Tag: Long Term Care

An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week

A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.

Now, not everyone believes that a shortfall of PCPs is a serious problem.

However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.

So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.

I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.

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Stepping Up to the Long-Term Care Crisis

It starts with a call that a loved one is in the hospital after being in a serious accident. Sometimes it comes from having chronic health conditions that minimize daily functioning as one grows older. These life-changing events present individuals and their families with a new set of needs and challenges that require a variety of human capital and financial resources to redefine and maintain daily living on their terms.

The likelihood that you or someone you love will need this kind of support is greater than you may think. While nearly all Americans hope to remain in their homes as long as possible—enjoying good health and living independently—the reality is that 70 percent of people over 65 will need some form of support to assist them with daily activities at some point in their lives, for an average of three years.

Over the next two decades, Americans will reach that milestone at a rate of nearly 8,000 a day. The older people become, the more likely they will need long-term care, and with advances in medicine and technology, we are living well into our 80’s and 90’s.

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Refocusing Long-Term Care on People: The Three I’s  

Both participants and caregivers in long-term care programs face a myriad of difficulties. Participants with long-term services and supports needs often have many health issues, meaning they are in constant transition between care environments and providers with their needs ever-evolving. As a result of visits to a number of doctors on a regular basis and the number of providers who support them, the participant’s information lives in multiple locations. This can lead to discrepancies between providers and the participant having to constantly provide the same information.

Caregivers, especially family members, are also facing great challenges. It’s a full-time job to care for someone in the home – it takes nearly 40 hours a week – and searching for a trusted service provider to take over can be another job in and of itself.

The root of the problem is that many long-term care programs are focused on the providers and not necessarily the people – those receiving the services and those providing them. Often, no one has the full picture of the participant’s health, which can lead to suboptimal care. An ideal situation is for everyone involved with the participant to be up-to-date and have a full-picture of their health and well-being at all times. When they are, services can be administered effectively with less risk for everyone involved.

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Congressional Research Service: Courts Could Force HHS to Implement CLASS Act, Despite Its Insolvency

Today, the U.S. House of Representatives will vote on H.R. 1173, the Fiscal Responsibility and Retirement Security Act of 2011, sponsored by Rep. Charles Boustany (R., La.). This two-page bill would repeal the fiscal disaster known as the CLASS Act, Obamacare’s new long-term care entitlement, which was “suspended” by the Obama Administration because Health and Human Services Secretary Kathleen Sebelius could not certify that the entitlement was fiscally sustainable. Why, you might ask, should Congress bother to repeal CLASS, given that Sebelius has suspended its implementation? Because, according to the Congressional Research Service, courts could force her to implement the new entitlement, despite the fact that it will blow up the deficit.

According to the text of the Affordable Care Act, Secretary Sebelius is required to “designate a benefit plan as the CLASS Independence Benefit Plan” by October 1, 2012. Back in November, the House Energy and Commerce Committee asked CRS to evaluate the question: based on this language, could advocacy groups file suit against HHS for failing to implement the program? Would a court be likely to side with these plaintiffs? According to CRS, it’s a real possibility.

“If the Secretary does not designate a plan by October 1, 2012,” write the CRS staffers, “this failure to act would appear to be the type of agency action that could be challenged under the judicial review provision for agency action unlawfully withheld.” A court could grant deference to Sebelius’ finding that the program was unsustainable, but it could also force implementation of CLASS by “declaring the Secretary in violation of 5 U.S.C. § 706(1) or issuing a write of mandamus to compel agency action, thus requiring the Secretary to renew her efforts to create a plan that is consistent with the statutory requirements.”

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Eliminating Medication Waste in Long-Term Care Can Help the White House Pay for its Health Plan

Corkern2 The news of an $80 billion White House deal with drug companies to lower Medicare drug costs targets $30 billion in savings for consumers covered by Medicare Part D, but the sources of the remaining $50 billion in savings that is supposed to accrue to the government “have not been identified at the moment,” according to an Administration spokesperson.

With the Administration scrambling to find ways to pay for a much-wanted healthcare package estimated to top a trillion dollars in just 10 years, every few billion in potential savings counts.  That’s why the government should take a close look at the extraordinary amount of medication waste that is literally flushed down the toilet every year in long-term care (LTC) facilities.

The United States spends an estimated $1.25 billion annually on direct cost of wasted medications in LTC settings – and this is before the Baby Boomer generation has entered the scene.  Long-term care facilities, pharmacies, wholesalers and manufacturers are expected to incur an additional quarter billion in costs annually due to the labor, distribution and operations costs for distributing and disposing of unused medications.  Throughout this process there are 800,000 medication errors made every year in these facilities.

In February of 2009, The American Society of Consultant Pharmacists (ASCP) surveyed its membership – pharmacists that work in the LTC industry – on the topic of unused medications.  The top three concerns of respondents were preventing diversion, developing cost-effective disposal procedures, and reducing the overall amount of pharmaceutical waste.

Where does all this waste and error originate?  A majority of the approximately 17,000 LTC facilities in the U.S. receive medications in punch cards, cassettes, and/or unit-dose packaging that are delivered on a daily basis by a local or regional offsite LTC pharmacy.  These medications are predominately covered through Medicare Part D.

The most prevalent type of packaging is disposable 30-day punch cards, often referred to as “bingo-cards,” which are sent when the prescription is ordered and every time it is refilled.  However, when a prescription is discontinued or the patient is transferred, discharged, or passes away before the supply is exhausted, the unused medications are either destroyed onsite or sent back to the pharmacy.

However, the ability to return and credit unused medications was not addressed when Medicare Part D was created.  And, because no electronic claim crediting process is available, pharmacies must bill upfront by dispensing the entire supply of medications, up to 30 days, with any unused medications becoming waste.  The pharmacy gets paid either way, because there is no incentive to offer credit for unused medication.

A pharmacy that wants to offer credit for unused medication must use what is known as post-consumption billing – but this requires a hassle that creates cash flow delays and reporting burdens that make it all but impossible to manage.

Baby Boomer demographics indicate long-term care facilities will soon be the new epicenter of spiraling medication costs, and the waste occurring today is astounding.  Medication distribution systems in LTC have not fundamentally changed in decades.  In addition, the current systems are riddled with errors that cost untold billions, and our environment is tainted with unused medications that are flushed or incinerated ever year.  The only group that really benefits from this mess is the pharmaceutical companies.

The U.S. taxpayer can no longer afford the status quo.  While policymakers have their sights set on major reform, they should pursue the needless waste that is growing in this segment of healthcare.

To do that, policymakers and regulators should look for ways to increase automation of medication dispensing in long-term care facilities.  This process is well established in acute care settings, where waste has been virtually eliminated and patient safety has improved dramatically.

Now is the time to incentivize long-term care facilities and the pharmacies that serve them to replace the status quo with systems that will free up taxpayer dollars for health reform, and deliver safer care to our rapidly growing senior population.

More on long-term care reform:

Carla Corkern, is CEO of Talyst,
Bellevue-based automated medication-management company. Previously she worked as
chief operations officer at aerospace supply-management company Vykor,
overseeing areas including software development, customer support.

Nursing Homes Get Old for Many With Disabilities


ST. LOUIS — Melody Ping never thought she would be trying to moveout of a nursing home. She lived in a St. Louis apartment for 19 years and worked as an
accountant until two years ago, when she lost her job. Ping, who has
multiple sclerosis, couldn't find new work. When her unemployment ran
out, she ended up on Medicaid in a nursing home.

Ping, 51, is among tens of thousands of people nationwide who want to
live on their own, but instead remain in nursing homes, rehab centers
or state hospitals, often at a higher cost to taxpayers because of a
historic bias toward institutional care.

Ten years ago today, the U.S. Supreme Court said that
bias amounted to discrimination
. Now, as disability advocates
celebrate the anniversary of that landmark ruling, they worry the Obama
administration is backing away from a pledge to give more people with
disabilities the option to live at home.

As a senator, Barack Obama co-sponsored the
Community Choice Act, pending legislation that would give
Medicaid recipients equal access to services in the community and not
force them into institutions. But the administration recently said it would
not address the issue
as part of its proposed health care

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Reforming Long-Term Care and Post-Acute Care Could Save Billions

Tumlinson Anne_46025_46026

Despite the extreme inside-the-Beltway focus on healthcare reform, there’s been hardly a mention of tackling reform of our long-term care system.  This is curious when you stop to consider that these services are used by the same seniors who use the most healthcare resources and that they account for hundreds of billions of dollars of personal and federal spending.  Our existing system strains already-stretched government resources and family networks and will become only more expensive as our nation ages.

A new report finds that a proposal to reform Medicare post-acute care could provide the funding needed to reform the long-term care system, resulting in overall savings of $35 billion over ten years—all the while improving efficiency in our post-acute care (PAC) system and creating a new, consistent, voluntary long-term care (LTC) benefit for seniors.

Reforming PAC is, in simple speak, a must-do.  Currently, Medicare payments for post-acute medical care – the kind of care that follows a stroke or major fall – are first based on where the care is provided, not on the actual patient condition and needs. There is widespread bipartisan agreement that reforming this disjointed, inefficient payment system could enhance care while also adding a healthy dose of spending discipline to Medicare. In addition, this could be a great area to showcase better evidence-based decision-making.

The question becomes what to do with the money generated through PAC reform.  The proposal at hand – which was developed by the American advanced by the American Health Care Association, the National Center for Assisted Living, and the Alliance for Quality Nursing Home Care – directs those savings toward the creation of a new, fully federalized, and voluntary LTC benefit system.

And there is certainly rationale for reforming LTC financing.  The nation currently spends more than $230 billion annually on a LTC system that inadequately protects today’s senior population from the financial devastation of a long-term disabling condition such as Alzheimer’s disease or stroke.  Seniors often rely on their savings, home equity, or children to pay for their care.  In the current economic climate, these sources of financing have proven to be a house of cards rather than a stable foundation—a problem that will gain urgency as the Baby Boomers swell the ranks of our Medicare population and families slowly recover from deep financial losses.

Specifically, the proposal seeks to combine PAC with LTC reform through the following measures:

  • Creation of a new, site-neutral Medicare payment system for post-acute care based on patients’ conditions and medical needs. Decisions would be based on more evidence using a standardized patient assessment tool.
  • Creation of a fully federalized, voluntary, catastrophic long-term care benefit. Medicaid would no longer pay for LTC for seniors.
  • An increased amount of private funds used for long-term care services. Individuals would share the cost burden of the new LTC benefit in the form of a personal responsibility allowance, scaled to income.

Using methods and assumptions similar to those employed by the Congressional Budget Office, Avalere Health built a model to assess the federal costs of these changes. According to the results, these Medicare PAC reforms would likely generate $81 billion in savings over 10 years of operation through more cost-effective placement of Medicare patients in PAC settings.  Those savings would offset the costs of launching a federal LTC program, which by Avalere estimates would cost $46 billion over 10 years.

The total 10-year program savings is $35 billion.

Any meaningful reform effort will involve a careful analysis of choices, policy options, and trade-offs.  This report illustrates how these types of tradeoffs and investments could play out—this time using PAC savings to fund urgently needed improvements to our LTC system.   It is precisely these types of policy choices that will guide this new chapter in national healthcare reform.

Anne Tumlinson has nearly two decades of experience in long-term care financing policy. She is currently a vice president at Avalere Health, directing research and analysis on post-acute and long-term care policy for government, foundation, and commercial clients.  She has co-published work with health reform experts including Jeanne Lambrew.