Health Care Reform: Is it working?
Health care spending in 2009 and 2010 grew at the slowest rates in 50 years. This is startling news given that health care spending has been in double digits forever! The information was reported by the Centers for Medicare and Medicaid Services (CMS). They attribute it to a shrinking economy. However, overlooked in the discussion is the lower spending that is projected through the end of the decade due to health reform. The health providers are beginning to shift their practice approaches in response to new incentives under health reform. Predictions that health reform or the Affordable Care Act (ACA) would fail to control costs and, in fact, accelerate spending have not been borne out by the early experience.
The reduction in projected national health spending is particularly important because the pre-reform estimate of health care costs were estimated to be much higher. The new projections for both the costs of covering the uninsured and Medicare spending are substantially below pre-reform estimates. These results are very positive and indicate that our health care system, although still expensive, is changing for the better.
New ACA and CMS initiatives that change delivery approaches and incentives have contributed to slower spending growth. As a result of the ACA, CMS has established some very creative system changing programs. Most notable are the Partnership for Patients that enhances safety methods, performance benchmarks, and high-value care. One of its programs focuses on the Community Based Care Transitions. Another focuses on safety in acute care hospitals, especially infections. The Care Transitions program is developing around the country with a $500 million incentive. Here in northern Nevada, it is my Center for Healthy Aging that is the Community Based Organization working with a coalition of hospitals, home care, care management, skilled nursing, social and senior services to provide more continuous care post acute hospitalization. This program will cut additional Medicare population re-hospitalizations and save millions.
Another system changing program just beginning is the CMS Health Care Innovation Challenge. CMS is providing one billion dollars to fund innovative programs that provide better care, better health, and at a lower cost. I am involved in this initiative as well, along with many others from Nevada. ROYL (Rest Of Your Life) planning is a web-based program that facilitates advanced care directives, designation of a surrogate power of attorney, and living wills for health affairs. All of this information will be accessible by electronic platforms and application technology. In addition, ROYL will provide Health Assistants that will serve as coaches to help people fill out the necessary documents so that their wishes will be adhered to if a health crisis occurs. Who doesn’t want to control their own lives? Yet only 30% of us have advance directives and only 20% of those that have the documents are actually used. This program, if funded through CMS, would change that. Our goal is to have 80% of the Medicare population have the advanced planning done and that it would be accessible to any health care provider. This in turn would provide millions in savings for the Medicare system.
Other health system changing CMS programs of the ACA are Accountable Care Organizations, Money Follows the Person, Medicaid Health Homes, Balancing Incentives Program, Independence at Home, Senior Medicare Patrol, Stop Medicare Fraud Now, and others. CMS and many private health and community organizations throughout the US are working together to find ways to make our health and medical care system function more effectively and efficiently. Ultimately these changes will integrate acute and chronic care, medical and social services, and provide for better care, better health, and at a lower cost.
On a similar note, a recent study sponsored by the Robert Wood Johnson Foundation revealed that 85% of physicians say that unmet social needs lead to worse health outcomes and only 20% of the doctors felt confident in helping their patients meet those needs. Some of the examples of social needs are transportation, meals, adaptive equipment at home, or social services for frail elders living at home. It is no surprise that physicians do not address these, nor Medicare or insurance since they are not reimbursable services. Three quarters of the physicians surveyed said that the health system should reimburse for at least referring their patients to social services…And how about reimburse the direct service as well. Actually, some of the new ACA programs, such as the medical home or transitional care services, can reimburse for certain social services. So stay tuned.
Is health reform working? Well, as recent data suggests staying the course toward a high performance health system shows a lot of promise. It will be particularly important to deploy all of the tools in the ACA to build on the positive results to-date and ensure that beneficial services are provided that “add life to years”, while duplicative, preventable, and unnecessary services are eliminated.
Lawrence J. Weiss, Ph.D. is CEO of the Center for Healthy Aging. Dr. Weiss welcomes your comments on this column. Write to him at larry@addinglifetoyears.com or c/o Center for Healthy Aging, 11 Fillmore Way, Reno, NV 89519.
Giving and Forgiving
It is the season to give, is it not? Christmas time is special. I remember as a kid getting gifts from Santa Claus. I do not remember giving gifts as a child. It was fun, but what message do we give to our kids. Giving is the key. It can be contagious. Haven’t you found yourself receiving a small courtesy favor like someone letting you in the grocery line before them, which in turn you pass on this giving of a small gift to someone else, and so on…”paying it forward”. Isn’t this what the holiday season is all about? Giving and not receiving.
On another note, the holiday season is time for loved ones – family and friends to get together. But many feel unrest, bitterness for something that happened in the past, stress, and even anger that exists between family and loved ones. Someone hurts you with a behavior or comment. You savor and harbor that bad feeling, feeling unloved, or even feeling that they wronged another person with a mean, unloving comment or behavior. The result is bad juju, bad feelings, and angry relationships and, ultimately, ill health.
Recently, I had the pleasure of participating in an educational session with Dr. Bob Weber from Harvard Medical School. He educated me on the importance of gratitude and forgiveness and their importance in aging well. Since my column is devoted to “adding life to years”, how does giving and forgiving relate to aging and the quality of life? A question very appropriate for the holiday season!
According to Dr. Weber and others, the secret to aging well is developing the capacity to give, be thankful, and forgive. Researchers in the behavioural sciences are discovering the importance of giving and forgiving in healthy aging (e.g., Seligman, 2002; Vaillant, 2001, 2002). For example, Dr. Vaillant (2001) analyzed data from a longitudinal study of Harvard graduates and drew the conclusion that “despite what Freud said, personality is not formed by age 5 or even age 45. After 60, age brings increasingly more adaptive coping mechanisms, a wider social awareness, and better marriages. In short, the study participants who have aged most successfully are those who worry less about cholesterol and waistlines and more about gratitude and forgiveness.”
Certainly cholesterol and waistlines are important to aging well, but according to these scholars our perception and attitudes about giving, being thankful, and forgiving are even more critical. This positive approach places emphasis on healthy functioning of the individual, emphasizing hope, togetherness, giving and altruism. Seligman’s research suggests that a person’s happiness and life satisfaction grow as he/she increases the sense of gratitude and giving.
Certainly the importance of gratitude and giving in achieving life satisfaction and aging well is understandable, at least more than forgiveness. Forgiveness is complex, but let’s explore it. First it is important to understand what forgiveness is and is not. According to Dr. Weber, forgiveness is not pardoning, condoning, excusing, forgetting, denying, or reconciliation. Dr. Enright and others define forgiveness as “a willingness to abandon one’s right to resentment, negative judgment, and indifferent behavior toward one who has unjustly hurt us, while fostering the undeserved qualities of compassion, generosity, and even love toward him or her.”
A longitudinal study by Matby, et. al. (2008) showed that people who were generally more neurotic, angry and hostile in life were less likely to forgive another person even after a long time had passed. Studies show that people who forgive are happier and healthier than those who hold resentments. The first study to look at how forgiveness improves physical health discovered that when people think about forgiving an offender it leads to improved functioning in their cardiovascular and nervous systems. Another study at the University of Wisconsin found the more forgiving people were, the less they suffered from a wide range of illnesses. The less forgiving people reported a greater number of health problems.
Dr. Luskin’s Research at Stanford University shows that forgiveness can be learned. His work is based on seven major research projects into the effects of forgiveness, giving empirical validity to the concept that forgiveness is not only powerful, but also excellent for your health.
So, what can we do about achieving forgiving? Worthington (1998), developed a therapeutic format in which he uses a model called “REACH,” to deepen people’s capacity for forgiveness. REACH is an acronym for the five steps involved in order to develop forgiveness: R—Recall the hurt in detail; E—Empathize with the offender to the extent possible; A—give the Altruistic gift of forgiveness; C—Commit yourself to forgive publicly; and H—work to Hold onto the forgiveness you have begun to develop. No doubt Worthington developed this approach as a result of the brutal murder of his elderly mother by two young intruders during an attempted robbery and his struggle to deal with the heinous crime and in turn to forgive them.
Certainly through the research mentioned above and my own personal experience of the power of achieving true forgiveness contributes significantly to healthy living and aging. Enhancing the capacity to forgive and give should be foremost for this time of year. Incorporating them in to our lives (although not easy) adds a very powerful force for effecting change in our lives and promoting greater well-being in living and aging. Clearly giving and forgiving “add life to years.” Cultivate these qualities yourself during the holiday season, it will be contagious.
Lawrence J. Weiss, Ph.D. is CEO of the Center for Healthy Aging. Dr. Weiss welcomes your comments on this column. Write to him at larry@addinglifetoyears.com or c/o Center for Healthy Aging, 11 Fillmore Way, Reno, NV 89519.
Re-Hospitalization is a Major Medicare Healthcare Problem: Is it Solvable?
I have written about this in the past, but this is too important to let lie. One in five Medicare elders who are hospitalized and discharged end up back in the acute hospital within 30 days! These readmissions or failed transitions in care lead to substantial increases in costs, morbidity, and mortality. It has been estimated that this readmission problem costs Medicare over $15 billion each year.
Avoidable readmissions and patient dissatisfaction with discharge care are growing problems nationwide. Of those Medicare beneficiaries who are readmitted within 30 days, 64% received no post-acute care between discharge and readmission. Combine that with mismanagement of medications and other causes for re-hospitalization, the leading experts believe that a total of 76% of readmissions may be preventable. Furthermore, research from the Centers for Medicare & Medicaid Services (CMS) shows beneficiaries report greater dissatisfaction in discharge-related care than any other aspect of care CMS measures. For Nevada, a readmission costs Medicare an average of $9600 and Northern Nevada has about 4,314 readmissions a year. You figure the cost benefit of reducing these!
Additional research shows that the majority of readmissions were medication related (66%) and 50% had lab results that were still pending at discharge (Roy, et.al., 2005). Clearly, this returning to acute care hospital is a major Medicare healthcare problem, but it is solvable.
In the 1980’s, Medicare started to reimburse hospitals to cut costs by diagnosis related groups (DRGs). This meant that hospitals would not be paid based on number of days the patient was in an acute bed, but by episode or DRG. The hospitals accommodated this method of reimbursement by getting the patients in out of the acute bed as fast as possible, usually “quicker and sicker.” Unfortunately, the hospital care would only include services up to discharge AND if the person came back within 30 days they could not get reimbursed again if the diagnosis was the same. However, for the normal Medicare person coming into the hospital, they would have several chronic illness problems, so when readmitted, the hospital would use another diagnosis and they would get reimbursed again. Therefore, the hospital had no incentive to provide post-acute care or any transitional care that would keep the person in their community or home.
This has all changed with the health reform law, the Affordable Care Act (ACA) Section 3026, signed in 2010. The law requires hospitals to change their discharging practices to include more thorough processes in transitional post-acute care to prevent readmissions to the acute hospital within 30 days. Several research and healthcare organizations have developed evidence-based services that are very effective in curbing the readmissions.
I have personally been working in the area of integrating acute and chronic care for years by establishing continuums of service and employing a care coordinator or “transitional health coach” to help the frail, chronically-ill elder Medicare beneficiary and the family or caregivers.
The problems associated with poor transitions of care and 30-day hospital readmissions are not solely the responsibility of a community’s hospitals. They are often the result of a breakdown in the transfer of information and communication between providers and patients at the time of discharge or transition, a failure to assure the patient and/or caregiver can manage their disease(s), and a lack of standard known processes to effectively manage patients’ transitions from one setting to another.
The Partnership for Patients Community-based Care Transitions Program (CCTP) under CMS is focusing on processes of care at a community level that engage providers and stakeholders across the continuum of care, not just in the hospital. This includes home health and hospice agencies, nursing homes and physician offices, as well as patients, families and other social or health service community stakeholders.
I am very excited to report that the Center for Healthy Aging has been designated by the Senior Coalition and a group of Northern Nevada hospitals, physicians, home health, and other health and social services as the Community Based Organization (CBO) to link the at-risk, chronically-ill Medicare elders to the “Transitional Care” services to keep them out of the acute hospital. We are working with Geriatric Care Specialty, Care Management Associates, and IntegriCare Clinical Associates, and several other medical, health, and social service organizations in seeking funds to develop this transitional care program, including a CMS application to provide this service for Northern Nevada Medicare beneficiaries.
The CCTP provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk elders hospitalized for common medical and surgical conditions. For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, the program emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management – all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient’s physicians.
The goal is to reduce acute readmissions by 20% in two years (2013). This will be done by employing Transitional Health Coach nurses and assistants to work with the patients and family members or caregivers to empower them to be accountable for changes in their own health, communicate to the their primary care and specialty physicians when appropriate, have their medications be reviewed and appropriate for their conditions, and secure the needed services in the community or home when appropriate.
In short, the Center for Healthy Aging and the established partnerships offer Northern Nevada the best combination of expertise and experience that will succeed in providing a CBO for the Community-based Transitional Care Program. We look forward to providing a community wide organization and service that will reduce the acute recidivism and improve the quality of life to our elders, “Adding Life to Years”.
Lawrence J. Weiss, Ph.D. is CEO of the Center for Healthy Aging. Dr. Weiss welcomes your comments on this column. Write to him at larry@addinglifetoyears.com or c/o Center for Healthy Aging, 11 Fillmore Way, Reno, NV 89519.