy numbers—lots of Tweeps engaged—but the most impressive thing was our experts’ ability to be so cogent in 140 characters or less. Well played, gang. Well played.

If you’ve got an idea or an expert for our Twitter chats, we’re thrilled to hear about them. My contact information is below, but if you insist on talking to someone who is competent, you can always try our Fragrant Managing Editor, Jackie Oberst.

The Global Village

In other news, Your Humble Correspondent is feeling like a genius, but is much too modest to admit it. (But enough about me—what do you think of me?)

Recall that we’ve discussed the internationalization of elder care at a couple of different points. Now comes a report from the fine folks at Prestige Market Research, who are forecasting a huge boom in the elder care markets in Asia.

They’re looking at things from the American perspective (and are quick to point out that several American giants such as Extendicare, Brookdale Senior Living, Genesis, Gentiva, Kindred, &c. are already overseas looking for business).

Two things to keep your eyes on, though. First, the wine dark sea runs in all directions, and we’re already seeing foreign firms entering the U.S. market.

Offshoring Elder Care

Second, we’re also seeing a niche develop in the overseas resorts market whereby elder care is, for lack of a better word, offshored.

Indeed, there are already some 100 Americans who’ve expatriated to the Philippines to deal with their dementia. In 2013, according to the fine folks at Patients Beyond Borders, some 900,000 Yanks took their medical custom overseas. (Not all of that was elder care, but you get the idea.)

Whatever else these emerging facts means, it also means that American providers can’t take for granted that they’ve cornered the market on American elder care.

In any other context, this reflection would be called “sobering.” But that would be extremely rude to Mrs. Jones.

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

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