Category Archives: Uncategorized

MOELI May Point Way to Better End-of-Life Planning, Author Says

By Patrick Connole

There is an interesting new development in the end-of-life planning space, with some experts in the field saying they back changes to the existing system to ensure that the wishes of patients are adhered to in a more organized and efficient manner.

Called MOELI (Medical Orders for End-of-Life Intervention), this new model is an improvement on the existing Physician’s Orders for Life-Sustaining Treatment (POLST) because it allows for more flexibility and acts as a more effective way to document and communicate patient wishes in institutional and community settings, according to Richard Stuart from the Department of Psychology at the University of Washington in Seattle.

He helped write an editorial in the September issue of JAMDA (Journal of the American Medical Directors Association) explaining how MOELI is an upgrade to the POLST Paradigm because it fills in gaps to increase the range of patients who can use the model. Stuart and others hope to spur a national conversation among various POLST organizations and collaborate with them to create a standardized national form for end-of-life patient wishes.

One major change would be to relax when POLST is offered. Currently, it is offered to patients with those of a life expectancy not exceeding 12 months due to a terminal illness or extreme frailty. MOELI would extend the offering to those who are 80 years or older, regardless of the life expectancy issue.

In the JAMDA piece, Stuart and company also recommend the development of a national evaluative database, creation of organizational policies and resources that support the paradigm’s use, and increased efforts to educate health care professionals and the general public about MOELI.

“Many patients get more invasive, expensive, and often harmful end-of-life treatment than they want, while others get fewer life-prolonging efforts than they want,” Stuart said. “The POLST program, and the MOELI that enhances it, are designed to help patients convey their treatment choices to providers who enter patients’ wishes in their medical records to increase the likelihood that care desired equates with care received.”

The enhanced end-of-life program would also assist long term care providers, considering that many patients are admitted to centers because of frailty, which can of course lead to declines in cognitive capacity.

“Facilitating the completion of a MOELI upon admission would allow patients to enter their treatment preferences in their electronic medical records. Doing so could save patients, their families, and the institutions that care for them a considerable amount of money due to the extraordinary unreimbursed cost of caring for patients with dementia,” the article said.

In a talk with Provider, Stuart days he does a lot of work in helping patients create living wills, but they are meaningless unless wishes are translated into medical orders. One of the problems is the lack of standardization across care settings. “A lot of patients are mobile so they go from place to place, and wishes validated in one setting may not be accepted in another,” he says.

Some of the other major changes MOELI would bring include what Stuart calls “middle” options in end-of-life planning. “POLST arbitrarily allows people to address certain options, but … the existing POLST system [doesn’t allow] people to choose or designate their preference for all of them. So, I try to make the menu complete so they indicate the kind of care that they would like,” he says.

There are also technical fixes Stuart would like to see made. One involves first responders. An example would be that as a first responder arrives to treat someone who is in shock, for example, that person may have a do-not-resuscitate order (DNR) in place. This means in a strict sense the first responder should not treat them and conceivably let them die.

“I want to put in a middle category if someone’s heart stops beating because of a treatable short-term event, then of course they want to be rescuitated. This is an example of why people in the past have been reluctant to make commitments because they realized they don’t want an absolute DNR order, which makes that middle category so important,” Stuart says.

Another example of a middle category in MOELI being an improvement from POLST is that many individuals who do plan for end-of-life voice their concerns about medical requests being taken out of context.

“It is often the case that patients are asked if they want active care or comfort care only,” Stuart says. With a middle category, people would be asked if they want to have active care as long as they can preserve their identity as the person they are now. “That middle category is extremely important. It gives people rational options,” he says.

Leave a comment

Filed under Uncategorized

Country Comes to the City: A ‘Cowpoke’s’ Day in a Dementia Care Center

Patrick Connole

Boundless energy. These two words come to mind when describing Chris Covell, the resident engagement manager in charge of the Life Enrichment Program at Forest Side in Washington, D.C. To witness her work, as I did during a recent all-day volunteer stint at Forest Side is to be challenged, in a good way.

Headshot2

Chris Covell

The challenge is to keep up with her as she progresses through a full schedule for her residents, all of whom have some form of dementia. On the day I was present, the theme was country life, as in country music, pioneer culture and the history of the American West.

Covell had created a roughly seven-hour program built to entertain, stimulate, and otherwise offer comfort and companionship for around 15 to 20 residents of the 33-resident facility.

When you walk into a volunteer situation like the one at Forest Side there is always a period of time you need to get accustomed to what are very foreign surroundings for most professionals. Usually, my day consists of working phones and the computer while anchored in front of a desk, CNN on in the background, news flowing all around. People come and go throughout the day, questions are asked and answered, and the pace of the day is pretty much self-dictated.

But when you enter the care center, the focus – all of it – is on the residents as guided. When you eat, when you break, when you assist, when you “play” and when you transport is all scheduled, based on a well-timed care plan and socialization platform meant to offer a fulfilling and interesting environment.

For this day, Covell starts with a drawing and coloring session, wherein each participating resident has a chance to create art from sheets of paper with a Western theme. As old-school country music plays on the large TV in a nearby lounge area, the residents occupy two large tables, which have been dotted by care givers with crayons, markers, glue and other arts and craft supplies.

Volunteers like myself assist one or two residents at a time in whatever they want to do within the 45 minutes or so allotted for the project.

My resident is one of the only males in the group, a former stalwart lawyer and investigator who prefers to take copious notes of the day’s activities versus actual drawing. But even as he goes his own way, there is a back and forth between and among the resident and staff, including Covell, and this volunteer. There is a quick rhythm and intensity to his actions, waking me up to the fact this is more than just regular work to care properly for residents, it seems to take supernatural patience and attention to detail.

As others create colorful art, the resident and I discuss who is doing what and where. It is during this time, around a half-hour in, that enlightenment starts to kick in. For all the writing I do on skilled nursing and assisted living facilities, the owners and operators, the nurses or the latest happenings in Congress that affect all of us, it is only at a time like this that I see what this industry is all about.

It is about sitting down and conversing with someone hampered by dementia, and doing so in a respectful, fun and patient manner. My own mind runs to the one thought I ruminate over again and again during the day: What dedication this must take to do this eight hours a day or more, everyday, because I am only in this position for less than an hour and I am exhausted.

We move on from the art to other activities and eventually lunch and an end of day ice cream social. All the time Covell is prodding residents to take part in whatever is being discussed, steering conversations to her themed subjects, prompting we volunteers to go outside of our comfort zones to assist and lead residents in for instance a pretend camp fire, complete with sing-a-longs to Gene Autry and Roy Rogers tunes from days long past.

We even build a fire with real sticks, paper cut outs for the flames. The session is led by the spirit and will of Covell and her boom box, which fills the air with the aforementioned music. It all makes sense.

I take a turn reading a historical account of what the Old West was all about. Sure, there are some residents nodding off, others offer only blank stares, but there are many engaged in their own unique way. And, despite the lack of give and take in what we call a normal way, there is a warmth that emerges, fittingly at a camp fire, as residents follow Covell’s lead and if they want, get into character by wearing fun Old West hats or playing with stuffed animals posing as our animals for the cattle drive.

For it only takes one set of eyes on you, and your eyes back, to tie yourself to the humanity of this place, this home for people afflicted with one of the most trying and devastating illnesses known to man: the loss of one’s memory and ability to live out an independent life.

It is when pretending to be a cowpoke that I understand what enormous strength it takes on the part of staff and resident alike to move through each day. And, to do so in the best way possible, to make a go of it, to be a pioneer of sorts in waging the fight for a life that is dwindling in many ways, but is lifted up to a higher plane than otherwise could be achieved through the love of families and friends, nurses, and the entire staff of caregivers.

At least for one day, one short day for this volunteer, we are cowpokes in the city.

Leave a comment

Filed under Uncategorized

Employers Seek New Designs to Control Cost of Health Benefits

Patrick Connole

When it comes to finding efficient and more cost-effective ways to provide health benefits to employees, it is likely that medium- to large-sized skilled nursing and assisted living operators are part of a national trend among larger employers to try new models for managing such costs.

The subject of what these new models may look like is part of the National Business Group on Health’s (NBGH’s) annual “Large Employers’ 2018 Health Care Strategy and Plan Design Survey,” which captures the latest trends for the remainder of 2017 and into next year.

According to NBGH, employers estimate the total cost of providing medical and pharmacy benefits to their workers will rise 5 percent for the fifth consecutive year in 2018. When taking into account premiums and out-of-pocket costs for employees and dependents, the total hit is pegged to be $13,482 per employee this year, and projected to rise to an average of $14,156 in 2018.

NBGH said employers will cover almost 70 percent of those costs with employees picking up the rest, or 30 percent, which is some $4,400 in real dollars for 2018.

These employers ranked specialty pharmacy as the top driver of cost increases, with nearly 80 percent of those surveyed putting drugs among the top three cost drivers. NBGH said specialty pharmacy costs will likely remain a paramount concern as new high-priced drugs come on the market.

With another 5 percent ride in health care benefit costs staring them in the face, NBGH said employers it spoke to are examining how health care is delivered and paid for while still pursuing traditional methods for controlling costs, like cost sharing and plan design.

Some forms of this new focus on delivery include allowing more employees access to broader health care services, including telemedicine, Centers of Excellence (where the most efficient health systems provide care) and onsite health centers.

In a breakdown of the numbers, NBGH listed the following trends to watch:

  • Telehealth utilization surging. Nearly 100 percent of employers surveyed will make telehealth services available in states where it is allowed next year. And, more than half (56 percent) will offer telehealth for behavioral health services, more than double the percentage in 2017. Overall, telehealth utilization is climbing rapidly, with nearly 20 percent of employers experiencing employee utilization rates of 8 percent or higher.
  • Accountable Care Organizations (ACOs) could double in use by 2020. This prediction comes from the survey question that showed 21 percent of employers plan to promote ACOs in 2018, but that number could double by 2020 as another 26 percent are considering offering them.
  • Employers opening health centers. More than half of employers (54 percent) plan to offer onsite or nearby health centers in 2018, and that number could increase to nearly two-thirds by 2020.
  • Centers of Excellence (COEs) embracing bundled payment arrangements. Almost nine in 10 employers (88 percent) expect to use COEs in 2018 for certain medical procedures such as transplants or orthopedic surgery. Of these, employers said bundled payments or other types of alternative payment arrangements will be used by 21 percent to 48 percent of COEs contracts, depending on the medical procedure or condition.
  • Controlling surging specialty pharmacy costs. Some 44 percent of employers will have site of care management tactics in place in 2018, a 47 percent increase over this year.In addition, 70 percent of employers will use more aggressive utilization management protocols.

Leave a comment

Filed under Uncategorized

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.

Leave a comment

Filed under Uncategorized

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 bgarner@medline.com.

Leave a comment

Filed under Uncategorized

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…

#AppGap

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 wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

Leave a comment

Filed under Uncategorized

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 wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

2 Comments

Filed under Uncategorized