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News Roundup: September 16, 2016

Sheila Guither: Illinois as Medicare's home health testing ground

Published by The State Journal-Register
By Sheila Guither
September 16, 2016

Deciding what's best for a patient's health is most often, and most appropriately, addressed within the trusted relationship between a doctor and patient. But for nearly 200,000 seniors across Illinois, as of Aug. 3, important choices now require another decision maker: The U.S. government.
As the first state in the U.S. to be subject to a novel Medicare demonstration project, physicians across Illinois, who know best that Medicare home health would clinically benefit their patients, no longer have the final say in prescribing post-acute and chronic care management services that they have deemed medically necessary for their patients. Instead, a government Medicare Administrative Contractor (MAC) makes the final call. It's a move that Medicare claims will save money by reducing health care fraud, but that compliant providers, patients and advocates justifiably consider a frightening, slippery slope with potential national application.
Health care providers, and the elderly patients they serve, have come to depend greatly on the availability of skilled home health care services. This type of care, offered in seniors' own homes by licensed practitioners, allows patients to recover from serious illness, injury, surgery or recent hospitalization comfortably and at lower cost to payers than facility-based care. In fact, a day of home health costs Medicare less than half the cost of a day of skilled nursing home care. Many doctors prescribe skilled home health as a condition for hospital discharge, since the days following a hospitalization can be some of the most critical for patients, when costly complications and readmissions are most likely to occur.
But Medicare's so-called "Pre-Claim Review Demonstration Project" for home health is a game changer. With burdensome and time consuming paperwork requirements prior to a third party contractor approving a claim for home health, the result will be poor care transitions, and still further complications involved with maintaining seamless care at home. More patients will find themselves in institutional (and more expensive) skilled nursing facilities — as the path of least resistance following inpatient hospital care.
In fact, providers in Illinois have reported that physical therapy, and in some cases, nursing care for knee replacement patients has been denied. Despite physician orders, the MAC responded by saying the documentation did not show medical necessity. If skilled care ordered by a physician after hospitalization from knee replacement surgery is now deemed medically unnecessary, the patients will suffer first followed by a rise in the cost of care due to higher institutional costs.
Pre-claim review simply isn't the answer to reduce costs, and it's certainly not what patients want. A recent national poll of nearly 2,000 registered voters over age 65 found that 83 percent of U.S. seniors agree that a doctor should be able to prescribe medications and services they choose for their patients without the government interfering. Three quarters most trust health care professionals (primary care physicians and nurses) to handle issues related to their health care — compared to just 6 percent who trust government officials. Lawmakers similarly object: A bipartisan group of federal lawmakers — including Illinois Representatives Tammy Duckworth, Bob Dold and Rodney Davis in the U.S. House and Senators Dick Durbin and Mark Kirk in the US Senate — asked Medicare to scrap a similar policy altogether.
Care provided to seniors in their homes is — without question — a key element of the health care delivery system for older adults, and one that we must encourage and protect. The Medicare patients we serve are older, sicker, poorer and are more likely to be female, a minority, and disabled than all other beneficiaries in the Medicare program combined. Coast to coast, 3.5 million homebound Medicare beneficiaries depend on the Medicare home health benefit and stand to be negatively impacted if pre-claim review becomes the standard.
Providers are committed to working with CMS to find a better way — one that stands a realistic chance of reducing fraudulent expenditures without also reversing progress in patient care, savings and outcomes.
Before this policy is expanded to other parts of the country, I urge federal regulators and lawmakers to closely examine how this demonstration is impacting our state's home health community.

What Top Population Health Trends Mean for Home Health

Published by Home Health Care News
By Amy Baxter
September 16, 2016

Population health is an eye-catching phrase with a vast opportunity for the home health care industry, as providers from all settings are encouraged to work together improve outcomes for their patients. Forward-thinking home health providers are engaged in population health, and identifying emerging trends can help providers stay ahead of the curve.

However, population health doesn’t have one definition; it can be defined based on the experience of the provider and aims to improve the average patient outcome of a patient population through care coordination. What can be easily defined is the role of technology in population health and many of the trends are related to data and the ability of a provider to capture and analyze it.

Currently, the method for technology integration is very segmented, and mostly pushed forward by new regulations demanding quality measures to get a read on how well providers are achieving goals, according to Jeffrey Springer, vice president of Healthcare Solutions at health tech consulting firm CitiusTech.

“Under current regulations, technology objectives become about shiny tools, and you end up with [so many] systems that become hard to mange,” Springer said during the HIMSS Pop Health Forum 2016 in Chicago this week. “Chasing shiny objects is very common. But how do we come up with a strategy for two to five years from now? Now one knows what it will look like.”

While the future of population health is unknown as health care regulations and policies continue to come into fruition at warp speed, there are a few emerging trends in this space that health care providers should notice, Springer said.

Alternative Payment Systems

As the payment system shifts away from fee for service to a value based purchasing system, population health will likely see a boost, according to Springer. Incentivizing the coordination of care between providers is crucial to population health success.

Behavior will only change as the payment system leads the way, Springer said.

“As we move toward payment reform, ROI has to come,” Springer said. “If you follow the money, you’ll figure out the behavior patterns. There was no population health because the payment model was fee for service. Different payments drive different behavior, different types of thinking.”

For example, bundled payment initiatives drive health care providers to coordinate care and become as efficient as possible.

“It’s about being proactive and breaking down the four walls of the institutions,” Springer said.

This shift offers a great opportunity for home health to help drive those efficiencies and better health outcomes for patients once they leave the acute care setting. They way home health can become more involved it through data, which is also emerging in a new light amid the changing payment landscape.

Bottom line, top executives will have to get involved, and value must be proven in a quantitative way.

“CFOs will have to get involved,” Springer said. “Show me the ROI.”

Regulation is Increasing Data Demand
Not only do health care providers have to report more quality measures, but business decisions are increasingly becoming tied to both margins and clinical outcomes. Regulations demand more data points be reported, and those outcomes are oftentimes tied to reimbursement.

“From a regulation perspective, there are probably 300 quality measures, and more are coming,” Springer said. “That’s impossible to manage by any one provider.”

This maze of data means that integration is quickly becoming the name of the game.

“There’s nothing uglier than health care data,” he said. “All systems have different data, and you’ve got to make sense of it.”

Business Features in Data

While IT systems in the past have largely focused on gathering data and have become adopted by health care providers as regulations mandate, demand for coordinated care means technology must also integrate business goals and features that go beyond clinical data.

For example, a chief medical officer who is thinking about clinical outcomes from a coordinated perspective needs IT to support that.

“[A CMO] needs a way to engage with other providers, engage patients,” Springer said. “In a fee-for-service world, they don’t think about shared savings decisions. They need a data strategy and analytics strategy that supports that.”

CMS says 49 states have reduced avoidable hospital readmissions

Published by Modern Healthcare
By Elizabeth Whitman
September 16, 2016

Every state in the U.S. but Vermont has reduced its avoidable hospital readmission rates since 2010, new data released Tuesday by the CMS show. These improvements follow the implementation of various CMS programs and initiatives to improve the quality of care, chief among them the Hospital Readmissions Reduction Program.

The overall decrease in readmission rates translated to about 100,000 hospital readmissions avoided for Medicare beneficiaries in 2015 alone, and some 565,000 readmissions since 2010.

“The Hospital Readmissions Reduction Program is just one part of the Administration's broader strategy to reform the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality,” wrote Dr. Patrick Conway, principal deputy administrator and chief medical officer for the CMS, and Tim Gronniger, the deputy chief of staff for tjhe CMS, in a blog post Tuesday announcing the new data. “The data show that these efforts are working,” they added.

The one state where Medicare's 30-day hospital readmission rate rose was Vermont, from 15.3% in 2010 to 15.4% in 2015. The CMS described this as “virtually unchanged.” Of the states where readmissions fell, 43 saw decreases of more than 5%, while in 11 states rates fell by more than 10%. Readmission rates also dropped in Washington, D.C.

Previously released data showed that national readmission rates fell 8% from 2010 to 2015. In a 2008 report to Congress, the Medicare Payment Advisory Commission estimated that such readmissions cost Medicare as much as $12 billion annually.

The Hospital Readmissions Reduction Program was created under the Affordable Care Act. It took effect Oct. 1, 2012, cutting Medicare payments to hospitals with excess readmissions for a handful of conditions. For the coming fiscal year, those cuts are capped at 3%.

The program is rooted in the idea that unnecessary readmissions are a sign of poor quality care, and that by devising the proper financial incentives, the CMS can encourage hospitals to prevent excessive returns through better follow-up care after patients are discharged.

The number of applicable conditions in the program has grown steadily since 2012, with coronary artery bypass graft surgery as the most recent addition. Starting in October with the new federal fiscal year, hospitals will be held accountable for readmissions for that condition and five others: heart attacks, heart failure, pneumonia, chronic lung disease, and hip and lung replacements.

The CMS estimates that it will penalize more than 2,500 hospitals—more than half those in the country— for excess readmissions in the coming fiscal year. Those penalties will save the agency about $538 million, up $108 million from the year before. It expects to spend about $746 million on inpatient hospital services in the coming fiscal year.

Bill Extending Home-based Chronic Care Project Wins AAFP Support

Published by AAFP
By Michael Laff
September 16, 2016

September 12, 2016 03:07 pm Michael Laff Washington, D.C. – Many patients with chronic illnesses are limited to such a degree they cannot even leave their homes to receive health care. Without proper medical attention, such patients often require repeated and expensive care.

A CMS demonstration project called Independence at Home (IAH)( is beginning to address this situation with a focus on primary care in the home supplemented by mental health and social services. The project, which began in 2012 and was authorized for three years, recorded more than $10 million in savings during 2015,( or about $1,000 per beneficiary. At that time, it received a two-year extension to continue until September 2017.

A Senate bill, the Independence at Home Act of 2016,( would make the program permanent and remove limitations on the number of beneficiaries who can participate. AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., sent the bill's sponsors a letter on Sept. 7(2 page PDF) expressing support for the legislation.

"The demonstration is showing exactly how comprehensive, coordinated, patient-centered primary care can help improve quality and lower costs in our health care system for patients with complex chronic illness," Wergin wrote.

Fifteen practices are caring for more than 10,000 beneficiaries through IAH. These beneficiaries are among the group health policy analysts call the "five and 50" -- the 5 percent of patients who constitute 50 percent of total health care costs. Wergin noted that expanding the project would increase access for more patients with chronic illnesses.

"With nationwide expansion of the demonstration, many more practices will participate, and accordingly, many more Medicare beneficiaries with complex chronic illness will benefit from 24/7 in-home visits that are proven to reduce hospital and emergency department admissions and improve overall quality of care," Wergin stated.

Seven practices received a total of $5.7 million in incentive payments from CMS under IAH in the program's second year. Two practices in which family physicians are actively represented, Housecall Providers and Doctors Making Housecalls, each received more than $1 million.

Panelists at a recent policy forum hosted by the Alliance for Health Reform discussed how home care helps patients with multiple chronic conditions.

One physician involved in the IAH project described how his understanding of patients with chronic care needs began with house calls and subsequently developed into a more coordinated approach. Peter Boling, M.D., who started making home visits in 1984, said he saw a difference between the care patients needed and the care they received. Interaction between physicians and home health agencies was limited, resulting in a heavy dependence on ambulance calls and ER services.

Now Boling, a professor of internal medicine at Virginia Commonwealth University, is part of the Mid-Atlantic IAH Consortium. He said that during the initial comprehensive visit at a patient's home, the physician and patient need to have a frank conversation about medication.

"The only time medication reconciliation is done is at the kitchen table," Boling said.

After that first home visit, patients are seen at least once a month and they receive same-day visits for urgent problems. Boling said there is now partial funding for the social support these patients need in the home, such as calling in construction workers to install bars on shower doors or along bathroom walls for patient safety.

Because many patients who could benefit from home care do not regularly visit a physician or hospital, some might ask how they are identified.

"Lots of people in the community know who they are," Boling said. "The home health agencies know who they are. The nursing homes know who they are, and the ER doctors know who they are."

ER physicians, in particular, are aware of such patients because they often make repeated visits for ailments that were thought to have been addressed previously.

Caring for home-based patients with chronic conditions spotlights a need for more medical professionals who have experience working in integrated teams -- teams that, Wergin noted in his letter, should always be led by physicians.

"While the AAFP strongly supports team-based primary care and robust cooperation between physicians and all members of the health-care team, the AAFP remains committed to the position that such teams be led by physicians," he wrote.

Why Population Health is the Future of Home Care

Published by Home Health Care News
By Amy Baxter
September 16, 2016

Technology in home health care offers many opportunities to reduce costs, streamline care efficiencies and improve overall patient outcomes. Not only are new technologies making it easier than ever for home health care agencies to track more data, they are also enabling population health.

With numerous new payments models coming down the pike, like value based purchasing, home health agencies have an opportunity to become more involved in population health with the support of new technologies. While the fee-for-service model doesn’t necessarily support population health aims, the home health industry can become much more involved in care coordination as new incentives push integration across care settings.

“It’s an exciting time for population health,” Michael Dulin, director of the Academy for Population Health Innovation at the University of North Carolina Charlotte, said during HIMSS Pop Health Forum 2016 in Chicago. “We have the data, we have the technology, and the current system is broken.”

To achieve population health goals, there are five steps a health care provider can take:

1. Strategy

The first step any home health agency should do is to take stock of current processes, according to Dulin.

“Take inventory,” he said. “You have to know what you’re doing now.”

From there, you can formulate a strategy by identifying where the business is meeting its goals and compare against other benchmarks. Part of strategizing also involved setting new goals with population health aims, such as improving care coordination and clinical outcomes. Within this step, businesses also need to look a the scope of the work and determine what tools and resources can help achieve these outcomes.

2. Data

After focusing on a strategy, leveraging technology can help businesses gather the data they need to become preferred partners and an instrumental arm in population health successes. Data can help a home health company understand their risks, particularly patient risks, and define populations of patients.

However, collecting data is not enough on its own. More data should help predict outcomes of certain patients and enhance care pathways that can help mitigate risks.

3. Engagement

Engaging key stakeholders in new processes and IT systems is essential. Patients, providers and partners all need to be engaged with the same goals in mind, and will allow businesses to pilot new approaches.

Engaging patients in the process can help agencies understand what is working and which areas need improvement. Data can provide a qualitative assessment to enable outcome improvements.

4. Implementation

When implementing and disseminating new business strategies with clinical aims, care coordination is essential, and so is determining the point of care decision support. For home health care companies, this can mean helping patients navigate the health care system and overcome some of the social determinants of health.

Linking to other community resources and partners is another crucial element of this, according to Dulin. While Dulin maintains that many of the responsiblities of solving the social determinants of health fall within the public health domain, population health providers can help facilitate patients around those challenges, particularly home health care and community-based services providers.

5. Reflection

Once new initiatives have been put in place, taking a qualitative and quantitative assessment is the key to moving forward, Dulin said. Technology can support thee evaluations, but creating meaningful population health successes includes analyzing those evaluations for improvements.

Raising a national strategy to support America’s family caregivers

Published by The Hill
By Jo Ann Jenkins and Elizabeth Dole
November 30, 2001

Imagine the joy of welcoming home a husband from his second military deployment to Iraq, followed by the anxiety of watching him develop seizures and other signs of post-traumatic stress and a traumatic brain injury.

Or imagine a middle-of-the-night phone call letting you know that your mother has just had a devastating stroke.

Every day, events such as these catapult loved ones into a daunting, demanding new role—that of family caregiver. The new role falls to people across the lifespan: spouses, parents, children, siblings, friends, neighbors, and more. It affects just about everyone. Few family caregivers come to the job with either training or experience. They find themselves scrambling for information, and most often they wind up learning by doing, with all the stress and uncertainty that entails.

Family caregivers are the backbone of services and supports in this country – the first line of assistance helping older adults, veterans, and people with disabilities to live independently in their homes and communities where they want to be.

These unsung heroes perform a stunning array of functions: wound care; navigating byzantine legal, medical, and financial matters; providing emotional and mental health support; helping with daily tasks such as bathing, hygiene, meal preparation and managing medications.

The 5.5 million military and veteran caregivers, including those caring for veterans from the most recent conflicts abroad, are confronted with an increasing number of devastating wounds, illnesses, and disabling injuries—visible and invisible.

Nationally, about 40 million family caregivers provide unpaid care valued at $470 billion annually. To put this in perspective: the estimated economic value of this uncompensated care surpassed total Medicaid spending ($449 billion) in 2013, and nearly equaled the sales ($469 billion) of the four largest U.S. tech companies combined (Apple, Hewlett Packard, IBM, and Microsoft) in 2013-2014.

Perhaps more important, family caregivers also help delay or prevent more costly institutional care and unnecessary hospitalizations, saving taxpayer dollars.

This comes at a high cost to family caregivers. They frequently have to juggle their own careers and, often, child-rearing, with their caregiving responsibilities. Many times, they put their own pursuits and well-being on hold, while taking on the physical, emotional, and financial challenges of their caregiving roles. It takes a toll.

We find it shocking that, although family caregivers’ responsibilities are many, and the service they perform so vital, no national strategy for supporting them exists. After all, most of us are, have been, or will be, a family caregiver, or will need help in the future to live independently.

Family caregivers will only face greater strains in the future, as we continue to live longer, but with smaller families. The ratio of potential family caregivers to the growing number of older people has already begun a steep decline. In 2010, there were 7.2 potential family caregivers for every person age 80 and older. By 2030, that ratio will fall sharply to 4 to 1, and to 3 to 1 in 2050.

How can we make their big responsibilities a little bit easier? As caregivers ourselves, we know how valuable guidance, information/direction—even a helping hand—can be when the challenges of caring for a loved one become overwhelming.

Right now, the U.S. Congress has a golden opportunity to take an important step, with the bipartisan RAISE (Recognize, Assist, Include, Support, and Engage) Family Caregivers Act, legislation that would require the development of a national strategy to support family caregivers.

The strategy would identify specific actions that communities, providers, government, employers, and others can take to recognize and support family caregivers. The bill would help share evidence-based and promising practices and maximize the effectiveness of existing programs to support family caregivers. The Senate has already passed the legislation unanimously and it awaits consideration by the Education and the Workforce Committee in the House.

At AARP and the Elizabeth Dole Foundation, we believe that supporting family caregivers is a top priority for all of us. Each family caregiver’s situation is unique, but every caregiver faces the same quandaries from the earliest moments of being thrust into the role: What do I do now? Where do I start? Who’s going to help me?

Let’s take a commonsense step to help them find the answers. It’s time for a national strategy to recognize, assist, include, support and engage the nation’s family caregivers. It’s time to pass the RAISE Family Caregivers Act.

Jo Ann Jenkins is Chief Executive Officer of AARP, the nation’s largest membership organization, with nearly 38 million members. Elizabeth Dole is Founder and President of The Elizabeth Dole Foundation, an organization that raises awareness and support for the nation’s 5.5 million military and veteran caregivers.

Health Care Providers Scramble to Meet New Disaster Readiness Rule

Published by The New York Times
November 16, 2001