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Westcare’s Decker Leaves a Legacy of Business Smarts, Gentle Touch

Bob Decker

Bob Decker

Patrick Connole

Through thick and thin, Westcare Healthcare Management founder Robert (Bob) Decker has held steadfast in his belief that hard work will be rewarded. And now with his own working days dwindling toward a July 1 retirement, those closest to Decker say a new generation will keep the tradition of perseverance and compassion going even when the founder is not at the helm.

Decker started Salem, Ore.-based Westcare in 1987, and along with a tightknit cadre has built the company into a mainstay in the management services space for the long term care industry.

As the company website says, “like a great caddy to a golfer, [Westcare] serves clients by seeing the dangers ahead.” With operational experience in ICF/ID Care, community-based waiver programs, skilled nursing care, assisted living, and residential care, Decker’s creation offers consultations on facility evaluations, analysis of internal systems, development of new programs, and leadership on financial services. Amid all of these specialties, however, is the overriding priority to put the care of residents first and foremost in every business plan.

To picture how Westcare became the company it is today from when it started 30 years ago, is really an examination of how Decker has skillfully guided the company, says Van Moore, senior vice president for Westcare. He speaks with authority on the subject, given the fact Moore has been with Decker for the long haul.

“He is a nice, warm guy, very outgoing. I’ve been with him for 30 years,” he says. “Bob and his former partner had sold something like 40 nursing homes to National Heritage and part of the deal was Bob had to stay on for a period of time as a divisional vice president,” Moore says. “That was in 1987 and the time of the stock market crash. National Heritage lost over 50 percent of its value overnight in that debacle and we could see the handwriting on the wall. So, Bob actually incorporated Westcare Management in November of 1987.”

The powers that be who ran National Heritage visited the first week of December 1987 and told Decker that his division was the only one turning a profit, “but they said we can’t afford you anymore, and that is how we started Westcare, on a lick and a promise. It was a lot of hard work.”

A Meaningful Motivation

In the midst of creating a new company, Decker showed his true colors, Moore says. “When we first sat down there were four of us and Bob who had come over from National Heritage. We sat in the rented office and he said ‘I don’t need to work, but I want to work.’ And he was only 50-years-old. And he said, ‘I am not ready to retire,’” Moore says.

Decker went on to say while his goal was to do well, “my real goal in life, he said, ‘is to be able to make you guys able to make the decision I made in my 50s as to whether I want to work or not.’ And it was far beneath us to stand in the way of his happiness,’” Moore recalls.

Of the four people, Moore was the only who stayed with Decker.

“The rest of them couldn’t handle lean times, could not cinch up their belts enough and got very, very dissatisfied. To me, it’s been a great ride, a tough ride, there have been a lot of 70- and 80-hour weeks. But Bob was putting in the same 70- and 80-hour weeks that I was. He’s just a man that I admire,” he adds.

Keeping Two Buildings

When Decker made his business move in 1987 by starting Westcare, he kept two buildings, a little 64-bed nursing home in Indio, Calif., and a 30-bed facility for the developmentally disabled in Idaho Falls, Idaho. “This is what we supported ourselves on, the meager management fees from those,” Moore says.

To scare up other business, Moore and Decker searched for long term care properties in need of management help, which often meant doing major fixes and working nearly every day of the week to get things right.

“You hustled, you took the work you got and you sucked it up and did what needed to be done. Over the years, I remember one job in about 1991 or 1992 in Pocatello, Idaho. We went in and I spent five months there, going home every other weekend. I helped straighten out their problems, recruit a new administrator and what not. Bob worked those same hours.”

It was, Moore says, what you did to put bread on the table but more importantly about making life better for the residents in the facilities Westcare consults for and/or manages.

Do the Right Thing

With Decker, he says, it is resident first and always do the right thing. “He’s always had philosophy that we do what is right for our clients, for our residents and because that is the only way we can be successful and the money will follow,” Moore says.

“We talked many times that neither one of us would ever be as wealthy as a lot of the people that we would see building companies very rapidly. But our focus was on doing it right and having a good reputation.”

An example, he says, was that in on of Decker’s previous ventures, another partner had self-insured for workman’s comp and after that company had folded Decker had found the partner had taken all the money out of the workman comp reserve for himself, a sum of more than $200,000. But when it came time to settle-up on a Medicaid audit for the property with this other partner, Decker still wrote the man a check for his share. “I said he took over $200,000 of your money….and he said ‘Van, what is right is right. He took my money but half of this money is his. And he’s going to get it.’ That is the kind of person he is,” Moore says.

And Here Comes the Next Decker

Even as Moore looks at the history he and Decker have built, July 1 ticks ever closer and the time for a new president arrives. Fittingly, that person is Bryan Decker, currently the controller of Westcare, who looks forward to continuing the family legacy that his father has built.

Bryan Decker

Bryan Decker

“I wasn’t sure that was in my plans when I started with him, but I have been at Westcare for about 22 years and it has been a good experience,” Bryan Decker says. “It has been great to have him as a father and as a boss because he kind of exhibits the same characteristics at home and at the workplace. And, that is what makes him successful.”

Beyond his father’s ability to manage the dollars and cents of Westcare, it is the true caring for clients and staff that he wants to emulate. “Everyone from the administrator down to kitchen staff to those elderly and disabled residents, he [Bob Decker] has a soft place down in his heart for caring for people.”

And with that care, comes the Decker mantra of hard work.

“He has a great logic in his thinking. That logic allows him to attack problems in a way that allows people to know he is thinking and considering their issues. At same time, it is a kind of great business sense. He says he may not be the smartest guy in the room, but he makes up for that through hard work. That is very true,” Bryan Decker says.

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Preparing for the Next Wave of Payment Reform

Brian Garner, Medline Industries

Brian Garner

Brian Garner, Medline Industries

The wait is over. The time is now.

While the rehab landscape prepares for more reforms, administrators should already have their facility and staff in line and operators need to be thinking about the future and how to deal with payment reform. Otherwise, they’ll be left behind and will ultimately lose out financially. The focus has to shift to functional rehab as employees are no longer working on a fee-for-service (FFS) model. Facilities are dealing with higher acuities and sicker patients, but being asked to provide better outcomes, and by the way, working for less money.

Due to the new quality measures from the Centers for Medicare & Medicaid Services (CMS), there’s now a greater burden on a staff as they’re being asked to do more with less to meet the Five Star quality rating. So how does a facility improve these quality outcomes with the same type of patient population while controlling their costs?

The Challenges
First off, it’s a consumer-driven market right now for Skilled Nursing Facilities (SNFs).

One challenge is we’re still in the midst of payment reform for nursing homes, especially when it comes to therapy services. With Section GG, introduced last year, nursing care centers are figuring out how to maneuver through the new functional assessments. There’s no real metric to get these patients to where they need to be and how to utilize limited resources to complete the expanding requirements. The plan for patient improvement starts with administrators and their interdisciplinary teams who must be smart and efficient when it comes to productivity and staff. That can all be achieved, especially with the proper equipment.

Also, part of the added stress is the processing of the new Activities of Daily Living (ADLs), looking at the functional mobility of patients. The federal government is tracking one of the stages of development, late-loss ADLs, and how that facility’s therapy team is impacting patient progress. More than a third of the Medicare population receives help with at least one important ADL.

Tie those challenges to the current mindset that there is still time to modify their approach. Some facilities don’t feel the immediate financial implications, which are causing some to hold off on their preparations for the pay-by-outcomes model. In this current health care climate, no one wins by waiting.

Keeping Rehab a Profit Center
With the state of nursing care centers today, administrators pay close attention to their therapy departments as it’s often considered the last profit center. With the new quality measures, there are concerns there will be less profit from the therapy department, moving away from a fee-for-service environment where the more you do, the more you get paid. The problem isn’t just the model, but it’s how the patient population fits into this new formula.

The numbers are staggering. The U.S. Department of Health and Human Services expects the number of people 65 and up to grow from 14 percent of the population to more than 21 percent by 2040. The patients aren’t just getting older. They’re sicker. The number of patients with diabetes continues to climb and the National Health Council is projecting 157 million Americans will have some form of chronic illness in just three years. Imagine this added and ballooning burden on therapists who must work one-on-one with a patient to achieve the same positive results, but in less time whereas before the facility was billing for that time, no rush and no consequences.

Therapists know the struggle, one in particular. About 20 years ago, Avi Nativ saw the challenge in helping his patients take a more active role to regain and maintain their mobility. He realized working with the patients one-on-one with the equipment he was utilizing wasn’t always safe for him or the patient. He struggled in achieving the outcomes he hoped for, and with his doctoral research in motor control and emphasis on brain plasticity, Nativ knew patients of all ages and conditions could regain strength and functional abilities. He created tools that enabled patients to practice functional strategies to regain mobility and prevent falls, by outlining three ideas essential to functional outcomes in the elderly: patient-enabled movement, functional activity and repetition.

Thoughtful Purchasing
Even with these new thoughts on tools, some skilled nursing care providers are panicking. Just last year, a customer received a negative survey that led to a serious downgrade and they became a Two Star facility. This operator, like many others in the same predicament, reached out to its vendor partner. In their quest to correct the deficiency-riddled survey results, they wanted to buy anything and everything for their therapy department.

This was not the solution. Their purchases appeared to have it all, costing $45,000 to almost $60,000 for each piece of new equipment, but the equipment was geared more toward high-performance athletes. The fancier products still required more than one therapist to get the patient into the equipment, a strain on staffing resources.

The expensive, fancy, futuristic products the facility thought it needed are now sitting in a corner, collecting dust.

Less Time to Treat Patients
Robert Tripicchio, PT, D.Sc., president of Community Physical Therapy, shared his facilities’ focus to meet the three tenants of healthcare reform: healthier populations, improved outcomes and decreased delivery costs.

“Regardless of what the product is called, we are transitioning from a FFS basis to one of cost containment and value,” said Trippichio. “Value can be expressed by the equation of outcomes over cost. The providers that will be successful are the ones who get better patient outcomes in a shorter period of time.”

Trippichio understands the transition is underway. Payment reform is no longer a discussion point in our nation’s capital. It’s a reality. Some of the changes have started, but do not go down this new path of payments alone. With the proper staff and equipment, facilities can still increase their reimbursement rates. Your therapy supplier should already be working with you to provide the wealth of knowledge they have to meet the demands in this new era.

Brian Garner is the Director of Sales, Rehab Division, for Medline Industries. He can be reached at

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The Gospel According To The #AppGap…

The fine folks at Westminster-Canterbury are spreading the gospel: Technology can help...

The fine folks at Westminster-Canterbury are spreading the gospel: Technology can help…

Bill Myers

Good morning, ProviderNation. It’s been a pretty good couple of weeks for the fine folks over at It’s Never 2 Late. Just last week, they announced that they had entered their 2,000th care center. But, perhaps even bigger, they’ve had some scientist types take a look at their work. They have been weighed in the balances, and not been found wanting.

Researchers at Eastern Virginia Medical School and Virginia Wesleyan College found that 40 percent of residents in a Virginia Beach, Va., nursing care center who were outfitted with It’s Never 2 Late swag saw “a clinically significant reduction of antipsychotic drug doses,” while 86 percent of the test group saw at least a little reduction in their antipsychotic doses. The numbers get even better:

  • Staff and family reported a 54 percent reduction in behavioral outbursts;
  • Thirty percent of the test group stopped acting out altogether, and the intensity of other outbursts declined significantly, too;
  • Evidence of depression fell by 41 percent; and
  • Perhaps even most striking, staff’s stress indicators fell by nearly half, the study found.

‘Preach This Gospel’

Lead researcher Scott Sautter, an associate professor at Eastern Virginia, called the findings “very exciting and important.” He and his colleagues are preparing their report for a peer-reviewed journal near you.

But the good people at Westminster-Canterbury on Chesapeake Bay aren’t waiting another second to share the good news.

“I’m going to preach this gospel all around the country,” Westminster-Canterbury President and CEO J. Benjamin Unkle Jr. tells Your Humble Correspondent. “We’re not trying to sell a product; we’re trying to sell an intervention that works. The message is, engagement through computer technology is affordable and has dramatic impact.”

Now, it is notorious that technology isn’t a replacement for human care, but what Unkle and others find so encouraging about their findings is that technology, used as a supplement for the human at the center of care, can work miracles.

Unkle has seen the light...

Unkle has seen the light…


Westimster-Canterbury volunteered its Hoy Nursing Care Center on its campus as the site of the experiment because Unkle was convinced that what some knucklehead or the other calls the elder care #AppGap is leaving money—and more important, care—on the table.

“Once the staff finds out the power of technology to make their lives easier, you’re going to do it with existing staffing models,” Unkle says.

Like many, Unkle sees the day coming (quickly) where relatives or friends of residents won’t just ask about gyms, or pools, or televisions, but about its hard-core, individualized technologies.

‘Going to Explode’

“There’s going to be a huge market for this,” Unkle says. “It’s just going to explode. Figuring out an app that is hardware agnostic and that can be customized to that person’s functional level… Some entrepreneur is missing an opportunity to make this better.”

It’s Never founder Jack York (who, as you know, is Your Humble Correspondent’s Personal Tech God), reacted to the news from Virginia Beach with a hearty aw-shucks.

“It’s been fascinating to be along for the ride,” he says of the experiments. “But it’s not about iN2L, it’s about a forward-thinking organization refusing to be satisfied with the status quo when it comes to delivering care.”

‘Taming Content’

As revolutionary as the InterWeb is, though, it can be hard for anyone to figure out how to use it properly. Services like It’s Never help folks “tame content,” Unkle says.

Seeing the results of the Eastern Virginia study, Unkle says he immediately ordered his staff to take an additional 18 computers “out of mothballs.” Since then, his care center hasn’t had a single request, for even a single moment, of extra staff time.

Unkle and his new friends aren’t done yet, either. The money donated to support the latest study—$228,000 from Westminster-Canterbury Foundation board member Sue Birdsong—will help support two other studies on the interaction between personalized technology and cognitive growth, Unkle says.

“The results were so compelling,” he says of the most recent effort, “that we felt that we needed to release the data that we had and start promoting this. It had too great an impact.”

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

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On Cheating Death…

The government claims it was defrauded by hospice because people didn't die fast enough. (Cartoon compliments the fine folks at WikiMedia Commons.)

The government claims it was defrauded by hospice because people didn’t die fast enough. (Cartoon compliments the fine folks at WikiMedia Commons.)

Bill Myers

Good morning, ProviderNation. There’s a terrific scene in the terrific movie, Erin Brockovich, where the feisty Erin confronts the cynical, smirking lawyers for the Big, Evil Company. After ticking off the human suffering the Big, Evil Company has caused, Erin reduces those smirking lawyers to dust:

“So before you come back here with another lame-a— offer, I want you to think real hard about what your spine is worth, Mr. Buda—or what you’d expect someone to pay you for your uterus, Miss Sanchez—then you take out your calculator and multiply that number by a hundred. Anything less than that is a waste of our time.”

That monologue has come to mind frequently lately as the government continues what it sees as a march toward “accountability” in elder care. Last week, a federal judge summarily dismissed a False Claims Act case against AseraCare, arguing that the best the government had offered was a mere difference of opinion.

The Shape Of Things To Come

To many providers, the case was absurd, anyway: the government arguing that hospice care—which is, at bottom, an effort to relieve pain and suffering—is not “medically necessary.” But drill down, ProviderNation, because the case is even more absurd than that. Court records show, for instance, that the government insisted that hospice wasn’t “medically necessary” even when AseraCare pointed out that some of the “victims” of the hospice care had actually died.  Take a moment and reread that sentence. Let it sit on your tongue. Rinse it on your pallet, and savor the aroma and balance, for three reasons:

1.)   Because you’ve just heard government lawyers claim that not even death is proof that someone needed hospice care in the first place.

2.)   Because you’ve also heard the government claim, a priori, that hospice care must be fraudulent if people aren’t dying fast enough.

3.)   And because there are likely to be a lot more cases like this one, after the Department of Justice announced it has created 10 “task forces” to crack down on elder care “abuse” by providers, and as government auditors pore through Medicare records of high-intensity therapy.

Same Problem, Different Expressions

We’ve reported often on provider advocates’ (increasingly frustrated) efforts to get regulators to focus on functionality rather than on cost as they sprint toward a value-based purchasing model. The fraud prosecutions are, to many providers’ way of thinking, the same problem, expressed in a different way.

“Throw all of those general business and economic principles out the window when discussing CMS payment models,” says Phil Fogg, an Oregon provider and board member at AHCA/NCAL. “They have created payment systems that incent provider behaviors which are no longer aligned with goals.  Then they want to accuse their contractors of ‘false claims’ and ‘fraud’ instead of taking accountability for their role in the problem when cost or utilization does not meet their goals.”

Recall, briefly, how official Washington recoiled from the mere suggestion that their health reforms involved “death panels.” Yet mark the sequel: Here sit government regulators and/or lawyers who say that fraud is proved by folks not being dead enough, and waste is curbed by making sure the best therapy is avoided.

Robin Hillier, an Ohio provider (and secretary treasurer of AHCA’s board), who is as close as this profession comes to its own Erin Brockovich, finds an irony that, at the same time regulators say they want to focus on “risk-bearing” payment, they’re doing everything they can to make sure providers take no risks for better care.

“The problem in health care is that it’s often a judgment call—‘Is this person sick enough to need hospice services?  How much therapy is really necessary after a stroke, a joint replacement, or a debilitating illness?’” she tells Your Humble Correspondent. “Much of these investigations of ‘fraud and abuse’ really come down to simply trying to reduce costs. Instead of clearly unnecessary services, there are often simply differences of opinion between health care providers. “

Value, Not Cost

And that’s just to consider litigation risk, Hillier says. She says she’s mystified that she hasn’t heard more from regulators about the real value of services, whatever they may be.

“How much would you think a fully functional knee or hip is worth? What price would you put on regaining your independence?  What do you think a good death is worth?” she asks, in full Brockovich voice.

For Fogg, policymakers must “establish their goals and provide clear value expectations that a provider is incented to want to achieve because of the economic benefit.”

Fogg has his own, freely stated argument (“In the SNF world, I would argue that we will not be aligned with CMS until we get to an episodic payment model—a solution that will properly incent providers to manage utilization and functional improvement in the most efficient manner possible”) . In the meantime, though, he says that it’s a shame that health care appears to be the place where reason and accountability go to die.

“By the way, supply and demand dynamics can also be discarded in health care,” he says. “Critical mass has resulted in more negotiating power and higher prices for CMS.”

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


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Where Have All The Good Times Gone?

Medicare patients and provider advocates may be ready to storm the Bastille after audit contractors denied skilled nursing treatment to patients in at least three states.

Fin de regime? Financial analysts are worried, après moi, le deluge(Art courtesy fine folks at WikiMedia Commons.)


Good morning, ProviderNation. Political economy has long been known as “the dismal science.” But some things are true even if Lord Halifax says they are, and a great many of those who follow the economics of long term and post-acute care are asking themselves, “Where have all the good times gone?”

Despite a record fourth quarter for mergers or acquisitions, “it looks as if M&A fever may have broken,” the fine folks at Irving Levin Associates say, gloomily, in their latest report. “This could be the start of something small.”

We’ve covered some of the concerns about a demographic dip at length in this space. Another factor, though, is that old Washington bugbear (which we’ve also covered at length), regulatory certainty. It’s not so much the scale of changes that are happening—it’s the pace.

Regulatory Squeeze

“I didn’t think it could get worse, but it’s going to do,” says Irving Stackpole, a veteran analyst and my own, private Eeyore. “It’s going to get worse because of pressure by CMS to move from volume-based payments to value-based payments.”

It’s notorious, Stackpole and others say, that providers have built their businesses around a large Medicaid population, subsidized by a lower Medicare population with higher turnover. Now, though, the margins are being squeezed from both ends.

Just last month, a key congressional committee passed a bill that would reduce the amount states can collect in provider taxes. It could cost up to 20 states more than $8 billion in Medicaid revenue (because of the various perversities of the current system).

Meanwhile, regulators are speeding through their massive Rules of Participation rulemaking, and Congress is weighing even further value-based purchasing bill for Medicare. The Rules of Participation alone could cost care centers up to $75,000 apiece, advocates at the American Health Care Association say.

Well, now, say all the dismal scientists, that’s how the game works—some win and some lose. Except, for Stackpole and others, those who are bound to lose are those who don’t have much to begin with.

“The SNFs that are serving the most vulnerable populations, those SNFs are going to go bust,” Stackpole tells me. “We’re going to see even more closures, more beds come offline.”

Small/Independent Jeopardy

Stackpole is not on an island here, either. AHCA’s own James Michel, who it must be said is not easily ruffled, says he’s worried, too.

“We are particularly concerned about access in smaller and rural communities where there may only be one or a handful of facilities operating. CMS’ new payment models are rooted in risk-bearing models that make it very difficult, if not impossible, for smaller and independent facilities to participate successfully while keeping their autonomy,” Michel tells me in an email.

“While highly competitive markets can bear some degree of consolidation and constriction of the market, because the demand can be absorbed by the competition,” he adds, “smaller and rural markets with fewer providers certainly cannot. And even if they could, that isn’t necessarily a good thing. There is a growing area of research on the relationship between provider and payer consolidation, and increasing health care costs. In its attempt to constrain growing health care costs, CMS inadvertently may be promoting payment and delivery models that reward consolidation and force the closure of smaller facilities, thereby increasing overall costs and creating access problems for our most vulnerable populations.”

But don’t worry too much, because it can get worse, Michel adds.

‘Silver Tsunami’

“All of this is happening as we teeter on the edge of the ‘silver tsunami,’ where we are set to experience a rapid growth in the number of older Americans who will need long term care,” Michel says. “Are we shooting ourselves in the foot by adopting payment and delivery models that will result in a constriction of our long term care infrastructure at a time when we are going to most need it?”

The regulatory trends are frightening enough. But consider, again, the apparent cooldown in Wall Street’s ardour for seniors housing. What we’re all witnessing is money fleeing a sector from all sides. And that’s before we even consider the seismic shakeup we may be facing as younger adults wake up to their own history.

“If you have a 25-plus-percent under- or unemployment rate among millennials, redistribution will happen around invested capital. What would come out of the system is the capital invested in the insurance sector—a huge amount of the $2.7 trillion that’s spent goes into the pocket of some very well-heeled insurance companies—and that’s where the pushback comes from,” Stackpole says. “How could that surprise you?”

‘A Race To The Bottom’

All of this is completely predictable, but rather dismal, to contemplate, Stackpole says.

“Consolidation is the hallmark of a mature business life cycle,” he says. “And that’s where we are. You could not find a better example of a business cycle moving from its early maturing to its late decline than skilled nursing. You’ve got consolidation, you’ve got closure, you’ve got growing awareness in the market—these are all hallmarks of a profession in late decline.”

But the rubber, inevitably must meet the road.

“The people who really need that nursing center are the families of people who have neurological disorders, the families of people who have Alzheimer’s and dementia, and the people who really need a cardiac or a pulmonary rehab,” Stackpole says. “What they’re going to have to do now is drive 65, 70 miles. Does that matter? Maybe not to some guy at CMS in Baltimore, but to the rest of those people, it sure as hell does.”

So, if you happen to bump into Irving at some conference or other, make sure you buy him a drink or two. He could certainly use it.

“It’s a race to the bottom,” he says. “An absolute race to the bottom.”

Mad Props Dept.

On that cheery note, a couple/three bouquets to throw out.

First, to the fine folks at It’s Never 2 Late, who this week have entered their 2,000th care center.

Second, to the good people at Benchmark Senior Living, who’ve just been named the Boston area’s healthiest employer.

Finally, to Delaware’s own Susan M. Levy, MD, who has just been named president of AMDA—The Society for Post-Acute and Long-Term Care.

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



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A Ruthless World…


SCHERERVILLE, IND.—Good morning, ProviderNation. Jack Heaney could talk a dog off a meat truck, but he preferred to harangue his victims until the paint peeled off the wall. He and his 10 children were always arguing, often on different sides depending on what room they were in, and were generally the kind of folk a publisher friend of mine referred to as “bicycle seat Irish.”

To say that it would take a special woman to love such a man is a grave understatement. But the difficulty in describing Ruth Adams is that you constantly run the risk of understatement.

How to convey the sweet majesty of the woman? She was in constant motion, and it seemed that she relied on a renewable stream of love—from the kitchen bands she played for seniors, to the volunteering at the Apostolate of the Handicapped, to the dozens of children and grandchildren she took on as her own. For those of us who were lucky enough to know her (and, as often as not, to be loved by her), the thought of life without Ruth is almost as obscene as the thought of Ruth without life.

Her cookies were the stuff of legend; her “dippy do” fought over so much at Heaney family gatherings that she began bringing double, and then triple, batches. Ruth was Jack’s third wife—he’d been widowed twice—but within a few short months, she was “mom” to Jack’s children. To Jack’s grandchildren (all 27 of us), she was ever “Grandma Ruth.”

If she ever felt an outsider (and who could blame anyone for feeling that way amongst the Heaneys?), she never let on. She introduced each of her extended family as “my son,” “my daughter,” &c.

“Step,” Grandma liked to say, “is a four-letter word.”

Jack Heaney, sadly, died suddenly in 1988, and Ruth was widowed for the second time (the love of her life, Ed Mullin, died in 1972, leaving her to raise two kids on her own). She later married Wally Adams, a fellow retiree, and Ruth folded even more children into the family.

The extended children of all her marriages were by her continually until she died under the tender care of the fine folks at Chateau Nursing and Rehabilitation Center in Willowbrook, Ill. (to whom, many thanks).

There were upper limits to her decency. Let the coins clink into the old margarine tub, let the Hank Williams Sr. play on the CD, let the cards be dealt, and may God have mercy on your soul. Ruth had no gift for bluff (“Who dealt this doodly-squat?”; “I’ve got a dog from every county”) but she had an utter gift for crushing those adoring grandchildren who had dared to take their seats at the card table.

By happy chance, I talked with Ruth on Friday, just two days before she died. She was feeling nostalgic, but—as ever—counseled love. “Make sure you tell the kids you’re proud of them, Billy,” she said. “ ‘Cause that’s all that matters. This life—it goes by so quickly.”

Death be not proud.

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








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Who Let The Dogs Out?

A day gone to the dogs. (Photo courtesy the fine folks at WikiMedia Commons.)

A day gone to the dogs. (Photo courtesy the fine folks at WikiMedia Commons.)


Bill Myers

Washington, D.C.—Hello, ProviderNation. Some days you’re the top dog; others, not so much. On Tuesday, provider advocates took their turn getting dogged. It began with the House Energy & Commerce Committee voting to take a bite out of provider taxes. It ended with the fine folks at MedPAC barking about cutting Medicare.

As is so often the case, the bite was worse than the bark: The House committee marked up legislation that denies Medicaid to mega-lottery winners and prisoners. But buried in the text, contentious bone that it was, was section 4, which rolls back the caps on provider taxes from 6 percent to 5.5 percent.

That was enough to get AHCA/NCAL alpha dog Clif Porter to release the hounds. Provider advocates charged the InterWeb (and the hearing room) in full howl.

‘A Broken System’

“Provider assessments are an ESSENTIAL part of … the funding picture,” Pennsylvania Health Care Association honcho Russ McDaid tweeted. “PA … rates still lag NF costs more than $25/day!”

To outsiders, it may seem strange that an offer to cut a profession’s taxes would lead to bared teeth, not wagging tails. But the provider taxes help raise states’ Medicaid payments because the feds are required to match state funds. Around 20 states have maxed out their tax rates, so a cut in the provider tax is a cut in Medicaid rates. And not a small one, either: Ohio, Pennsylvania, and Florida each stand to lose more than $1 billion over 10 years if the cuts become law.

“Provider taxes are far from the best form of public policy,” says Good Samaritan executive Dan Holdhusen. “However, they prop up a broken system.”

Same Ole, Same Ole

But the dogs’ days were not done. Just a couple of hours after Tuesday’s House committee vote, MedPAC had some thoughts for skilled nursing providers.

MedPAC “recommends reforming their prospective payment systems to more equitably distribute payments among providers and better maintain access for all beneficiaries. It also recommends two years of restraining and rebasing home health and skilled nursing facility payment rates,” the group said in a statement.

To provider advocates, MedPAC’s report seems a bit dog-eared.

“This is the same recommendation MedPAC has made for the past eight or more years,” AHCA said in a statement.

Changing Models, Changing Math

But AHCA officials added they were hopeful that an old dog could learn some new tricks.

“Specifically, while MedPAC’s margin analysis includes Medicare, commercial payers, and Medicaid, the commission does not account for the decreasing proportion of overall revenue attributed to Medicare and Medicaid fee-for-service,” AHCA says. “First, MedPAC only notes a growing number of Medicare beneficiaries enrolled in Medicare Advantage plans, which in general pay less than their Medicare fee-for-service rates. Second, MedPAC indicates that Medicaid rates present less of a shortfall than in the past. Again, MedPAC bases this analysis on Medicaid FFS data and does not account for the rapid expansion of Medicaid managed care for long term care.”

Dog-tired as he undoubtedly was, Porter says he’s not tucking his tail between his legs.

The Dog Days

“If nothing else, days like this show how important it is to get our members engaged,” he tells Your Humble Correspondent, in his bravest Indiana Jones voice. “We have a great story to tell— we just have to tell it ourselves. Really proud how well folks responded at every level. We’ll need that kind of sustained effort from now on.”

Even if MedPAC were to get its way overnight, even if the provider taxes become law tomorrow, the dog days of provider advocates may only be beginning. On Wednesday, for instance, the fine folks at Kaiser Health News examined a private long term care insurance market that seems is begging to be put down. This space has already examined how investors are feeling skittish about long term and post-acute care. And it appears likely that the younger generation will, sooner rather than later, want their “share” of their elders’ wealth.

In other words, demand’s coming in the front door, but money is fleeing out the back.

So, dispense with the muzzles, ProviderNation. Cry havoc! and let slip the dogs of war.

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




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