Fault Lines And Frontiers In Person-Centered, Long Term Care Part 3

V. Tellis-Nayak

Robert Murray sat at the desk with three octogenarian fellow residents; they had an air of authority. Across the desk, the young, shy, but confident Angelica Riviera took her seat.
At the Bethel Health and Rehabilitation Center, a meeting of the ages was about to begin: knowledge developed over 300 cumulative years, arrayed against the untested idealism of the 19-year-old Angelica. This was the final meeting where this team of seniors would declare whether Angelica measured up to the certified nurse assistant (CNA) job she was seeking.

Elders in skilled nursing centers recruiting their own caregivers is something you would expect Diane Judson, director of nursing, to initiate. She has a cultivated way of relating to residents. She connects with the person concealed within an aging body; she recognizes the human spirit yearning to be whole, to reach its potential, and to rise above selfishness and to serve others.

The four residents who interviewed Angelica are the Recruiting Council Judson installed over a year ago. As recruiters, they take over after the routine preliminaries and paperwork. They have the final say in CNA hiring. Robert Murray, a victim of Lou Gehrig’s disease, is an active member. He led the interview with Angelica. His amplifier headset muffled his labored words, but Angelica sensed the pathos in the question Murray directed toward her.

Compassion Over Competence

Murray asked her, “Angelica, you see, I am only 42, but I am not a whole person anymore. ALS has crippled me. I can barely move around. I cannot talk with you without this amplifier headset. I was a full person once. I am not anymore. Angelica, as my caregiver, what can you do to make me feel whole again?”

Angelica could not stop the gush of tears. “That is not what I had expected,” Angelica says. “I thought they would ask me about my training, my skills, and my experience. Bob’s question cut through all that I anticipated, it went deep inside me. It told me that what they were looking for was not a CNA. They wanted a caregiver that made them feel like a whole person. I cried.”

Angelica is now a caregiver at Bethel—a happy one. She has a special bond with Murray.
The recruiting elders are uncanny in detecting the kindness an applicant brings to the job. Not all applicants pass the test. Of the 40 or so prospective students or CNAs thus screened by the residents and recruited in the past year, only two have left Bethel: One was hired by Judson against the team’s recommendation—she soon discovered they were right—and the other, although big in heart, fell short on competence.

The “Residents Recruit CNAs” story is as much a tribute to Judson as it is a warning about the gaping lacuna in the person-centered approach in long term care. Not all well-regarded programs that preach or practice humanistic principles capture all the essential elements that make the human person.

Service Is Joy

A history written in blood, sweat, and tears finally brought the world to agree on a lofty vision of the human person; it is now shared by nations, religions, and cultures. That model posits that five innate yearnings define our goals, endow us our inalienable rights, and confer on us our humanity. We have distilled these primal needs and birthright as: to be, to become, to belong, to be your best, to reach beyond.

To reach beyond selfishness and to lift those in need are tendencies to be compassionate etched in our DNA. Adam Smith, the widely misquoted godfather of economists, refers to compassion as a “principle of human nature, the most exquisite sensibility to feel for others.”

Compassion is the most divine of human virtues. It brings blessings not only to the receiver and the giver, but also to the bystanding observer. The science of compassion has documented the beneficial changes in brain, body, mind, and soul.

As a Nobel Prize laureate put it,
“I slept and dreamt that life was joy.
I awoke and saw that life was service.
I acted and behold, service was joy.”
—Rabindranath Tagore

Compassion Spreads its Blessings

The residents in nursing centers know much about the rewards of selfless sacrifice. They were parents, teachers, doctors, lawyers; they volunteered and were good neighbors; they gave. Why should we presume that in their ripe years they desire to disregard life’s lesson, to become self-absorbed and egocentric?

It is rare that the person-centered agenda specifically caters to the noblest human instinct that yearns to transcend, to serve, and to give. Ironically, this is a glaring deficiency in many well-funded programs. However, compassion thrives in innovative practices at many nursing centers.

At Bethel, Judson opened one route to attain fulfillment via compassion. Other people like Judson at other sites have opened different pathways to compassion:
Residents partner with hospice staff; they bring comfort and peace to their dying friends and co-residents.

Residents serve on advisory groups that plan menus and improve layout, décor, and furnishings.

They serve as ambassadors-at-large that facilitate communication, troubleshoot, and spread cheer and smiles.

One nursing center in New Jersey reinstated a resident’s past career role as a judge. She arbitrates disputes and grievances that residents and staff bring to her.

At another Eastern site, a resident with a distinguished career on the stage was helped to turn residents and staff into actors; they put on stage shows for their families, friends, and neighbors.

In a California nursing center, residents make fancy colored soap, market it at fairs and online, and spend the profit feeding the homeless.

Many nursing centers across the nation connect with churches and schools. They host children; encourage intergenerational play; do foster-grandparenting and baby-sitting; and help with homework, writing letters, and so on.

At other sites, residents pass on their skills and wisdom to the younger generation. They teach, mentor, and counsel.

Kindness and compassion are deeply felt urges that seek fulfilment even as our body ages. Compassion spreads its blessings all around. As Judson says, “Seeing residents hire their caregivers is rewarding enough. Sitting on the sidelines, I listen to residents, I understand what they really want. At each session, I learn something new. It has made me a better leader. It has blessed us all, made each of us a better person.”

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He and his wife, Mary Tellis-Nayak, have co-authored a book, “Return of Compassion to Healthcare,” which upholds humanity as the ultimate measure of success. He can be contacted at vtellisn@gmail.com.

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Possible New Federal Medicaid Policies Put Pressure On States

Patrick Connole

With Congress weighing whether to alter how shared federal and state payments work in the Medicaid program under a Republican federal per-capita cap, the possibility of such a shift could leave long term and post-acute care (LT/PAC) providers much more focused on state policymaking moving forward.

That is the thinking of Robin Arnold-Williams, a partner and head of the Medicaid practice for Leavitt Partners in Salt Lake City, Utah, who tells Provider that if a per-capita cap comes to be then states will be faced with enormously tough decisions on “who they are going to cover and for how long.”

Of the many factors playing into how states decide, under a possible cap system, to allocate money to the various populations able to receive Medicaid funding (low-income elderly, disabled, pregnant women, etc.) is the Affordable Care Act’s (ACA) eligibility expansion. What the House Republican bill, the American Health Care Act, currently proposes is that enhanced federal funds, or matches under the ACA, will continue to be paid for enrollees on the books by Dec. 31, 2019.

So, states like Kansas, which is slowly moving forward in its legislature to possibly expand eligibility under the ACA for its Medicaid program, may want to act sooner rather than later in order “to get critical mass” and take advantage of the enhanced match of 90 percent, Arnold-Williams says.

How these state decisions on ACA eligibility directly affect LT/PAC funding is that if a state does or does not take on the more generous federal match and more enrollees, then they may or may not have more money for other buckets, or populations, in need of the capped federal funds.

All of this is very complex to understand, she explains, and will leave state Medicaid offices working overtime if the House Republican bill survives its trek through Congress.

“I imagine there are a lot of Medicaid directors looking at their data and trying to calculate that. That will take some sorting through,” Arnold-Williams says. “There are different per-capita rates for each group: children, adults, seniors and the disabled and the blind. It is one thing to say the money is going to flow to the state in those set per-capita rates by group, but it is quite another thing at the state level to say how that revenue will be allocated.”

An example of the tough math ahead is if you have different inflation costs for seniors and people with disabilities versus children, leaving states to allocate Medicaid budgets for these different groups and services within Medicaid without open-ended entitlement.

Some states, she says, will be more generous and may even weigh keeping their program open-ended with possible tax increases, decrease in health benefits, or other moves to pay for it, but more likely it sets up an intense period of competition between various Medicaid groups when the Republican proposal would go into effect in 2020.

“And one decision point in 2020 will be a state making a conscious decision to roll back ACA expansion in order to manage money better. It is hard to manage expansion and not have new people come on at lower match rate,” Arnold-Williams says.



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Fault Lines And Frontiers In Person-Centered, Long Term Care: Part 2


V. Tellis-Nayak

V. Tellis-Nayak

When did you last notice a doctor sitting at the bedside, totally absorbed listening to the patient’s story? Danielle Ofri, MD, recalls bygone days whenever she talks with admiration of her mentors. They were white, male doctors in starched shirts and bow ties, schooled in lily white settings.

“Their old-fashioned doctoring made them approach the bedside as a sacred act,” Ofri says. “They examined each patient—whether a homeless Ecuadorian alcoholic, a veiled Muslim woman, or a visiting Swiss diplomat—with a thoroughness that in itself exuded respect.”

She speaks of Dr. Spenser, blustering in style but who coached young medics-to-be on compassion. He would drag a metal stool to the exam table, swivel it down to the lowest level, and sit on it with his head level to the exam table. Then he would say, “Whenever you speak to a patient, you seat yourself at the patient’s level or lower. You never hover over them high and mighty. They are the ones who are sick. They run the interview, not you.”

Eclipse Of The Art Of Relating
A kind caregiver whose eyes bespeak concern, whose touch conveys compassion, and whose words reassure, does more than just communicate; kindness and caring speed up recovery and hasten healing more surely than does the cold potency of the formulary.

Institutional medicine is quick to report that 70 percent of the avoidable, massive acute-care damage inflicted on patients is caused by miscommunication. Such analysis is typical of the biomedical mindset—it skirts the real issue; it begs the question.

Advances in communication make the world flatter and smaller, and social contact easier than ever. Why then is miscommunication epidemic in health care? The answer is obvious.

The communication revolution helps us to connect easily, but it does not help us to relate meaningfully. Relations are the soul of health care. But human contact is turning cold and sterile.

The Art Of Listening
Surveys of residents, families, and staff are commonplace in long term care (LTC). But the art of listening is in eclipse. Many policies, regulations, and programs are elegantly designed and aimed to benefit LTC residents. But we sadly watch many of these residents flicker, flame out, or linger on as cooling embers. Too many LTC initiatives are born of logic that is not always in sync with what beneficiaries want and need.

Regrettably, LTC discourse on culture-change is loud in tone, light in theory, and lax in its phraseology. My disappointment sparked a research interest, which in turn resulted in a book I co-authored with my wife, Mary Tellis-Nayak: “Return of Compassion to Healthcare.” Importantly, we reviewed what we had heard from residents, family, and staff in annual surveys—several million respondents over 15 years.

We asked, “Who is the person in person-centered care?” All lines of inquiry converged on the humanist axiom, which we summarized as follows: Five primal yearnings make us human and endow us our inalienable rights: to be, to become, to belong, to be our best, to reach beyond.

History’s March Toward Human Rights
These five “Bs” are what make us human. However, many societies throughout history have not recognized select groups as humans, including women, children, slaves, and ethnic outsiders.

Our forebears paid a heavy price in blood and treasure before reaching a consensus about the humanity that is our ultimate birthright. We believe the five Bs distill the content and spirit that fueled history’s major upheavals—those whose intent was to clarify and ensure that birthright:

  • Milestones in democracy: Magna Carta, Emancipation Proclamation, Women’s Suffrage.
  • Revolutions: American (“life, liberty, happiness”); French (liberty, equality, fraternity); Russian (You have “nothing to lose but your chains”).
  • Religions: Christianity (We are “made in the image and likeness of God”; “People of God”); Hinduism (“Atman is Brahman”); Islam (“All the born are born with the God-given nature”).
  • Caregiver oath: “First, do no harm.”
  • Humanist precept: Maslow, Frankl, Adler (“Our humanity is the measure in all things”).
  • International consensus: 193 signatories to the United Nations declaration of human rights.

The five Bs encapsulate the primal yearnings intrinsic to a person, whatever the context or circumstance. We take inspiration from the great humanitarian, Albert Einstein, who advised, “Remember your humanity, and forget the rest.” We propose that the five Bs serve as a preliminary touchstone for new understanding of human yearnings—especially of those under our care.

The skeletal outline that follows narrowly focuses on LTC residents and is meant to illustrate how the five Bs could be a “GPS” that pinpoints our person-centered destination and guides us on an assured route.

Five Self-Evident, Inalienable Rights

  1. To Be: To live in a risk-free setting, safe, without fear of injury from medication error, abuse, under-staffing, inadequate infection control, substandard wound care. To live without pain and to die in dignity.
  2. To Become: To be respected for your unique self; to participate in care decisions and day-to-day choices; to have ready access to all your health records. To maintain self-reliance and maximize self-care.
  3. To Belong: To lead a fulfilling social life, to bond with caregivers and to be mutually supportive of fellow residents; to stay connected to family, children, animals, nature, and the outside world, real and virtual.
  4. To Be Your Best: To grow mentally and spiritually as a person; to use your skills to advise, to teach, to mentor; to display your talent and use it to entertain fellow residents; to
    find meaning in suffering, and to make disabilities and illness a teacher.
  5. To Reach Beyond: To find joy in serving others, to be part of resident council, of an advisory group that plans menus; to comfort those in pain and in hospice; to be a foster grandparent.

Heed what the residents, families, and staff say, and what they yearn for. Always honor their humanity. That will keep you on the high road in pursuit of life, liberty, and happiness.

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He has conducted research in the United States and abroad, and his major findings have reached a wider public through his writings in trade magazines. He can be contacted at vtellisn@gmail.com.

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Health Policy Change Coming in Waves, Ready or Not

700Patrick Connole

By now, early in the Trump administration, it is clear that any and all policies are up for grabs. But even as issues like immigration and border security can be altered quickly with the stroke of a pen on an executive order, the changes coming to the Affordable Care Act (ACA) and other health care rules and regulations will take longer to unravel—measured in months and possibly years rather than weeks because Congress must act first.

What these reforms will mean to long term care (LTC), post-acute care (PAC), and assisted living is of course not known. If anyone can figure out how Congress will replace the ACA, and what if anything they decide will be to the liking of President Trump, is beyond a betting person’s capabilities. But one expert in analyzing the LTC-PAC universe says even with D.C.-based changes looming, the attention of providers, especially PACs, should not waver from two fundamentals that will survive: to get your clinical house in order and to get your costs down.

This is because the march toward value over volume and the trend for hospitals to tighten their PAC networks is only going to continue, no matter who resides at 1600 Pennsylvania Avenue, says Shawn Matheson, manager for Leavitt Partners. That doesn’t mean, he notes, that Congress and the administration won’t overhaul existing CMS bundled payment and related demonstration pilots. What it means, instead, is that hospitals and managed care payers will be narrowing networks even if policy goes in new directions.

“In the rapid shift to value-based payments, many hospitals and medical groups are shifting referral patterns and creating PAC value networks,” Matheson says. “I see two main ways of change that have brought about these shifts for hospital-to-PAC referral patterns. The first wave began since fiscal year 2013 when the Medicare hospital readmissions reduction program began and the second wave, a much bigger and much more sudden one, began in April 2016 with the advent of Medicare’s Comprehensive Care for Joint Replacement bundled payment program.”

These policies helped put hospitals on alert to partner with top PAC providers, those that demonstrate high-value outcomes, low-cost spend, and clinical specialization in order to reduce readmissions, he says.

“Bundled payments are creating winners and losers in the PAC space,” Matheson says. “Referrals are going to the high-value providers that can demonstrate value, and those actively willing to work on lowering their length of stay.” There is an inherent risk and reward for a PAC provider participating in bundles in that decreasing your costs has to be offset by the volume of referrals from the hospitals,” he says. “The key is to get hospitals to compensate with volume,”

This is happening even as skilled nursing care centers are being left out of some of this planning in favor of home- and community-based care in many cases. The pendulum, Matheson says, will likely swing back to using PAC providers as the first site of care. This is because more and more anecdotal evidence is emerging that too many patients are coming back to the hospital from the home- and community-based settings who should have gone to PAC care first.

With much of the ACA being eyed by Republicans for replacement, there is still an expectation the pay-for-value movement will survive, albeit in some new forms.

“We think bundled payments will continue in the new administration. CMMI [Center for Medicare and Medicaid Innovation], for example, has significant statutory authority to test payment models. We feel like the Trump administration will use that authority to test the models that appeal to them,” he says.

“Indications are favorable for more state control [under the Trump administration], with states implementing programs through Medicaid system bundles and advanced payment models.”

With this attention to new payment models continuing, the onus will be on providers to state their case to acute care entities. The key idea, Matheson says, is it pays for PAC providers “to really reach out to hospitals, MA [Medicaid Advantage] plans, and managed Medicaid to build stronger relationships.” And with that outreach comes the need for hard, cold data showing real outcomes success in an efficient manner. “Data talks in this new environment,” he says.

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Our Humanity— The Ultimate Goal and Measure in Long Term Care: Part 1


V. Tellis-Nayak

V. Tellis-Nayak

The day’s surprise came in the sixth meeting of NRC Health’s marathon series of interviews with clusters of long term care (LTC) residents and families. Life-long experience had prepared my wife, Mary, and me to lead this study. Still, we had not anticipated that so many new twists on old truths would set so many neurons firing full cylinder.

The Resident Surrenders
The surprise came when Marcie, a wizened 94-year-old, narrated the story of her first days at her LTC community. She felt anxious when she first arrived.

“It was not long before I got into the new routine. It came easy, I lowered my expectations.”

Marcie’s words were an electric jolt. I wondered what maledictions would have rained down if trial lawyers, regulators, and advocates were here listening to Marcie? These critics bemoan that LTC communities run on institutional logic; they do not support resident autonomy. Residents all too quickly surrender personal choice. Institutional routine asks new entrants to sacrifice individual lifestyles.

Did Marcie lower her expectations, and thereby surrender her independence? For a true answer, we need to look beyond what advancing age does to our body and see how far, how wide, and how deep its effects echo.

Self-Demolition In Slow Motion
When aging signals, my body starts to fall apart. The self-demolition occurs in slow motion, it is relentless, it spares nothing. Old age disables the body, dulls the best talent, blunts well-honed skills, and clouds beautiful minds. Worse, it chips away my self-image. I desperately grasp at any symbol that prolongs the illusion that I am still self-sufficient and in control.

As I stumble along on my final lap, the prospect of LTC threatens to uproot me and make me spend my last days among strangers. LTC centers are modern-day public symbols of human life at its most undesirable. They broadcast to the world that I am on my last legs; I am of little value, am a drain on resources. My life has no purpose, has no meaning, is not worth living. Many elders try to escape the humiliation and take the exit through suicide, active or passive.

Victories Of The Spirit
The dread prospect that drives many to despair, paradoxically, is also the test that vindicates the resilience of the human spirit. Research offers many a glimpse into human fortitude that can ride out the roughest waves and into the human quest for transcendence in the meanest conditions.

Meditate on the wisdom that shines through in the following findings of good research.
One in four Americans spends some time in a nursing center. One in three dies there after a stay of two years. Two in five of the lucky ones who live to be 85 die in a nursing center.
The 100 elders in 15,000 nursing centers who each year die by suicide, make up a lower rate than the suicide rate for elderly in the community. Half of the nursing center suicides occur in the six months after admission.

Up to 40 percent of nursing center residents and their families rate their satisfaction as “excellent;” 2 percent rate it as “poor.” Their judgment correlates with the state survey

Residents and families praise the staff for their care and concern, for their respectful ways, and for making residents feel safe.

Most LTC staff are satisfied by the quality of their workplace. Their greatest joy is knowing they make a difference in the life of the elders. LTC staff turnover is lower than in many service industries.

Fantasy Versus Reality
Three significant themes run through these scattered findings. First, the image of LTC in the public imagination is a cruel caricature starkly contradicted by the testimony from residents, families, staff, and state surveyors—the most credible witnesses to quality at ground zero.

The negative stereotype adds to the fear and anxiety of many elders. It is particularly unfair to the caregivers who, day in and day out, allay the fears of frail elders and make them feel safe, wanted, and respected.

Although mediocrity dogs LTC, a second underlying pattern shows through. The kindness of staff touches residents and families so deeply that they take in stride the irritants of group living. They do not blame a kind caregiver; they see the rush, delays, and missteps as normal to the give and take of life.

Beth, a feisty centenarian uncovered yet a third truth when she responded to Marcie. “It is like getting married,” Beth said wisely. “You fall in love, you get married, and you fall into reality. Sharing your life with another curbs your independence. You love each other, so you make the sacrifice and live happily ever after.”

You Get What You Negotiate
Our survival instinct has taught us well: When you cannot control the wind, adjust your sails; let not the best be the enemy of the good. Elders know the survival strategy too well: In life, you do not get what you deserve but what you negotiate.

The human spirit is indomitable in its quest for happiness. It adapts, accommodates, compromises, and concedes—shrewd tactics hidden under the guise of surrender. Many fail to recognize the silent victories of human ingenuity.

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He has conducted research in the United States and abroad, and his major findings have reached a wider public through his writings in trade magazines. He and his wife, Mary Tellis-Nayak, have co-authored a book, “Return of Compassion to Healthcare,” which upholds humanity as the ultimate measure of success of any human endeavor. He can be contacted at vtellisn@gmail.com.

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


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