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News Roundup: January 25, 2013

Home Health Care Revenues to Reach $120 Billion in 2021

Published by Home Health Care News
John Yedinak
January 24, 2013

Spending on senior care services, which includes skilled nursing, home health care and assisted living are predicted to grow 5.2 percent annually and will amount to $319.5 billion by 2016 according to the Freedonia Group.

Skilled nursing saw facilities revenue come in at $106.9 billion in 2011 according to the study and are projected to grow to $126.5 billion in 2016 and $146.5 billion by 2021. Revenues for home health care services were reported and projected to be $61.1 billion, $85.5 billion and $120.5 billion for the same time periods.

The growth will be driven by the baby boomers entering their retirement years, but could be constrained by efforts at the state and federal levels to cut Medicare and Medicaid.

“There is no question that there will be an enormous growth in demand for eldercare services which will place an enormous burden on families,” declares Jesse Slome, executive director of the American Association for Long-Term Care Insurance. “Medicare and Medicaid will not be able to carry the burden without seeking additional tax revenue or forcing states to reduce allocations to other programs such as education. You just can’t have everything unless someone is willing and able to pay.”

Slome predicts the growth of interest in long term care insurance a private form of coverage already owned by some eight million aging Americans. “If you want to have some choice in your care you either have to have sufficient dollars to pay, have a family member willing to provide free care or some insurance that will cover some of the cost,” Slome explains. “People are increasingly aware of the importance and more are looking into the area every day.”

Americans Want Deficit Addressed Without Medicare Cuts, Poll Finds

Published by Kaiser Health News
Mary Agnes Carey
January 24, 2013

Most Americans want quick action to reduce the deficit, but almost six in 10 oppose cutting Medicare spending to achieve that goal, according to a new poll released today.

Lawmakers should examine other alternatives, including requiring drug makers to give the government “a better deal” on medications for low-income seniors (85 percent) and making higher-income seniors pay more for coverage (59 percent), according to the survey conducted by the Kaiser Family Foundation, the Robert Wood Johnson Foundation and the Harvard School of Public Health. (KHN is an editorially independent program of the Kaiser Family Foundation.)

More than seven in 10 Democrats, independents and Republicans say that if the President Barack Obama and Congress made the “right changes,” they could reduce the deficit without making major cuts to Medicare. Just over half (51 percent) oppose raising the Medicare eligibility age from 65 to 67, an idea discussed by both parties on Capitol Hill, and 85 percent oppose requiring all seniors to pay higher Medicare premiums.

Forty-six percent of those surveyed said they would not accept any reductions to Medicaid, the federal-state insurance program for the poor which has been a big target of Republican lawmakers. Those percentages are largely unchanged from two years ago, “suggesting the past year of debate over the need to make cuts had not greatly altered the general shape of public opinion,” the survey found.

As millions of baby boomers are becoming eligible for Medicare, the president and congressional lawmakers face tough choices about whether and how to rein in spending on federal health care programs to help reduce the deficit.

In his inauguration speech, Obama said that America must make “hard choices to reduce the cost of health care and the size of our deficit,” even as he defended entitlement programs. “The commitments we make to each other — through Medicare and Medicaid and Social Security — these things do not sap our initiative. They strengthen us,” Obama said.

The survey, conducted in early January after lawmakers resolved the “fiscal cliff” standoff, found that the public wants Obama and Congress to act to reduce the deficit, rather than waiting for a stronger economic recovery.

The support for quick action comes from Republicans (74 percent), independents (71 percent) and Democrats (57 percent), as well as seniors (73 percent) and non-seniors (63 percent).

The poll also found bipartisan support for implementing some provisions of the 2010 health care law. Fifty-five percent said it was a high priority for their state to create new online health insurance marketplaces under the law, to help people buy coverage. Support for exchanges cut across party lines, with 60 percent of Democrats, 55 percent of Republicans and 49 percent of independents backing the idea.

“Governors are largely splitting along partisan lines on the exchanges, but the public is not,” Drew Altman, president and chief executive officer of the Kaiser Family Foundation, said in a statement. “People like the idea.”

The survey found that 52 percent of Americans also think their state should implement the health law’s expansion of eligibility for Medicaid, while 42 percent did not. Support for the Medicaid expansion, expected to extend coverage to as many as 17 million people, varied by party, however, with most Republicans (66 percent) preferring to keep the program as it is, and most Democrats (75 percent) supporting expansion.

The poll, conducted from Jan. 3 through Jan. 9, surveyed 1,347 adults and has a margin of error of +/- 3 percentage points.

Researchers urge a broad-based approach to cut Medicare rehospitalizations

Published by McKnight's
Tim Mullaney
January 24, 2013

Efforts to reduce the rehospitalization rate for older patients should not strictly focus on measures tied to particular diseases or diagnoses, researchers recently proposed.

Columbia University Medical Center researchers issued their recommendation after analyzing 2007-2009 data related to rehospitalization rates of about 3 million Medicare patients who were initially admitted for heart failure, acute myocardial infarction (heart attack) and pneumonia.

Within 30 days of discharge, 24.8% of heart failure patients were readmitted, researchers found. The rate was slightly lower for heart attack (19.9%) and pneumonia (18.3%).

In many cases, rehospitalization was due to a different condition than the one that caused the initial admittance. For example, recurrent pneumonia accounted for only a quarter of the rehospitalizations among initial pneumonia patients. What this means is long-term care providers have to treat patients holistically rather than zero in on a specific illness, researchers said.

“This heightened vulnerability of recently hospitalized patients to a broad spectrum of conditions throughout the postdischarge period favors a generalized approach to preventing readmissions that is broadly applicable across potential readmission diagnoses and effective for at least the full month after hospitalization,” the researchers wrote. “Strategies that are specific to particular diseases or periods may only address a fraction of patients at risk for rehospitalization.”

The results of this study – “Reasons for and Timing of Readmission for Older Patients Following Hospitalization for Heart Attack, Heart Failure, or Pneumonia” – were published in the January 23 The Journal of the American Medical Association, which focused on the issue of rehospitalization.

Home Care Programs Rise 30% in 2011, Triggers Market Trend

Published by Home Health Care News
Jason Olivia
January 23, 2013

The growing demand for home-based services in the past several years have been fueled by an ailing housing market, technological innovations and seniors’ demand to remain in their homes, according to CliftonLarsonAllen.

The number of at-home programs offered by the largest 100 nonprofit senior living organizations in the U.S. grew by 32% between 2010 and 2011, according to the 2012 LeadingAge Ziegler 100 Fact Sheet.

A Continuing Care at Home (CCaH) program is one way entrepreneurial providers are seeking to help mold the future — in most cases by building on core strengths that have been developed over time and balancing the demands of a new and distinct service line.

An important aspect of the program is care coordination.

When developing and operating a CCaH-type program, sound actuarial pricing is key, the white paper says. Actuarial studies should include several components, such as a clear definition of the package of services and their costs; the criteria a member must meet to qualify for services; a daily cap on expenses; and the estimated future utilization of services.

Consumers can choose from various pricing options that may include a variety of co-pays for future services; home care only; long-term car insurance (LTCi) policy credit; limited total life-time benefit amount; or a refundable membership fee.

Since the CCaH concept is fairly young, the actuarial firm hired to price the CCaH program must have experience with CCRCs, CCaH programs, and LTCi, notes CliftonLarsonAllen.

The firm stresses importance on LTCi data since these insurance companies offer a variety of policies and have longer, as well as older, policy data to help validate future utilization of services.

While CCaHs are believed to help boost occupancies in other senior living residences, CliftonLarsonAllen does not find the CCaH program to dramatically influence occupancy in independent living facilities, however, CCaHs do promote transitions for seniors moving from the program to retirement community campuses.

“Moving from the CCaH program into independent living on campus sometimes depends on the financial incentives offered to members,” writes CliftonLarsonAllen.

Members of some programs even receive 90%-100% credit of their CCaH membership fee to apply toward entrance fees if they decide to move onto campus, says Pamela Klapproth, vice president of community outreach services and managing director of the Seabury at Home program in Bloomfield, Connecticut.

Originally designed to provide security for individuals placed on the program’s waiting lists, Klapproth notes that seven Seabury program members have moved onto campus since the introduction of the entry fee credit program in 2009.

“Overall, we find that most of our at-home members have different desires and interests compared to our campus residents in regards to where they want to live,” says Klapproth.

As it matures, the CCaH model will continue to have a role in shaping, refining and strengthening what has already been a successful, innovative care, writes CliftonLarsonAllen.

Why Some Hospices Turn Away Patients Without Caregivers At Home

Published by NPR
Michelle Andrews
January 23, 2013

Choosing hospice care is never an easy decision. It's an admission that the end is near, that there will be no cure.

But even after a family has opted for this end-of-life care, some still face an unexpected hurdle: Twelve percent of hospices nationwide refuse to accept patients who don't have a caregiver at home to look after them, according to a recent survey of nearly 600 hospice providers published in Health Affairs.

That doesn't jibe with the reality facing many hospice patients — roughly 42 percent of whom were living in a private home when they died, according to numbers for 2011 provided by the National Hospice and Palliative Care Organization. And it's not uncommon for elderly people, even if family members are providing their care, to be on their own during the day, say advocates.

"Lots of families can't afford to stop working to care for a patient," says Terry Berthelot, a senior attorney at the Center for Medicare Advocacy's Mansfield, Conn., office, where she works with seniors who've been denied hospice care, among other things.

Medicare typically pays most of the bills for hospice care. Under Medicare rules, patients who enter hospice care typically have less than six months to live.

Once a patient chooses to enter hospice, the benefits include medical treatment for non-curative purposes such as pain and symptom management, as well as emotional and spiritual support for patients and their families. Depending on a patient's needs, a nurse, home health aide or other hospice worker generally visits a patient on a regular basis.

When a physician orders hospice care for a patient, but the hospice refuses to provide services without a caregiver, it's usually because the hospice considers the home to be an unsafe environment, says Berthelot.

Such policies are a holdover from the early 1980s, when Medicare first began to cover hospice services, says Jeanne Dennis, senior vice president at Visiting Nurse Service of New York, which provides hospice care to 900 patients daily, among other services.

"That was one of the first barriers that many programs eliminated," says Dennis. Today, most hospices focus on making it as easy as possible to access hospice services, she says. "You don't need to have a primary caregiver at home."

The good news for patients and their families is that such restrictions are increasingly rare, says Dennis. (The bad news: As the Health Affairs study points out, it's far more common for hospice enrollment policies to discourage patients with high-cost medical needs.)

But if hospice says "no" because there's no caregiver, it shouldn't be hard to find another that will accept the patient.

"It's no surprise that people want to remain at home," she says. "We make a plan with them as best we can for a way in which people's wishes can be honored to remain at home."

In-home health monitoring to leap six-fold by 2017

Published by Healthcare IT
Lucas Mearian
January 22, 2013

Wireless remote monitoring devices will be used by more than 1.8 million people worldwide in four years, representing a six-fold increase in adoption of telehealth technology, according to a new study by InMedica, part of research firm IHS.

The study shows that in 2012 caregivers remotely monitored 308,000 people with chronic illnesses.

Of the billions of dollars spent on health care each year, 75% to 80% of it goes for patients with chronic illnesses such as diabetes, heart disease, asthma and Alzheimer's Disease, according to Dadong Wan, who leads the health innovation program at Accenture Technology Labs.

The majority of those using remote monitors were post-acute patients who had been hospitalized and discharged and suffered long-term conditions such as congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, hypertension and mental health issues.

According to InMedica, congestive heart failure currently accounts for the majority of telehealth patients, and it is one of the costliest for hospitalization. COPD is second in terms of telehealth patients. However, by 2017, diabetes is forecast to supplant COPD with the second largest share of telehealth patients. Although home monitoring of the glucose levels of diabetes patients is more often done now with personal glucose monitors, there is a push to integrate these monitors with telehealth systems, allowing caregivers access to patient glucose data.

Telehealth is seen as a significant tool among healthcare providers for reducing hospital readmission rates and to track disease progression.

Telehealth devices run the gamut, from blood glucose meters to a wireless cardiovascular monitoring device that looks like a Band-Aid.

Even telepsychiatry, or the use of secure Web-based video conferencing technology, has found a significant following among healthcare professionals.

In addition to post-acute patients, telehealth is also used to monitor ambulatory patients - those who have been diagnosed with a disease at an ambulatory care facility but have not been hospitalized, according to InMedica's study.

However, telehealth is used far more often in post-acute care patients, who are only considered for home monitoring after hospital discharge to prevent readmission. In the U.S., for example, 140,000 post-acute patients were estimated to have been monitored by telehealth last year, compared to 80,000 ambulatory patients.

"A major challenge for telehealth, is for it to reach the wider population of ambulatory care patients," Theo Ahadome, a senior analyst at InMedica, wrote. "However, the clinical and economic outcomes for telehealth are more established for post-acute care patients. Indeed, even for post-acute care patients, telehealth is usually prescribed only in the most severe cases, and where patients have been hospitalized more than once in a year."

State quality projects curbed readmissions: study

Published by Modern Healthcare
January 22, 2013

A Medicare initiative aimed at smoothing transitions of care through community-based interventions successfully lowered 30-day readmission rates and all-cause hospitalization rates among beneficiaries, according to a study.

Led by Medicare quality improvement organizations (QIOs), which contract with the CMS to lead statewide quality-related efforts, the 14-community project relied on patient coaches, medication-management strategies, home health tool kits, enhanced discharge planning and other interventions to keep patients out of the hospital.

Communities that had multistakeholder care-transition programs in place had lower rates of 30-day all-cause readmissions and all-cause hospitalizations than did comparison communities with no such interventions, according to the study, which appeared in the Journal of the American Medical Association.

Mean 30-day readmission rates per 1,000 beneficiaries in communities with QIO-led projects fell from 15.21 in 2006 through 2008 to 14.43 in 2009 and 2010, when the interventions were implemented. That’s a larger drop than was seen in 50 comparison communities, where 30-day all-cause readmission rates fell from 15.03 to 14.72 during the same periods, the authors found.

Additionally, all-cause hospitalization rates per 1,000 beneficiaries fell an average of 5.74% in the communities with care-transition programs, compared with a 3.17% average decrease among the 50 comparison communities.

Despite those differences, there was no change in the rate of 30-day readmissions as a percentage of hospital discharges, an often used metric, between the intervention and comparison groups. “In this project, the reductions coincident with the (quality improvement) work were equal for rehospitalizations and hospitalizations, thus reducing the numerator and denominator equally and leaving the rate unchanged,” the authors explained in the study.

The federal government has paved the way for many similar initiatives, they added, citing the healthcare reform law’s Community-Based Care Transitions Program and HHS Partnership for Patients, a federal initiative whose goals include a 20% drop in readmissions by the end of 2013.

Hospices, Wary Of Costs, May Be Discouraging Patients With High Expenses

Published by Kaiser Health News
Michelle Andrews
January 21, 2013

Many people who are terminally ill delay entering hospice care until just a few days or weeks before they die, in part because they or their families don't want to admit that there's no hope for a cure.

"It's a hard decision to say yes to," says Jeanne Dennis, senior vice president at the Visiting Nurse Service of New York, which provides hospice care to 900 patients daily, among other services. "Everybody knows it means you're not going to get better."

A recent study published in the journal Health Affairs found that there may be another reason that patients don't take advantage of the comprehensive services that hospice provides: restrictive enrollment policies that may discourage patients from signing up.

The survey of nearly 600 hospices nationwide found that 78 percent had enrollment policies that might restrict patient access to care, especially for those with high-cost medical needs. The policies included prohibitions on enrolling patients who are receiving palliative radiation or blood transfusions or who are being fed intravenously.

Medicare pays the majority of hospice bills, and officials have raised concerns in recent years about possible misuse of federal funds. Eighty-three percent of hospice patients are 65 or older, according to the National Hospice and Palliative Care Organization.
To qualify for hospice care under Medicare, a patient's doctor and a hospice medical director must certify that the patient has six months or less to live. Patients must also agree not to seek curative care.

Once a patient chooses to enter hospice, the benefits include medical treatment for non-curative purposes such as pain and symptom management as well as emotional and spiritual support for patients and their families. Most patients receive hospice care at home.

The Health Affairs study points out that some treatments typically considered curative also may be used to manage the symptoms of a dying patient. For example, someone might receive radiation treatments to shrink a tumor to make breathing easier or be given a blood transfusion to reduce fatigue.

But such care can be expensive, costing upward of $10,000 a month, according to the Health Affairs study. That puts hospices in a financial bind. Last year, the Medicare program paid a base rate of $151 per day to cover all routine hospice services, adjusted for geographic differences.

"It's a fixed, per-day cost that doesn't relate to the complexity of care provided," says the lead author of the study, Melissa Aldridge Carlson, an assistant professor of geriatrics and palliative medicine at New York's Mount Sinai School of Medicine.

Large hospices that care for more than 100 patients are better positioned to absorb the cost of such treatments, experts say.

"They've got the economy of scale to be able to manage high-need patients," says Diane Meier, director of the Center to Advance Palliative Care in New York and a professor of geriatrics and palliative medicine at Mount Sinai. "Smaller hospices don't have that luxury."

Nearly two-thirds of hospices care for 100 or fewer patients per day, according to the National Hospice and Palliative Care Organization.

Hospice of the Bluegrass in Lexington, Ky., cares for more than 900 patients daily.

"It gives us the capacity to not be completely money-driven, so we can afford expensive treatments," says Gretchen Brown, the chief executive.

Still, hospice operators walk a fine line sometimes in distinguishing between palliative and curative care. Medicare reviews their work closely, Brown says, and sometimes raises questions when patients are in hospice care longer than six months.

"We really can't pay for something that's going to cause someone to live longer than six months," she says.

Worries that Medicare might deny coverage for a certain treatment is truly palliative rather than curative may contribute to smaller hospices' more restrictive enrollment policies, as the study found, Carlson says.

"The risk is that . . . they'd have to return the money," says study author Carlson. "So for a small hospice, it's very risky to enroll a patient who has these needs."

Some experts question whether smaller hospices actually do turn away patients with expensive needs, even if their enrollment policies suggest they would deny enrollment to those patients.

"Yes, the hospice may have [such] policies, but the study wasn't clear to what extent those policies impact admissions," says Jon Keyserling, senior vice president for health policy at the National Hospice and Palliative Care Organization.

As a patient or concerned family member, the important message is that all hospices are not alike, Meier says. If you encounter a hospice that won't provide the care you need, "it's worth your time to explore others, particularly those that have more than 200 patients a day," she says.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.