Thursday, March 31, 2011

Face-to-face requirements set to kick in tomorrow

This from the Visiting Nurse Associations of America.  In short... bad news for home care agencies and the most vulnerable patients they serve.
VNAA Disappointed with CMS Decision and Pledges to Continue Improving Face-to-Face Requirements.

(Washington, DC) – March 31, 2011 – Jonathan Blum, Center for Medicare Management Director, notified the Visiting Nurse Associations of America (VNAA) and other national organizations via phone today that the Centers for Medicare and Medicaid Services (CMS) will stick with full enforcement of the face-to-face encounter provision effective April 1.

During the call to Kathleen Sheehan, Vice President of Public Policy for the VNAA, Blum said that CMS felt it was time to move forward with full implementation and that it would carefully monitor any problems that patients might face with access. While the face-to-face provision was put into effect on January 1, 2011, a grace period of 90 days had been granted by CMS before financial penalties for noncompliance would be levied.

The phone call was made to Sheehan in her role as the convener of a coalition of national organizations that have worked with CMS over the past couple of months to iron-out expected problems with implementation. Members of the coalition, which includes AARP, the American Hospital Association, the Catholic Healthcare Association, the American Medical Association, American Case Management Association, the Society of Hospital Medicine and the National Association for Home Health and Hospice had met with Jonathan Blum and CMS on several occasions to address implementation issues and asked that the grace period on financial penalties be extended for another 90 days to provide time to educate physicians about their new responsibilities and make system changes. The coalition's effort was unprecedented in terms of bringing together such a wide spectrum of beneficiary and provider groups behind regulations that impacts payment for home health and hospice services.

“We are deeply disappointed that more time was not provided as there was a strong consensus among diverse groups that it takes about 6 months for an educational and system change of this magnitude," said Andy Carter, VNAA President and CEO. "Our nonprofit members are most likely to take the risk of serving patients who may not have a primary care physician and may not be able to get the documentation done within the timeframe. Our goal now is to work with VNAA members and others to document and report the problems implementing this provision that will most certainly delay or limit access to care for some patients. ”

Carter also noted that while VNAA members and the Face-to-Face Coalition were not able to win a further grace period, they have worked hard to convince CMS to make the implementation less onerous and that they will continue to do so.

For more information, visit the VNAA's Face-to-Face Webpage

Wednesday, March 30, 2011

Co-pays for home care

The Massachusetts Home Care Alliance hosted an event for members of the Massachusetts elected delegation and their staffs. I had an opportunity to address them. Here are my remarks:

Thank you for the coming to our luncheon today and for this opportunity to speak to you about home health care.

I am Rey Spadoni, the President of the Visiting Nurse Association of Boston... an organization that is celebrating, this year, our 125th anniversary as the very first home health care provider in the United States. In the late 1800s, a group of bold and visionary women took note of the unmet needs of the most vulnerable members of the Boston area community... the individuals who were falling through the cracks of the then emerging network of infirmaries, clinics and hospitals. We are most pleased to be able to say that their vision is alive and well in our organization a century plus later as we continue to fill in those gaps for those among us who are, in fact, the most vulnerable.

I begin my comments by expressing our gratitude for all that you, your colleagues and our entire elected delegation from Massachusetts have already done for these members of our community and the agencies such as the VNA of Boston who care for them. Thank you for making us in this room the envy of our colleagues from 49 other states.

I also want to acknowledge that in my almost 30 years of working in the health care industry, I've never seen it like this before. It's a time of great change... and great stress.

There's no doubt that every one of us in this room believes in the importance of ensuring high quality home care services. Services that are good, dependable and consistent. There's also little doubt that all here believe that it's important to ensure access for every single person in our community.... whether they are people of means or people who struggle. But now, the third leg of the stool, the cost of health care, is front and center. Reigning in the escalating costs of health care has emerged as critical to not only preserving the health care system, but also in helping to address the larger economic problems and even long-term fiscal viability of our nation.

We certainly get that.

In the years I've worked in this industry, I have come into this building... sometimes talking about the issues of the acute care hospital industry, sometimes post-acute hospitals and on one occasion, the needs of federally qualified community health centers. On each occasion, I offered perspectives... perspectives you are all very familiar with... that each segment of the industry I represented at that time had unique needs and that we were part of the solution, not part of the problem. The points I made were legitimate.

But as I come here today to talk about organizations such as the VNA of Boston, I would like to point out two important differences between home care and the other parts of this industry.

First, we keep people out of those institutions. We keep people where they want to be most of all... in their own homes... living as independently as they are able... keeping families together... and providing dignity.

In the home care industry, we don't talk about the fixed costs associated with brick and mortar construction projects and we don't need to recoup R&D dollars associated with new and costly diagnostic technologies. We keep people out of those settings and in their own homes.

The second point relates to the fact that patients are being discharged more quickly and sicker than ever before from the hospital. Across the United States, 29% of all home care patients are readmitted to the hospital because their medical condition has deteriorated. At the VNA of Boston, that figure is 25%. It's 25% because we invest in training for our staff, focus on medication reconciliation, and deploy remote technologies into homes so that we know right away when a patient's condition requires immediate follow-up care. That 4% difference spread to larger populations... that is... paying for home care services instead of hospital readmissions, is a critical component of cutting overall costs in the health care industry. It is also a vital component of the emerging Accountable Care Organization movement.

If you or your colleagues have never been on a home care visit, I would like to invite you to accompany one of our skilled nurses or therapists on one. I guarantee that it will be eye opening and that you will enjoy it.

If you have not been on a home visit, I would like to tell you about one I recently made.

Pat, a 20-year home health veteran nurse, and I traveled together out to perform an admission of a 59 year old man named Richard. Richard lives alone in a large apartment complex in Quincy, Massachusetts. I learned upon arriving in his small three room home that Richard was honorably discharged from active service in Viet Nam when he sustained a nearly life-ending injury serving this country. The reason for our visit was due to a recent orthopedic related hospitalization, but the home care admission process requires a very thorough examination of a whole variety of health related topics... and thank goodness for that for Richard.

I couldn't help but notice as we entered his apartment that there was visible evidence of great patriotism everywhere, as well as signs of a hobby constructing intricate small scale models of 18th century ships. I subsequently learned that this was a long past hobby due to the advancing arthritis in Richard's hands. I also could not help but notice the multitude of prescription bottles on the coffee table in front of us. Because of Richard's arthritis, he can't contend with child-proof caps and so all bottles were open, with several tipped over, leaving a multicolored array of pills before us.

As I said, it's a good thing that the home health admission process calls for a thorough evaluation on a number of issues because it was during that process that Pat discovered a significant discrepancy between the medications listed on his hospital discharge summary and the one his primary care doctor had given him just a few months earlier. When questioned, Richard appeared to be confused over exactly which set of prescriptions he should be following. Rather than spending 45 minutes in his home, Pat and I were there for nearly two hours. During that time, Pat contacted the hospital staff first and then the nurse practitioner at the medical practice where his doctor works. She sorted through the complex set of drugs, focusing mostly on the ones he takes for diabetes, and ultimately came up with not only a game plan but also secured an appointment for him very next morning with his physician.

As she was on the phone dealing with this, I learned more about Richard. I learned about the reasons he is now homebound, I learned about the challenges he faces... including financial... and I saw firsthand just how much he trusts the VNA.

As we walked out of his apartment, Pat told me that it was likely that Richard would have experienced a significant medical problem, diabetes related, within days caused by the medication confusion. That problem would have most assuredly resulted in an ambulance ride to the emergency room and a 2 or 3 day hospitalization. That trauma, those additional expenses, were all avoided. Matter of factly, Pat told me "it happens all the time" as we drove away.

It happens all the time.

And so, I wanted to tell you about a proposal to levy $150 co-payments per 60 day episode of care upon patients such as Richard. MEDPAC has suggested the institution of these co-pays as a way to control Medicare spending.

When our nurses, who care for patients in the poorest neighborhoods of Boston, hear about this suggestion... they roll their eyes and tell us that most... most... of their patients will not pay them. They will prioritize paying for their prescriptions, their rent and food before they will pay for home care services. For most of our patients, age 80 and above, they are already spending 30% of their limited incomes on uncovered medical care.

At the VNA of Boston, we support initiatives that foster a greater degree of engagement and participation in health care decisions and costs... which co-pays are designed to do. But we have evidence that they are not the answer in home health care... having been tried before and eliminated in the 1970s when they were found to increase inpatient spending.

A recent "New England Journal of Medicine" article profiled 900,000 Medicare Advantage beneficiaries and the impact of new ambulatory visit co-pays. They found that for every $7,000 saved through the adoption of the co-pays, inpatient costs increased $24,000. Patients avoided the ambulatory visits, their health status had worsened... and their care cost our system more. Not only do co-pays not work for this population, they backfire.

We need your active help in preventing this mistake from happening once again.

Co-payments are short-sighted. They are ineffective. And unfortunately, they are cruel.

Please join in our fight to prevent them.

Thank you...

Sunday, March 27, 2011

The Cherry Blossom Chill

This weekend marks a most welcome start to the annual Cherry Blossom Festival in Washington, DC. This yearly rite ushers in expectations of warmer weather, sunnier skies and bursting beauty to offset the declining frost and grays of the season just ended. We sense great hope, we anticipate, and we are optimistic.

But as I peck this post onto the onscreen keyboard of my iPad (yes, I'm in Airplane Mode; I'll upload when we land), I wonder about the snow that is now falling in the city of blossoms. Our pilot just instructed us to expect a choppy ride as we descend into wintry conditions.

This weekend also marks our annual trek to Capitol city with our National Association for Home Care & Hospice colleagues to plead our case to elected legislators and the surrounding multitude of policy makers, regulators and analysts.

I recall last year at this time...

Rumors of forthcoming cuts to home health care reimbursement prevailed and so we readied strategies of pointing to evidence that home care is the solution... not the problem... in terms of escalating health care expenditures. On paper, we looked good. We were hopeful and we were optimistic. And we had good reason to be. Everyone who met us on The Hill told us they were on our side. They described themselves as The Good Guys and our hearts warmed a little to be surrounded by so many good guys. We clapped and cheered at luncheons and patted each other on the back in front of cheese trays and regal china.

But then the cuts did come...

And for organizations such as the VNA of Boston, agencies who don't skim off the topmost layer of best-paying customer cream, we reeled. We planned for difficult days and we hunkered down and readied for the storm. But would the storm linger... or pass by quickly?

That is the question as we prepare to descend into the wintry conditions of the "rebasing" and "copayment" talk now in DC. Talk that portends of more cuts.

And I fully anticipate I'll meet up with The Good Guys once again. They will tell us we are preaching to a choir and that our fight is with others. But our message this time is to enlist them in this fight, to request their entry into our fray.

The most vulnerable among us need that. The ones who are homebound... and who rely upon us to be their voice... deserve that.

Otherwise, it will all... once again... be merely frost upon a cherry blossom spring.

- Posted via BlogPress/iPad

Friday, March 4, 2011

A Day on the Hill...

This time, it was on Beacon Hill, the location of the Massachusetts Capitol and home base for the Commonwealth's government officials.


I, and two of my VNA of Boston colleagues, attended a reception hosted by our local association, the Massachusetts Home Care Alliance.  Our positions:

  • Allow trained and certified home health aides to administer certain medications in the home.
  • Change how specific home health services are reimbursed, including paying for telehealth.
  • Establish a more equitable rate of payment of home care agencies providing continuous skilled nursing care to children.
  • And most importantly, create reasonable reimbursement rates for services provided to Medicaid recipients.


Pictured: Maria Dunn, RN,, clinical manager, and Janice Sullivan, vice president of external affairs.


From our meetings with representatives, it's clear that the process to develop a comprehensive and unified health care cost containment bill will be long and contentious.  Despite Governor Patrick's proposals, it's likely he will have a long road ahead of him to push through the reforms that his bill contains.  Some members of the legislature perceive that the Governor seeks a quick victory on this topic to aid in this emerging national role in pushing the President's own health reform law across the country.  And not everyone's willing to play it seems.

Then again, no one predicted that the Massachusetts legislature would give then Governor Romney a health care victory he could tout for his own presidential ambitions.  The Democrat controlled legislature did just that for the Republican governor... so, a decisive win for Governor Patrick could certainly still be in the cards.

Door to door scams still exist

I was just visited at my home by a pleasant young man asking if he could see a copy of my most recent gas and electric bill.  He said he was here in partnership with my energy companies.  In fact, he noted, his company, "Just Energy", was doing this service for the energy companies' customers by switching the "underlying supplier" of the energy to a cheaper and greener source.

When I told him I was uncomfortable with giving this information to a stranger, he asked me whether I was uncomfortable with saving money.  Uncomfortable with saving the planet.

Uhm... red alert.

A google search pointed out quite a bit about "Just Energy".

To which I reply, just be careful