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News Roundup: December 7, 2012

Baucus: Don't shift health costs to seniors in 'fiscal cliff' deal

Published by The Hill
Sam Baker
December 7, 2012

A deal to avoid going over the "fiscal cliff" should include controlling healthcare spending but shouldn't shift costs to seniors, Sen. Max Baucus (D-Mont.) said Tuesday.

Baucus acknowledged that rising healthcare costs are a burden on federal spending, and he said controlling those underlying costs is the way to tackle entitlements.

"Shifting costs to seniors is not the solution," Baucus said. "We cannot break the promise of Medicare and Social Security."

Baucus chairs the powerful Senate Finance Committee, which has jurisdiction over Medicare and other healthcare programs. He's also up for reelection in 2014, and has been angling for a key position in negotiating a deal to avoid the fiscal cliff of automatic spending cuts and tax increases set to hit next month.
"As chairman of the Finance Committee, I can influence a lot of policies, but I can’t keep folks from getting older. We need to focus on what we can influence, and that’s overall health care costs," Baucus said at a conference sponsored by the group Fix the Debt.

Baucus did not refer to any specific proposals for cutting federal healthcare spending.

He cited the rapidly growing number of new Medicare beneficiaries — a point often used to make the case for raising the program's eligibility age. But some Democrats also see raising the eligibility age as a form of shifting costs to seniors, because private insurance is more expensive than Medicare.

Baucus also took a shot at Republican critics of President Obama's healthcare law, which Baucus helped craft. He said the overall prospects for entitlement reform weren't helped by campaign ads that accused the president of "raiding" Medicare to pay for a new entitlement.

"If you turned on any television during the campaign season, you likely saw fiction: attack ad after attack ad claiming billions in cuts to Medicare, putting America’s seniors at risk. Nothing could be further from the truth," Baucus said. "There were zero cuts to Medicare beneficiaries in the Affordable Care Act. These ads are the exact types of misleading political attacks that prevent progress."

Majority of hospices exclude some patients due to Medicare daily fee, researchers discover

Published by McKnight's
McKnight's staff
December 7, 2012

Despite the fact that hospice is one of the fastest growing parts of Medicare, 78% of surveyed hospice operators turned away patients with the potential for high-costing care, according to a new study published Monday in the journal Health Affairs.
The findings illustrate the hospice community finds Medicare's reimbursement rates too low to pay for expensive medical services, said lead study author Melissa Aldridge Carlson. Payments are $153-per-day rate for routine hospice care and an $896 rate for around-the-clock care, according to the Centers for Medicare & Medicaid Services. The report recommends an increase in Medicare reimbursements so more high-cost patients can be enrolled.

Hospice is one of the fastest growing segments of Medicare. Numerous experts applaud it as a humane and cost-effective way to care for those in the last half-year of their life. But surveyed hospices contend that Medicare's daily fixed fee has discouraged them from accepting people with expensive needs.

For-profit hospices are more likely to limit special needs patients, researchers found. Hospices that average care for 20 or fewer per day also had a higher incidence of turning away those with high-cost treatment needs. Larger hospices spread the financial risk of high cost-patients the report noted.

Some services, such as radiation and chemotherapy to alleviate pain, can cost more than $10,000 per month, according to the survey. Patients also were turned away due to intravenous feeding, blood transfusions or getting pain medication with an automatic pump.

Physician-health service collaboration can bring quality care back home

Published by PhysBizTech
Madelyn Kearns
December 7, 2012

The trouble starts at home. But with some industrial savvy and a bit of physician intervention, safety and health could easily start there as well.

With a massive generation of baby boomers barreling over the bridge toward life’s second half, the conceptualization and experience of home will also inevitably undergo its own kind of transference.

“Elderly folks are going to be sort of forced to age in their homes — which we think is the best place for them to be — especially as all these Baby Boomers come of age,” Kerry Pawl, a founder of Mission Healthcare (a home health agency) specializing in physical therapy, told PhysBizTech. “There’s not going to be enough room in the existing assisted-living facilities. People are going to want to be in their homes.”

Thus, for these aging patients, the sharper comforts of the homestead, previously withstood without much hassle, will need to be filed down. Free-flung throw rugs will need to be either fastened to the floor or done away with completely; handles will need installing in slip-susceptible locales, such as showers and other bathroom fall zones; and cords will need to be vanquished from footpaths and walkways entirely. All of this becomes more imperative as the body develops into later life — whereas a fall once meant seldom more than a bump, it could potentially mean fracture or worse as a patient settles into retirement status.

But while the above precautions seem simple and “obvious, a lot of people just fail to do them,” Pawl said.

So what’s a healthcare system to do to ensure patient safety beyond the parameters of the doctor’s office? Get physicians and home health service providers to establish more prominent relationships, Pawl suggested.

“For physicians, home health care is really the eyes and ears into a patient’s home. The more that utilize it, the more often they’re going to know what’s going on in those homes.”

Moreover, “home health services are often an under-utilized Medicare benefit that some physicians don’t know about and/or just don’t know enough about to know when it’s appropriate,” Pawl added.

Alongside basic check-ups and consults with patients, many home health organizations/companies also provide a number of services that can aid in achieving a more comprehensive level of care moving forward.

“One of the first things that we do in home health is go into a home and do an entire home safety assessment and make recommendations to the patient and/or family regarding what needs to get done,” Pawl said. “If that patient or family does not have the resources to get those things done, we make recommendations for either getting a medical social worker involved or we have a list of vendors we work with [resources who can get the job done for a certain, more reliable sum].”

Following assessments, many home health workers will report back to the patient’s physician.

“If Dr. Jones has five patients on service with me, he/she should have at least monthly, if not every-other-week, reports from me as physical therapist letting him/her know (A) physically, how is this individual doing and (B) how safe is their home, what recommendations have been made,” Pawl continued.

Physicians should ensure that the home health servicer they choose to collaborate with is able to make these frequent and timely reports back. Pawl and Mission Healthcare also recommend physicians inform patients and/or their caregivers about the below inexpensive ways to increase home safety, categorized by room:

Bathrooms: Bathrooms are important to make safe because of splashing water onto the floor and an increase amount of going from a sitting to a standing position. Installing grab bars on walls around the tub and besides the toilet will help with the sitting and standing. To avoid slipping add nonskid mats to bathtubs and on floor surfaces that may get wet.
Kitchen: Keep commonly used items within reach. If an item is high up be sure to have a sturdy step stool. Also, make sure appliance cords are out of the way to avoid tripping.
Bedroom: For the bedroom, adjust the height of the bed to make it easy to get in and out of. A bedside table is important. Be sure to have a bedside light with a switch that is easy to turn on and off and also put a cordless telephone within reach.
Outdoors: It is important to remember there are also hazards outdoors. Be sure to repair any abrupt edges of sidewalks and driveways to avoid tripping. Installing adequate lighting by doorways and along walkways will help nighttime vision problems.
“Although you can never eliminate the risk of falls throughout the home, you can certainly minimize it,” Pawl concluded.

It’s a tall order, no doubt, but one made all the more successful through collaborative efforts between doctors in the office and off-site professionals in the home.

AARP hits Capitol Hill to warn against benefit cuts in deficit deal

Published by The Hill
Elise Viebeck
December 5, 2012

Staff and volunteers with AARP met with lawmakers Wednesday to warn against cuts to Social Security and Medicare in a year-end deficit-reduction package.

The nation's largest senior lobby has been vocal in its opposition to benefit cuts as lawmakers negotiate with the White House to avoid the so-called "fiscal cliff," a combination of tax increases and spending cuts set to hit Jan. 1.

"Americans have spoken and they don’t want Congress or the president to make changes to Social Security or Medicare in any last minute deficit deal," said AARP’s volunteer President Rob Romasco in a statement.

"In the long-term we need to strengthen Medicare, Social Security and Medicaid, but shifting costs to the older and less fortunate among us is not going to make our country stronger," Romasco said.
Wednesday's talking points included AARP's opposition to raising the Medicare eligibility age and to extending the Social Security payroll tax cut.

The group also opposed changing Social Security's cost of living adjustments to conform to a chained consumer price index. Such a move would reduce payouts to seniors, AARP said.

Republicans insist that entitlement cuts be on the table along with new tax revenues in any deficit agreement.

President Obama indicated Tuesday that he would consider entitlement reform if the GOP agrees to higher tax rates for wealthy households.

"The issue right now that’s relevant is the acknowledgment that if we’re going to raise revenues that are sufficient to balance with the very tough cuts that we’ve already made and the further reforms in entitlements that I’m prepared to make, that we’re going to have to see rates on the top 2 percent go up," Obama told Bloomberg. "And we’re not going to be able to get a deal without it."

But congressional Democrats appear split about the scope of entitlement reform in deficit negotiations.

House Minority Whip Steny Hoyer (D-Md.) said that entitlement cuts should remain on the table during fiscal-cliff talks.

"They clearly are on the table," Hoyer said of changes to Medicare, such as raising the eligibility age. "They've been on the table for some period of time. That does not mean that I'd be prepared to adopt them now, but they're clearly, I think, on the table.”

Other Democrats have said that while they would back spending reductions in Medicare, cuts to benefits should not be part of the deficit discussions.

"The moment you want to privatize Social Security, or voucherize Medicare, or block-grant Medicaid — that's where you lose us. Because we want to strengthen those programs, not let them die on the vine,” said Rep. Xavier Becerra (D-Calif.).

Huge Experiment Aims To Save On Care For Poorest, Sickest Patients

Published by Kaiser Health News
Mary Agnes Carey and Sarah Varney
December 5, 2012

It is usually after the mail arrives that Della Saavedra comes undone.

That's when she sits in her living room in this struggling Los Angeles suburb and sorts through the latest round of letters from her health plan, each rejecting her appeal to stay with her trusted oncologist at City of Hope, a local cancer center. For as long as she can remember, Saavedra, 53, a former cafeteria worker who suffers from bone marrow cancer, has been insured through Medicaid, the joint federal-state program for low-income people. For most of that time, she could go to any doctor willing to take her, but last year, the state revamped the program and assigned her to a managed care plan with a restricted network of doctors. Her oncologist is not on its roster.

"I have been sick for years and no problem," says Saavedra. "Now, it’s a huge problem."

Saavedra is one of a large group of disabled Medicaid enrollees in California who have been moved out of traditional fee-for-service health coverage into a managed care plan. Officials hope to learn if the transition provides this vulnerable population, which has complex medical needs, better medical care while saving the government money.


The California experiment, now in its second year, has national significance. Federal officials have begun to roll out a similar, but larger effort required by the Affordable Care Act. That program will move up to 2 million of the nation's sickest and most expensive patients into managed care. Twenty-five states have applied to be part of the managed care experiment for so-called "dual-eligibles," people who qualify for both Medicare and Medicaid. All dual-eligibles are poor, two-thirds of them are over 65, and many of them suffer from multiple chronic illnesses like diabetes and heart disease.

Massachusetts and Washington, the first states to be approved, will start their programs April 1.

Patient advocates around the country, and some lawmakers in Congress, warn that managed care plans – some run by for-profit, publicly traded companies – are ill-equipped to deal with the complex health needs of those who are elderly, mentally ill or disabled. Advocates are looking closely at the experiences of patients like Saavedra in California to see what the pitfalls of the national program may be.

"We have to think about the fact that people’s lives are at stake," says Kevin Prindiville, an attorney with the National Senior Citizens Law Center.

Sick, Frail And Expensive

Federal and state governments spend nearly $300 billion each year on the medical and home care needs of patients who are enrolled in both Medicaid and Medicare. They account for 31 percent of Medicare’s spending and 39 percent of Medicaid’s spending, according to the Centers for Medicare and Medicaid Services.

"Medicare-Medicaid enrollees include some of the most chronically ill and complex enrollees in both programs," says Melanie Bella, who is overseeing the experiment as director of the Medicare-Medicaid Coordination Office. "The current system presents many navigational challenges due to complex and often competing requirements."

The goal is to improve the care of these fragile patients by coordinating it better. The system could save money by eliminating needless tests, duplicative office visits and too many hospitalizations.


Those are sound principles, but the size of the experiment worries many. "They are too big to fail," says Robert Berenson, a former vice chairman of the Medicare Payment Advisory Board.

Attorney Vanessa Cajina concurs. She has represented several patients in the California Medicaid managed care experiment in her work with the Western Center on Law and Poverty in Sacramento. "[It's] too much, too fast, too soon," says Cajina. A recurring theme, Cajina has identified, is that the health plans did not have the range of specialists in their networks to care for people with complex or rare medical conditions.

But Emma Sandoe, a spokeswoman for CMS, says the upcoming national experiment will have a safety hatch for patients: they will be able to opt out of managed care if they wish.

Berenson and other experts say the opt-out is not sufficient because it’s likely to be too daunting a bureaucratic hurdle for many of these patients. "Fifty percent of duals either have cognitive impairments or serious mental illness. How’s that going to work?" says Berenson.

Lessons From California

California's plan for the federal experiment is by far the largest of all the states applying, with officials proposing to gradually move 685,000 duals into managed care starting next summer. The state predicts the shift will yield $663 million in savings in next year’s budget and additional savings in subsequent years.

Howard Kahn, CEO of L.A. Care, the nation's largest public health plan with one million members in Los Angeles County, says the effort will allow plans to knit together all the medical care patients receive and root out physicians who are abusing the fee-for-service system. "There's a whole bunch of really unnecessary care being delivered and worse. Not only unnecessary, but inappropriate and fraudulent care," Kahn said.

But California's experience of moving the subset of people on Medicaid with disabilities into managed care has led many to wonder if the federal demonstration project puts the most fragile at too great a risk. A report by the California Health Care Foundation determined the change-over in California was rushed – there were only seven months between federal approval in November 2010 and when mandatory enrollment began. The transition was riddled with problems.

In interviews, insurers and legal advocates say privacy rules prevented the health plans from receiving complete patient records. Patients had difficulty determining if their preferred doctors were in the plans offered to them, and those who wanted to be exempt because of a medical emergency, like active cancer treatment, found the appeals process onerous.

The result has been that many patients are severing decade-long bonds with trusted doctors, while others are being shifted to generic drugs they say are ineffective. Some, like Juan Cameros, a 34 year-old disabled architecture student from South Los Angeles have found themselves in a bureaucratic labyrinth worthy of a Kafka novel. (See accompanying video here.)

"They refer me to [a doctor]," says Cameros, who has a disease that makes his knees swell to the size of grapefruits, requiring a highly specialized surgery. "But he was a specialist on [the] spinal cord. He doesn’t do knees." Indeed, Cameros, his lawyer says, had been referred three times by his health plan to the same spinal surgeon. An administrative judge recently sided with Cameros allowing him to step out of managed care. But the knee specialist who has operated on Cameros before – and will only accept traditional Medicaid patients – initially said he couldn’t schedule the surgery until more paper work is filed.

Perhaps one of the biggest concerns about the experiment centers on patients who depend on home health and personal care aides to live safely at home.

At a conference in September in Sacramento, Calif. of local and state health directors from around the country, community service providers say the insurance companies that will be contracted under the combined program have little experience overseeing the long-term, home care needs of frail – and in many cases, isolated – patients. Many of the insurers "wouldn’t have had in-home supportive services," says Steven Wallace, chair of the Department of Community Health Sciences at the UCLA Fielding School of Public Health. This includes patients who need support every week, not just the week they are discharged from the hospital, he says.

Those needs are not all medical. Experts on aging say the "personal care benefit" paid for by Medicaid in many states will now become part of a bundled payment to health insurance companies that are ill equipped to handle to social problems at home that often have more to do with poverty, living conditions and isolation.

Ready For The Challenge

For their part, health plan administrators say they will be ready to meet the needs of their newest members. "Plans are going to be covering services that they haven’t done before," says Lisa Kodmur, program manager for seniors and people with disabilities at L.A. Care Health Plan. "It doesn't mean we can’t. It just means we haven't done it."

Indeed, L.A. Care has begun to tailor its services by dispatching visiting nurses and medical assistants to members’ homes to check blood sugar levels and blood pressure. It also promotes a 24-hour nurse hotline.

Steven Sample is a 63-year-old Vietnam veteran who lives in a group home in Glendale, Calif., and suffers from a debilitating nervous condition and diabetes. Sample says he loves the attention L.A. Care provides. "My heart was beating really fast the other day, and I called and the nurse said to lay down," he says. "I would have gone to the emergency room if I didn’t have the advice line."

As for Della Saavedra, the cancer patient in Pico Rivera, she recently received some good news in the mail: her health plan, L.A. Care, has given her permission to go out of its network of cancer specialists and get treatment from her long-time doctor.

How The 'Fiscal Cliff' Affects Health Care: Six Questions

Published by Kaiser Health News
Mary Agnes Carey
December 4, 2012

The impending "fiscal cliff" is a package of automatic spending cuts and tax hikes set to kick in next month unless President Barack Obama and Capitol Hill agree on a way to stop them.


Negotiations to avert the cuts are ongoing and both sides have exchanged offers. The president and congressional Democrats have said they will reduce spending on entitlements, including Medicare, if Republicans will agree to increase tax rates on the highest earners. While Republicans have agreed to more revenue, they oppose increasing tax rates, preferring to focus on closing loopholes and eliminating some deductions.

Here are a few questions and answers about what could happen in the weeks before the end-of-year deadline.

Q: If no deal is struck, how would that affect Medicare patients as well as the hospitals and physicians and other providers who care for them?

A: Under the series of automatic spending cuts known as "sequestration," Medicare providers would be subject to an across-the-board 2 percent payment cut, or $11 billion in fiscal 2013. According to a September report from the Office of Management and Budget, hospitals would bear the largest share of the cuts, with payments reduced by about $5.8 billion.

Seniors would see no changes in their benefits.

Q: How does that 2 percent cut in payments to physicians affect the 27 percent cut in Medicare payments to doctors already scheduled to occur in January?

A: Physicians who accept Medicare patients would face the 2 percent cut on top of an already scheduled 27 percent reduction in January unless Congress steps in to stop it.

That payment formula was created in a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth. It’s known as the "sustainable growth rate" (SGR).

For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors reacted with fury when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size – and price tag – of the fix needed the next time.

A deal on the SGR could be part of a "grand bargain," if congressional fiscal cliff negotiators decide to include it. To that point, Obama’s offer to Republicans included $25 billion to stop the scheduled cut. Congress could also pass separate legislation to stop the cuts. Some doctors say that if Medicare reimbursements are further reduced they may stop accepting Medicare patients.

Q: If negotiators do reach a deal, what could that mean for Medicare?

A: It depends on how large a role Medicare plays in a broader deal. Some of the proposals include raising Medicare's eligibility age to 67, asking wealthier Medicare beneficiaries to pay more for their coverage and paying Medicare providers less. All are complicated and many Democrats have said that they do not want to make changes that harm beneficiaries or shift costs from the government onto seniors. Republicans are insisting that entitlement savings play a large role in any deficit reduction deal.

Q: How is Medicaid affected, either way?

A: Medicaid does not face any automatic cuts starting Jan. 1. The Supreme Court's ruling made the health law’s Medicaid expansion optional for states, so there’s concern that any reductions in federal Medicaid spending might make governors even more reluctant to expand the federal-state program.

Many Republicans, including GOP presidential nominee Mitt Romney and his running mate, Rep. Paul Ryan, R-Wis., favor changing Medicaid into a block grant, where states are given a set amount of money and more freedom to decide who is covered and what benefits they would receive. But the block grant concept is a non-starter with Obama and Democrats.

Q: If no deal is reached by Jan. 1, what happens to federal funding for medical research?

A: The National Institutes of Health would see a $2.5 billion reduction in 2013, which means that the agency would "have to halt or curtail scientific research," according to the OMB analysis. Other agencies would see cuts, too. For example, the Centers for Disease Control and Prevention would face cuts of $490 million, and the Food and Drug administration would see reductions of about $318 million.

Q: If no deal is reached, what happens to health care for members of the military and veterans?

A: The TRICARE program for active members of the military system would also face an across-the-board 2 percent cut. The Veterans Affairs health system, however, is exempt from sequestration.

Home health care moves toward new trends

Published by WAFF 48 News
Bobby Shuttleworth
December 3, 2012

Felicia Clark is a caregiver for Peggy McKeen. Peggy suffered a fall in her home last year that left her paralyzed from the waist down, but she said she is getting better, and having a competent caregiver helps.

"It helps me to be able to stay at home. They're here to give me my baths, to give me comfort, encouragement," said McKeen.

She considers her "helpers" to be God sent.

"They are my family. I am so thankful, very thankful for the two girls that's been in my life," added McKeen.

"We're not talking about nursing. We're talking about simple care, to keep that person at home and to keep them out of a nursing home," said Ronald Grantland.

Grantland, Elder Care's vice president, explains the concept behind his home-based agency.

"We help them with their daily activities, such as bathing and grooming, walking, meal preparation, cleaning of the house - this type of thing," said Grantland.

Grantland said caregivers are well trained before they begin working and have additional education, constantly. Background checks are also run on the workers.

"It's the future of health care. A lot of the states have already gone, big time, to this type care," added Grantland.

A former lawmaker, Grantland said this also eases the burden on state coffers.

"Of course Medicaid Dollars are very scarce, and if we can spend that money wisely and keep these clients at home, it's very cost effective and it gives the client a quality of life - at home where they had rather be," he said.

That's where Clark and her co-workers come in.

"It's awesome for us. You've got to have a heart for one and we love going in and helping. What they can't do, we can," said Clark.

In this household, this relationship has led to a healthier body and mind.

"We comfort each other," added Clark.

Medicare Costs Pushing Home Care to Be Creative

Published by St. Joe Channel
Robert Lowrey
December 5, 2001

Funding cuts are affecting everything, even your health.

Signs are pointing to fewer personal visits from a nurse for in-home healthcare.

"I've been a home health nurse now for 19 years and there were times that we would see a patient twice a day," said Becky Hunstman.

But those times have changed.

Healthcare costs are going up and funding for things like in-home healthcare are taking a hit.

Personal visits are no longer affordable.

So nurses have to train friends, family, and even the patients ways to take care of themselves.

"Most of us, our hearts are here and we want to provide more care than we have funds for and that makes it very difficult for us," said Chris Weigel.

It is a change that may be different from what people are used to with home healthcare.

But with rising healthcare costs, Medicare funding has remained unchanged.

"There used to the way of how home health used to be and trying to get them back on board with the changes that are being made," said Weigel.

Technology, though, is allowing for more personalized attention away from the home, something that was not available in years past.

It is a customized attention that comes with a necessity to stretch healthcare dollars.

"What we're doing is going in and assessing the patient to see if they are performing whatever we need to be doing in the home," said Huntsman.

Immigrants Key To Looming Health Aide Shortage

Published by NPR
MARISA PEŃALOZA
November 30, 2001

In the shadow of the Capitol on a recent sunny morning, about 50 home care workers from around the country gather to lobby their legislators for basic labor rights. Most are native-born Americans, but about a quarter are documented immigrants from Africa, Latin America, India and the Caribbean.

Elizabeth Castillo is one of them. Born in central Mexico, she's now a U.S. citizen. She's been working with an agency for 30 years in El Paso, Texas, and she says she currently makes $7.75 an hour. Castillo says she's here because she wants people to know that caring for the elderly is an important job. "I'm a social worker, a psychologist," she says in Spanish. "I wear so many hats on this job. I wish we were valued because we provide much more than companionship."

Currently, about 2.5 million home health aides care for the elderly, and 23 percent are foreign born. As the boomers retire and choose to age at home, many see documented immigrants as offering one of the best hopes to prevent a labor shortage in the home care industry.

Growing Demand

"I think that the immigrant workers bring with them outstanding work attitude, but they also bring with them customs of how care is given at home in their home countries," says Dowell Myers, a demographer at the University of Southern California and author of Immigrants and Boomers: Forging a New Social Contract for the Future of America.

Myers argues that the two groups need each other. As more boomers age at home, they will need aides to care for them.

"We are starting to wonder: Where are the workers going to come from who are going to take care of the baby boom elderly?" he says.

According to the Bureau of Labor Statistics, employment for home health aides is expected to grow by 69 percent by 2020, much faster than the average for all jobs. Myers says the country should be thinking about issuing work visas for aides.

Most aides make around minimum wage — often less than crossing guards and janitors. They don't get paid vacation or sick days. And almost half of them receive food stamps or other public benefits.

"We have about 65,000 caregivers now, and we're going to have to double that number in the next five to seven years," says Paul Hogan, head of Home Instead, one of the largest home-care agencies nationwide. About a quarter of Home Instead's current employees are documented immigrants. And Hogan says legal immigrants are vital for his industry to grow.

Michael Elsas, president of Cooperative Home Care, agrees. The size of his agency has quadrupled in the past 10 years. "This is a wonderful entry-level position, and we shouldn't be ashamed of that," Elsas says.

But to attract more workers, says Elsas, salaries need to be higher.

"We value the fact that people come and pick up our garbage every single morning. How do i know that?"asks Elsas. "Because we pay those people more than we pay the worker that takes care of our elderly population"

Many in the industry, including Elsas, agree that unless assumptions of who does this work changes, the profession will lack respect. "Some of the most perceptive people that I've ever met are home care workers," says Elsas. "Not only are they caring, they're excellent at negotiation, they're excellent at problem-solving. They're people who know how to compromise and still get what they need to get."

Like many agencies, Cooperative Home Care runs training in English and Spanish, graduating about 500 aides a year. But demographer Myers worries the country isn't prepared for the thousands of boomers that will retire every year. "This is a very big challenge because the clock is ticking, and this is really the calm before the storm right here," he says.

We know how many boomers will need home care, and, says Myers, it's in everyone's best interest to invest in that workforce, including legal immigrants.