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News Roundup: January 11, 2013

Huge opportunity for dual eligible cost savings, report says

Published by McKnight's
Tim Mullaney
January 11, 2013

Better coordination of care for individuals eligible for both Medicare and Medicaid could result in savings of nearly $190 billion by 2022, according to a recent UnitedHealth Center report.

Medicare and Medicaid spending on dual eligibles is estimated to reach $330 billion in 2013, according to the report. The long-term care sector will be significantly impacted by efforts to bring this number down in the future, as a majority of the $150 billion in Medicaid spent on dual eligibles is for long-term care services.

The Centers for Medicare & Medicaid Services (CMS) is acting to address spending on dual eligibles through a Financial Alignment Demonstration model. In the most popular version of this model, a managed care plan or an organization such as an Accountable Care Organization receives blended payment streams of Medicare and Medicaid.

UCH estimates the current CMS model will cover roughly one-fifth of all dual eligible beneficiaries. The report proposes states can more aggressively institute managed care models to better manage Medicaid funds for dual eligibles.

The number of dual eligibles is certain to increase as implementation of the Affordable Care Act swells Medicaid rolls, PricewaterhouseCoopers stated Wednesday. The firm noted that 70% of state Medicaid spending on duals goes to long-term care services.

Home & Community Care Services Fastest Growing Senior Care Segment

Published by Senior Housing News
Jason Olivia
January 10, 2013

As the “baby boom” generation approaches retirement, the demand for senior care services will rise and will drive industry revenue, according to a study from Freedonia Group, Inc., a Cleveland-based market research firm.

Revenues for senior care services are expected to grow 5.2% annually and reach $319.5 billion through 2016, according to the Freedonia Group’s Elder Care Services report.

While skilled nursing facilities accounted for the largest share of senior care revenues in 2011 with 43%, home- and community-based services, such as home healthcare and assisted living, are expected to achieve the fastest growth.

Advances for these services will be driven by continued efforts to draw Medicaid payments away from skilled nursing, says the report, often by limiting reimbursements or directing patients to less expensive forms of care.

Despite the general consensus that many Americans will want to age at home, the study suggests revenues for continuing care will experience strong growth given an upturn in the housing market.

Increased progress toward recovery for the housing industry will encourage older Americans to sell their homes, which they can use the proceeds to pay for steep entry fees associated with continuing care communities.

Additionally, for-profit entities accounted for 66% of elder care services in 2011, which the study notes benefitted from dominance in the skilled nursing segment and its leading positions in the home health and assisted living markets.

On the other hand, nonprofits accounted for the larger share of revenue in both the continuing care and social services markets.

Access the report here.

'The Matrix' Meets Medicine: Surveillance Swoops Into Health Care

Published by Kaiser Health News
Michael L. Millenson
January 10, 2013

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age.

In an inconspicuous control room at the Sioux Falls, S.D., headquarters of the Evangelical Lutheran Good Samaritan Society, nurses keep round-the-clock watch on motion and humidity sensors in the living rooms, bedrooms and bathrooms of elderly men and women in five states.

The seniors -- a handful in their own homes and the rest in assisted living facilities owned by Good Samaritan -- are part of one of the most comprehensive remote health monitoring efforts anywhere. Using sophisticated sensors, computerized pattern recognition and human responders, Good Samaritan hopes to show it can detect and head off health threats to the elderly and thereby accomplish two important goals. The first is saving money on medical costs. The second is helping seniors feel secure enough to "age in place" at home or avoid moving from assisted living to a skilled nursing facility.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain. So, too, is whether a benign health care purpose can help overcome the unsettling "Big Brother" overtones for some potential users. What is clear, however, is that health care is joining a national trend toward greater surveillance of everyday life.

For example, more than 70 U.S. cities now use ShotSpotter sensors to pick up the sound of gunfire and alert authorities even before 9-1-1 is dialed. Auto insurers are hooking up sensors to a car's computer system to monitor driving habits and, with the driver's permission, calculate premiums accordingly. Even some farmers are equipping cow collars with monitors allowing automated milking systems to track the cow's milk production, amount of feed eaten and even how long it chews its cud. If the system detects a problem, it can call the farmer on his phone.

What benefits bovines might also help humans, albeit with appropriate modifications. Good Samaritan is the nation's largest nonprofit provider of senior services, operating more than 240 facilities in 24 states. Working with the University of Minnesota, the system recruited 1,600 seniors in North Dakota, South Dakota, Minnesota, Nebraska and Iowa to test the impact on cost, quality of care and senior independence of a comprehensive set of monitoring tools. With an $8.1 million grant from the Leona M. and Harry B. Helmsley Charitable Trust, the LivingWell@Home study began collecting data at 40 of its assisted living facilities in January 2011, and will stop at the end of June 2013.

LivingWell@Home comprises three technologies. First, sensors from WellAware Systems are distributed throughout the living space. (The company stresses that no cameras or microphones are involved.) When a senior is sleeping a motion sensor records how often he or she moves in bed. Showering, toileting and other activities of daily living are also analyzed by WellAware algorithms and scrutinized by nurses for changes that might signal health problems.

The second piece is a medical alert button from Philips Lifeline that includes an auto-alert function designed to detect a fall and call for help even if the user is incapacitated. Lastly, remote monitoring is provided by the telehealth unit of Honeywell through a clock radio-sized console in each apartment. It turns on each morning and prompts seniors to strap on a special blood pressure cuff, step on a special scale and transmit that and other information back to the monitors in Sioux Falls.

Jacci Nickell, who is Good Samaritan's vice president of development and operation delivery systems, emphasizes that the technology is just a tool. "Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn't going to help anyone," she says. "It's what you do with that data, and how you optimize wellbeing."

Good Samaritan isn't waiting for the study results to be finalized to roll out the LivingWell@Home service, in which the system has a financial stake, as an option in all its assisted living facilities. It's also putting parts of the technology into some skilled nursing facilities and even into seniors' own homes.

The organization's website tells the story of an elderly woman who agreed to have the sensors installed in the South Dakota farmhouse where she lived alone. Not long afterwards, the sensors detected a change in her toileting that prompted a call from a nurse. In response, the woman sought out her doctor, who discovered a bladder infection. "Maybe it was God talking to me," says 83-year-old Carol Tipton in a website video, seemingly near tears.

"We think the use of the technology can reduce the need for physical visits and will save expense and time," Nickell says. Still, the high-tech security blanket doesn't come cheap. The technology costs $500 to $750 per month per person at home and about $175 a month for residents in Good Samaritan assisted living facilities that already have a personal emergency response button service. By comparison, notes Mary Cain, managing director of consulting firm HC3, conventional disease management costs well under $100 per month per patient.

"It's a very small percent of the population that's going to benefit from [the Good Samaritan] level of monitoring," Cain says. "How many will you monitor, and who is paying?"

A similar cautionary note comes from a spokeswoman for United Healthcare, the nation's largest health plan. United already covers devices such as those used to detect abnormal heart rhythms or measure blood sugar. But "health insurers typically rely on guidance from the clinical community in making coverage decisions," says the spokeswoman, and with sensors and similar technology "it's too early to do so at this time."

Privacy also remains a concern. Some critics may detect overtones of a 1983 song by The Police that warns, "Every breath you take, every move you make, we'll be watching you." As Christine Sublett, a health privacy and security consultant, put it: "Individuals should have the right to know exactly what information is being transmitted and that appropriate controls are in place." Good Samaritan says it takes appropriate precautions, but the research study may not provide a rigorous test of protection against hackers. Nor has Good Samaritan or its vendors yet encountered patients demanding their own data feed, as has happened to makers of defibrillator monitors and similar technologies.

Still, other companies are jumping into this market. For instance, StealthHealth offers a radar beam to provide in-home monitoring of vital signs, activities of daily living and falls. The company suggests its equipment be placed inconspicuously behind a picture frame. And GrandCare Systems offers to collect data from motion, temperature, door, chair and bed sensors, in addition to pill box sensors for monitoring medication use and caller ID information to keep an eye out for telephone scams.

Choices are also proliferating for consumers willing to pay out of pocket for detailed quantification of their diet, exercise and sleep patterns. In just one example, BodyMedia sells wearable sensors said to gather 5,000 data points a minute on skin temperature, heat flux and galvanic skin response. The company says its aim is to provide users with a personalized assessment of health issues such as stress, fatigue and depression.

FCC Earmarks $400 Million Annually for Rural Telehealth

Published by Healthcare Finance News
Mary Mosquera
January 10, 2013

The Federal Communications Commission will make $400 million available annually to healthcare providers to expand the development of broadband telehealth networks from a pilot to a permanent program.
The pilot program has supported 50 provider healthcare networks in 38 states.

The telehealth networks will link urban medical centers to rural clinics or offer instant access to electronic health records (EHRs). The agency will begin accepting applications for the grants in late summer, according to the Jan.7 announcement by FCC Chairman Julius Genachowski.

[See also: Telemedicine lets doctors 'monetize their time']
The fund will enable thousands of new providers across the country to benefit from connectivity to improve the delivery of care and dramatically cut costs for both hospitals and the FCC's Universal Service Fund, which underwrites advanced telecommunications services. Many other providers will have the means to upgrade their connections.

The Healthcare Connect Fund program builds on the agency’s Rural Healthcare pilot program. For years, the FCC's primary healthcare program has made it difficult for hospitals serving rural patients to get high bandwidth connections needed for modern telemedicine by limiting the services eligible for funding and by making it hard for groups to effectively bargain for the lowest cost service, the agency said.

The fund will enable patients at hospitals and clinics around the country to access specialists at major health centers through telemedicine and support the exchange of electronic health records, which can lead to better coordination of care and lower costs. The program will also encourage formation of state and regional health care consortia to save costs and expand access to health care.

[See also: Telehealth services make business sense]
The FCC fund will offer a 65-percent discount on broadband services, equipment, connections to research and education networks, and provider-constructed and owned facilities if cost-effective. Healthcare providers will contribute 35 percent of the costs.

Healthcare organizations that will be eligible are public or not-for-profit hospitals, rural health clinics, community health centers, health centers serving migrants, community mental health centers, local health departments or agencies, post-secondary educational institutions/teaching hospitals/medical schools, or a consortia of the above. Non-rural providers may participate in the Healthcare Connect Fund as part of consortia, but the group must remain majority rural.

Telemedicine has demonstrated that it can drive down costs, the FCC said. For example, in South Dakota, e-ICU services have saved eight hospitals over $1.2 million in patient transfer costs over just 30 months. In upstate New York, a network of about 50 providers expect $9 million in cost savings from providing cardiology, trauma, mental health, neurology and respiratory services over their broadband connections.

The FCC will also launch in 2014 a New Skilled Nursing Facilities Pilot Program to test how to support broadband connections for skilled nursing facilities. Funding will be up to $50 million total over a three-year period.

Who should lead care teams?

Published by Fierce Healthcare
Alicia Caramenico
January 9, 2013

With new delivery models promoting collaboration across the healthcare continuum, the question remains: Who should lead teamwork between providers and nonclinicans?

Having doctors take charge of formalized interprofessional teams not only works best but is what patients want, according to an editorial in American Medical News.

Studies have shown that doctor-led team arrangements, such as accountable care organizations or medical homes, have successfully reduced costs and lowered hospital and emergency department use.

And according to a 2012 American Medical Association survey, 75 percent of patients agreed that "patients benefit when a physician leads the healthcare team," the editorial noted.

However, other research points to nurses as effective care team leaders. Nurses have been increasingly taking on leadership positions and playing important roles in the success of ACOs. What's more, nurse-led programs have been shown to reduce medication errors and cut sepsis mortality rates in half.

Regardless of who's in charge, care teams must include patients to achieve better care quality and outcomes, Fox23 News reported.

"If we are going to be successful moving forward with whatever system we have, it's going to be essential more than ever that doctors, patients and everybody are working on the same page, on the same field [and] on the same team," said Dean Limeri, an internal medicine and primary care physician with Ellis Primary Care in New York.

Is Video Care the Next Trend in Home Health Services?

Published by Home Health Care News
Jason Olivia
January 8, 2013

A California company announced Thursday that it is expanding its home care services with a new technological innovation that might be the start of a larger trend in home health services.

VideoCare is Homecare California’s touch-screen system that offers two-way video connection between care recipients and their families, progressional caregivers and friends. It is the latest in home care tech that the company believes will provide increased comfort for both families and care recipients.

VideoCare does not require a keyboard, mouse or any technical skill, says Homecare California, so the system is easily accessible to anyone who wishes to age in place independently.

“VideoCare is a huge complement to our traditional in-home care giving services that allows us to connect with our clients and their families much more frequently,” says Greg Hartwell, founder and CEO of Homecare California.

A family-owned company that serves San Mateo and Santa Clara, Calif. county residents, Homecare California understands the need for the well-being of seniors who want to remain in their homes.

Management of the VideoCare system is handled remotely by care managers and family members that enables access to individuals’ medication schedules, among other features that foster quality of care and individual well-being.

Aside from serving as a monitor for seniors and their caregivers, VideoCare also provides a secure internet portal to share pictures, videos or web content with family members and friends. The system can also be connected to wireless medical devices such as blood pressure units or weight scales, notes Homecare California.

“Social connection is perhaps the most important factor in keeping seniors mentally and physically healthy,” says Hartwell. “Our clients and their families can now share their lives in ways that were never feasible before. It’s like magic to our elderly clients.”

Statistics show that 72% of seniors over the age 75 do not use this type of technology, according to Homecare California’s findings.

A valuable tool for seniors, family members and caregivers alike, the company hopes that VideoCare will not only give families another way to become engaged in their aging loved ones’ lives, but also minimize the isolation many seniors experience while aging in place.

Home care shines in rural Minnesota

Published by Marshall Independent
Steve Browne
January 5, 2013

Home care has been described as the missing link of health care, the cost-effective personalized, patient-centered alternative to lengthy hospitalization or nursing home care.

There are roughly 10,000 home care facilities in the country, according to the National Association for Home Care and Hospice. Three facilities in Lincoln, Lyon and Yellow Medicine counties are rated by the Home Care Elite organization among the top 25 percent, top 500, and top 100 most successful home care providers in the nation.

The facilities are ranked according to a number of measures that include patient satisfaction and medical outcomes.
"It's a distinction that's given to agencies that rank according to a number of health care measures," said Elise Williams, director of the Tyler Home Care and Ridgeview Hospice.

Tyler Home Care was rated among the top 25 percent last year and among the top 500 facilities for 2012.

"It's not easy to show success," Williams said, "because a lot of our patients are elderly, some on the bridge between treatment and end-of-life care."

Home care facilities usually operate in association with a hospital or clinic, the difference being that the staff goes to the clients in their own home, offering services that offer an alternative to in-patient care. Typically home care personnel operate within a 30-mile radius of the facility.

"Nurses go to the home and offer services patients need," Williams said. "It could be post-surgery, medical assessments, physical therapy, medical set-ups, or help for someone home from the hospital."

Scott Lawrence is a Registered Nurse with Tyler Home Care.

"We have IV therapies," Lawrence said. "If someone has an infected knee we can help them at home instead of a facility."

Though home care clients are mostly elderly, they also include infants with health issues, and teenagers who are accident victims or have chronic health care issues.

Asking home care personnel what makes an excellent facility, a few factors come up in all cases.

One is technology.

The Internet allows rural home care personnel to keep on top of new developments in medicine. Remote monitoring equipment helps providers monitor patients conditions without having to be physically present. Once bulky and expensive medical equipment is more portable and less expensive these days.

Jody Hempel is director of Granite Falls Home Care, which Elite has rated among the top 100 in the nation three years in a row.

"We can provide Telehealth, a piece of equipment set up in the home to monitor special health issues," Hempel said. "It monitors blood sugar and pressure, heart rates, oxygen levels, weight, questions specific to a patient."

Another factor is longevity of the staff. All three facilities have very low turnover rates for nurses, LPNs, and nursing aids.

Marianne Boerboom is director of Shetek Home Care, which is affiliated with the Sanford system and has facilities in Tracy, Slayton and Westbrook. Elite rated Shetek among the top 25 percent of home care providers in 2007, 2011 and 2012.

"I have an excellent staff that has been with me for a very long time," Boerboom said. "They're seasoned, and most have been in home care for at least 10 years. I think they truly have a knack for caring for the elderly."

For many medical professionals, the slower pace and personal nature of the service is quite rewarding.

Helen Gunderson, RN, joined the Granite Falls Hospital staff in 1971 and switched to home care 15 years ago.

"I just felt I wanted a change," Gunderson said. "It was a nice change from the acuteness over there. Home care is a little slower paced. We still have acute things, but not as much as the hospital."

Home care personnel also cite the personal relationships with their clients.

"I love it," said Jenna Hempel, a nursing assistant with Granite Falls Home Care. "Just being in their homes, working one-on-one with them, I work in the Manor Home also, and it's a whole different atmosphere."

And though there are many first-ranked facilities in the major metropolitan areas, there is something about the rural environment that gives rural home care agencies an advantage.

"It's the small-town atmosphere," Lawrence said. "We know the patients and we know their needs."

Carrie Timm, an RN with Tyler, agrees.

"We have open communication with their families," Timm said.

According to Hempel, people in the community feel comfortable calling up and asking what they can do for themselves or a relative, helping the agency educate people to become proactive in their own health care and provide services prior to a crisis.

"The most cost effective way of health care is home care," Hempel said. "Maintaining people at home is where they're happiest and healthiest."

On the Way to Hospice, Surprising Hurdles

Published by New Old Age
Paula Span
January 3, 2013

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.


Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”