Apr 082016

By Joanne Lynn

The time has come to seek cooperation from the Centers for Medicare and Medicaid Services (CMS) so MediCaring Communities can get underway in many parts of the country. These programs are as necessary to an aging society as pediatrics and obstetrics are for children and maternal care. Empowering communities to take care of their own residents who aim to age in place and eventually live with frailty is a challenge we can meet without impoverishing younger people or stalling the economy. But it will take some action now. Can you and your community be among the pioneers?

The core ideas are simple and well-proven. Now is the time to pull them together into a workable and affordable system of care. First, we have to be willing to acknowledge that becoming old and frail—having two or more limitations in Activities of Daily Living, presence of cognitive impairment, or being older than 85—is now an expectable part of life for most Americans. When this period arrives, we usually need a more supportive and adaptable care system. The arrangements we have now for health care and supportive services are frustrating, wasteful, and a serious misfit for providing the comfort, meaningfulness, personalization, and reliability that are so greatly desired at that point in our lives. Critically important, we become more and more individual as we grow old: each of us has a unique set of relationships, values, resources, aspirations and fears, as well as a particular medical situation. This demands that frail elderly people have a thoughtful care plan for the services needed across time—one that fits their individual preferences and priorities.

Medical care for frail elderly Medicare beneficiaries also needs to fit their situation. Screening to prevent illnesses that are unlikely to become a serious problem for a decade or more is a good example of low-value care that should be avoided, while preventing falls and delirium assumes a very high priority. Going to the hospital may sometimes be essential; however, for frail elders, this entails much more risk (e.g., infections and falls) than it did earlier in life, so hospitalization decisions need to be carefully considered. More medical services should be provided in the person’s home once it becomes very difficult and disorienting to go to a doctor’s office or clinic.

Here’s another key point: For the mainly homebound frail elderly Medicare population, supportive services are critically important to daily well-being and must be readily available and reliable. Some frail elders need food delivered or housing adaptations. Others need ongoing personal care or supervision. The great majority hopes to stay in their homes and not have to move to institutions, and most want to keep up relationships with neighbors, family, religious groups, and others. Family caregivers of the future will be both less available and will face more substantial challenges than in the past, and we need to support them.

Scores of improved practices are known to achieve better care, but to date all have been small projects, hard to sustain and difficult to scale up and spread. The current funding rules in the United States encourage overuse of medical care while providing scant supportive services and almost no tools for communities to evaluate local needs and priorities. It is bizarre that any physician can write a prescription for a drug costing $100,000 that has been found to be only a little helpful for only a few potential patients, but neither the doctor nor anyone else can order up a substitute caregiver when the spouse is ill or find a way to get food delivered when there is a long waiting list for Meals on Wheels. Most families and elderly people find this strange as well, once they experience the situation. But most people are only gradually realizing that this sort of distortion is a direct result of policy choices—and that we could choose differently.

MediCaring Communities is a way to choose differently. Here’s how: Each community would develop a way to reflect the voice for its frail elders, which we’ll call a “Community Board,” though it could have a number of names and organizational features. The important thing is that it would help guide providers in the local system toward achieving and maintaining high-value care. For example, the Community Board would work with health care, public health, and social services providers to monitor performance metrics that reflect the priorities of frail elders in the area, including the preferences of individuals, and help decide on priorities for investments and improvements.

Where would funding for investment and system management come from? The funding would come from savings arising from much-improved coordinated services that are adapted appropriately for the population of frail elderly Medicare beneficiaries, follow their preferences, and adhere to the principles of geriatrics, and that reduce overutilized, low-value services in Medicare! The potential for savings varies, but an average of about 30% is plausible for almost any MediCaring Community program. Even saving 10% would enhance the ability of communities to make supportive services that are needed by elders—and which are the mainstay of long-term care—much more available. A program could be built on a managed care platform, an Accountable Care Organization arrangement, or a Program of All-Inclusive Care for the Elderly (PACE) program.

Recent legislation has made a new avenue possible through the PACE program, the most established, community-based service delivery model for older adults. The PACE Innovation Act (P.L. 114-85), signed into law on November 5 2015, provides the Centers for Medicare & Medicaid Services (CMS) with the authority to loosen the rigidity of the PACE program. CMS’ Center for Medicare & Medicaid Innovation (CMMI) can now pilot expanded PACE models to serve a broader population. For the first time, the program can be readily adapted to serve Medicare-only beneficiaries who have a need for some LTSS but are not yet functionally at their states’ nursing home level of care and have incomes above their state’s Medicaid financial eligibility threshold. Building MediCaring Communities on an ACO, MA plan, or PACE platform will require some cooperation with CMS.

That’s where your help is needed. The time has come to ask CMS to take up the challenge of working with willing applicants, starting by opening the door to allow pioneer MediCaring Community programs, including willing PACE programs, to move ahead.
Here’s what we have found likely to be important in the first set of communities, enabling them to lead in building reliable, sustainable services for frail elders in the MediCaring Communities model:

  • A history of cooperation in the public interest;
  • Implementation of some improvements already in frail elder care, such as some experience with models like PACE, GRACE, INTERACT, local support of nutrition and transportation services, age-friendly environments, or similar models and programs;
  • Leaders who are concerned about the future effects of increases in the numbers of persons needing daily help in old age;
  • Enough frail elders to field a convincing project but still small enough to be able to make improvements quickly (perhaps 500–10,000 is a reasonable range, and frail elders are about one-tenth of all persons older than 65);
  • Reasonably self-contained area, with boundaries that are well-known, that is, the health care and supportive services to people who live in the area are generally provided by services anchored in the area.

There will be other considerations, but none are as important as commitment and leadership. We invite you to think on it and talk it over with others, and if building the elder care system of the future is plausible and appealing in your community, city, or county, please let us know! We are planning some webinars and perhaps some meetings to spell out details, answer questions, and shape up our request before we head to CMS to get approval for leadership communities to get underway.

Serving a far larger population of elders is a solvable problem—it is only made difficult by protocols and regulations that were developed for a different (younger) demographic reality. Let’s modernize our care system for our old age and create a trustworthy set of arrangements that generate pride instead of waste and frustration. Send us an email today.

What do you think? Can you help to make this happen? Write to us at [email protected] if you can see a good opportunity in a community that you know. Also encourage support from the leadership of professional and advocacy organizations, political leaders, and CMS. Let us know if you are doing this and what progress you are making. If you contact us, we’ll be in touch and will aim to include your community in the list of potential pioneer communities to help persuade CMS to let us proceed.

Feb 222016

By Anne Montgomery

A tremendously positive legislative achievement occurred on November 5, 2015, when the PACE Innovation Act (P.L. 114-85) was signed into law. Although it has received little notice, what this five-line statute does is provide the Centers for Medicare & Medicaid Services (CMS) with the authority to loosen the rigidity of the best, most established service delivery model for a geriatric population wishing to “age in place” at home: the Program of All-Inclusive Care for the Elderly. Some of the most salient possibilities for evolution of the PACE model are wrapped up in a potential PACE Expansion.

PACE already has a solid reputation as a comprehensive program tailored to dually eligible beneficiaries who need a mix of medical care and long-term services and supports (LTSS). Yet it has a small footprint across the country, serving about 35,000 adults age 55 and older. With the additional flexibility provided by the new law, PACE is now in the ambit of CMS’ Center for Medicare & Medicaid Innovation (CMMI). For the first time, the program can be readily adapted and tweaked to serve Medicare-only beneficiaries who have a need for some LTSS but are not yet functionally at the nursing home level of care (which varies between states) and have incomes above their state’s Medicaid financial eligibility threshold. During the height of the Baby Boomer-driven “age wave” a little more than a decade from now, when tens of millions of seniors living into their 80s and beyond will be seeking reliable, affordable assistance to remain in their homes, many might welcome a flexible, comprehensive program that offers both ongoing medical care and tailored LTSS.

Here is how an adapted PACE model might work: Medicare-only beneficiaries would be empowered to buy into PACE for their LTSS services with private dollars, whether in the form of tiered bundles of services, on a menu-driven basis, or a combination of both approaches. These at-risk beneficiaries would be appropriately motivated and incentivized to buy just the amount of LTSS that they actually require, which would be determined based on a comprehensive assessment and a corresponding comprehensive care plan. The amount they would pay would be far less than what has long been required for Medicare-only PACE enrollees, who, by regulation, are now forced to pay the full Medicaid capitation rate. Because the Medicaid capitation rate is a blended rate to cover the needs of those who are eligible for nursing homes and to stay with them to the end of their lives, the fee is typically several thousand dollars a month. Vanishingly few Medicare-only elders think that they will need this level of service, so there are very few Medicare-only PACE enrollees today. If, instead, Medicare beneficiaries could secure tailored LTSS at much more reasonable premiums, this would stretch and conserve their retirement savings. From the vantage point of states that are struggling to plan for substantially larger Medicaid LTSS populations, this could have a positive impact on slowing spend-down rates.

In addition, it may be possible to consider whether the out-of-pocket payments made in such an arrangement could be made through a revised, more affordable private long-term care insurance (LTCI) market. Some initial promising ideas for improving LTCI have recently been announced by the Bipartisan Policy Center.

More importantly in the near term, the overall state of readiness of the Aging Network (AN), which is still not well-understood within the health care industry, must be enhanced. For an expanded PACE program or any other health care provider to succeed in serving a significantly larger population of Medicare beneficiaries with varying needs for LTSS, which are delivered in the home, will require much more focused attention to the AN by policymakers and stakeholders in the health care sector. Composed of thousands of small, locally administered Area Agencies on Aging (AAAs) and related community-based organizations across the country, the AN is charged with arranging for and providing social services and supports (e.g., home-delivered nutrition services, respite care and flexible, adapted transportation systems) to all older citizens who are deemed to be in need in any given community. In practice, the ability of the AN to deliver on this promise is compromised by an inadequate financing base. Although the AN is moving as quickly as possible to transition to partnering with health care partners, some of the key infrastructure required (e.g., data systems to collect, report, and analyze performance metrics that are compatible with what health care providers are asked to submit) is poorly developed. This suggests that more focused attention, as well as well-targeted financial investments, must be made in order to create a reliable, comprehensive, cost-effective service system that spans the health and social services sectors.

To date, investments by the health care agencies in the federal government to link the AN’s service delivery system with the health care system have been miniscule. Along with chronic underfunding through the appropriations process despite steadily rising need among aging seniors in communities across the country, underinvestment in the AN’s infrastructure is arguably stymieing further development of this sector. Questions about how an expanded PACE program (and similar evolving initiatives) can be positioned to work with the AN most cost-effectively are probably best answered through prudent investments in research, pilots, and demonstrations, along with ongoing monitoring and quality improvement efforts. Without such investments, LTSS services for millions of community-dwelling Medicare beneficiaries could become increasingly unreliable or perhaps even completely unavailable. If this happens, the likely outcome will be that health care costs for a rapidly growing population of older adults who need LTSS services but cannot secure them will continue to rise quickly.

On the other hand, an expanded PACE model approach offers the possibility of connecting an already established, high-quality, interdisciplinary health care model with an existing, though still loosely organized, community-anchored social services sector. It is a possible and exciting adaptation of the best that our current care system has to offer. To make it a reality will require timely, concerted action on the part of CMS and interested stakeholders. Also needed are local leaders and community and aging services advocates who recognize that there is an opportunity at hand to create a strong foundation for a more comprehensive system of care—one that explicitly includes supports that address the social determinants of health.

Click here to view a slide deck on the Frail Elder Expanded PACE Program.

Jul 092014

by Anne H. Montgomery and Joanne Lynn, MD, MA, MS

Congress is gearing up to put a legislative glide path in place that is intended to culminate in major reform of Medicare’s post-acute care (PAC) payment system. Following several months of soliciting and reviewing comments on a discussion draft, the “Improve Medicare Post-Acute Care Transformation Act” (H.R. 4994/S. 2553) was introduced on June 26. Sponsored by Sens. Ron Wyden (D-OR) and Orrin Hatch (R-UT), together with Reps. Dave Camp (R-MI) and Sander Levin (D-MI), the IMPACT proposal (https://www.congress.gov/bill/113th-congress/senate-bill/2553) is believed to have good odds of being enacted during the 113th congressional session.

One of IMPACT’s primary goals is to establish a system of uniform assessment in the PAC sector (or perhaps more accurately the “after- hospital” sector) along with improved quality measurement. This information, which would be transmitted to CMS and available for analysis and research, would be used to help redesign payments across skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals and home health agencies, with recommendations due from CMS and the Medicare Payment Advisory Commission by 2022.

“Without comparable information across PAC settings, policymakers and providers cannot determine whether patients treated and the care provided in different settings is, in fact, the same or whether one PAC setting is more appropriate,” a summary of the bill notes.

“Absent this information, it is difficult to move forward with PAC payment reforms.”

This is true enough: Clinicians and thoughtful experts knowledgeable about the care of older adults have advocated a uniform assessment for several decades, and having a high-quality, standardized tool in hand would enable better prognostication and decision support.

But there are other factors that could heavily influence the way that PAC reform played out. One is the “Bundling and Coordinating Post-Acute care Act of 2014” (BACPAC) bill (https://www.congress.gov/bill/113th-congress/house-bill/4673) introduced on May 19 by Rep. McKinley (R-WV) and Tom Price (R-GA). As proposed, the policy would give control of PAC services to a PAC coordinator – which could be a hospital, health insurance issuer, third-party benefit manager or PAC provider; no government entities or locally-managed coalition efforts are envisioned. PAC coordinators would be given full authority to authorize, deny and coordinate all PAC services for 90 days post-discharge. These services are defined as post-hospital extended care services, home health services, inpatient services provided in a rehabilitation facility, inpatient hospital services provided by a long-term care hospital, durable medical equipment, outpatient prescription drugs and biologicals, and skilled nursing facility services. Physician services and hospice are not included. Standardized assessment is called for, but there is no mention of the information being transmitted to CMS.

Starting in January 2016, PAC coordinators receiving a single payment from the HHS Secretary for PAC services would manage PAC services within a designated “PAC area” (no standardized geographic definition of these areas is provided), and would reimburse “PAC providers” (providers or suppliers furnishing PAC services) at current rates.

After January 2019, PAC coordinators would be empowered to negotiate rates and savings targets with PAC providers. Under the terms of these negotiated agreements, PAC coordinators would keep up to 70% of any savings realized, with 10% or more to PAC providers, 10% or more to the PAC physician, and 10% or more to the discharging hospital. Although unlikely to be enacted in this Congress, BACPAC will probably be reintroduced in the 114th session. And while it may be financially attractive for certain providers, beneficiaries would not see financial gains, and the benefits from better “navigation” of services are not well established. Nonetheless, unless careful attention is paid to the implications of the bill, it is even possible that some of the proposed reforms could be implemented administratively.

But the most interesting issue is where PAC dollars that are saved will go before any of the proposed legislative reforms culminate in a rebased PAC financing system. In the IMPACT bill, financing reforms are more than seven years away. This provides a window of opportunity for capturing large savings in this sector, now that research and private companies has established that substantial efficencies in the PAC sector are feasible.

This raises two related questions: Are there models already in use that are capturing PAC savings, and if so, where are the savings going? The answers are “yes” and “to private investors.” More specifically, evidence-based proprietary protocols are now being used by some risk-bearing contractors and managed care plans to significantly reduce PAC expenditures (http://healthaffairs.org/blog/author/jlynn/). Under these arrangements, savings from taxpayer-financed PAC services are not being reinvested in further improvements, but rather are being funneled via contractual agreements directly into private pockets.

Business as usual, you say? Classic American capitalism? Certainly. But for policymakers and other guardians of the public purse and the public welfare, the merits of this approach may best be examined in a larger framework: the future of the U.S. health and long-term care systems after 2020, when the largest generation of older adults in U.S. history will rapidly drive up demand for a mix of services that are aimed at controlling chronic conditions and mitigating the impact of functional disability. Since evidence suggests that about 45% of the roughly 23% of total Medicare dollars that are spent on PAC services can be harvested
(http://healthforum.brandeis.edu/meetings/materials/2014-18 march/naviHealth.Scully.pdf), this represents an important opportunity to have a robust policy discussion about whether PAC savings — or a portion of them – could be set aside to re-engineer the health, PAC and post-PAC (i.e., long-term care) systems into better-organized integrated care systems.

The sheer size of the possible PAC savings that are available to possibly be captured over the next seven to 10 years – roughly 10% of all Medicare spending – makes this a particularly important case to debate thoroughly – rather than merely standing by and letting the money quietly disappear.

The reality is that today, we are still billions of dollars away from having the necessary infrastructure to grow our modestly-sized coordinated care and shared savings models into the stable integrated care system that will be needed for tomorrow’s large cohort of older adults. For American health care to have become so chaotic and poorly designed that private companies can design ways to pull about 10% of Medicare spending out of services and mostly into profits points out just how poorly we have built our care system for complex chronic conditions.

Some private gain using public dollars may be necessary to catalyze reforms of the PAC sector. However, the size of the looming potential loss for the Medicare Trust Fund is stunningly large, especially when the services provided are primarily decision support and navigation. If, instead, the strategy can be shifted to reinvesting a hefty portion of realized savings in care systems that are deliberately designed to deliver consistent and reliable supports for frail elders and their families, while also reducing their overall health care costs, our future will look very different.

One such comprehensive and community-focused system, the MediCaring model, has been developed by Altarum’s Center for Elder Care and Advanced Illness [now Program to Improve Eldercare]. Others may emerge from the dual eligibles demonstration and ongoing research efforts, while smaller-scale plans such as PACE may devise successful expansion strategies. These models spring from efforts to serve the target population, rather than opportunistically attending only to the happenstance period after hospitalization.

Making these and other high-quality comprehensive models larger and economically viable and sustainable – capable of both driving down unnecessary utilization while improving outcomes — will take ingenuity and innovation, significantly more efficient deployment of services and workforce, and greater flexibility in how existing financial resources are used. Given the likelihood that Congress will not want to make substantial resources for further reforms available in the form of new programs and large grants, this is an important time to think carefully about how greater efficiencies in the PAC sector can both be reliably achieved and how any resulting savings can be best leveraged to build the care system we need to handle the demands of the “age boom.”


key words: Joanne Lynn, IMPACT, BACPAC, MediCaring model, congress

Feb 052012

Earlier this year (2012), the Agency for Health Care Research and Quality (AHRQ) released an innovation profile about Vermont’s  Support and Services at Home (SASH – https://sashvt.org/) program, which provides onsite assistance to older adults and other Medicare beneficiaries so that they can age in place. As AHRQ describes it, SASH offers key evidence-based services, such as “an initial assessment by a multidisciplinary onsite health team, creation of an individualized care plan, onsite nursing and care coordination with team members and other local partners, and community activities to support health and wellness.” Basically, SASH combines supportive housing with critical medical and nursing services on-site. In a year long pilot study with 65 residents, the program reduced hospital admissions and readmissions, had decreased falls, improved nutritional status, increased levels of physical activity, and no bounce backs to nursing homes.

Cathedral Square Corporation (CSC) Executive Director Nancy Eldridge spent an hour talking with MediCaring to offer more insights into the successful program. Conceived in 2006, she says the program came in reaction to a realization that the community faced a “backlog of people in need in our communities, people who had significant complex physical needs, cognitive impairment, depression, and medication management issues.”

“We were involved in looking at models that would be scalable, replicable, and sustainable,” says Eldridge. “We need a system in this country of making sure that people can stay in their homes, a system that is as comprehensive and robust as our public education system, which was developed in response to the needs of the same population, the Boomers. We needed a system then to make sure Boomers were educated, and we need an equally comprehensive and sustainable system for the long term care they will need.”

Cathedral Square owns or manages 24 sites throughout four Vermont counties. Originally funded through a combination of state funds and philanthropic donations, SASH is currently funded through Medicare’s Multi-Payer Advanced Primary Care Practice Medicare Demonstration program, one of 8 states in the country funded for this 3 –year endeavor.  As part of the demonstration, SASH will expand to 112 sites throughout Vermont.

Building on its successful SASH pilot, leaders at Cathedral Square approached leaders at other affordable housing organizations, going “organization by organization until we had covered all corners of the state,” says Eldridge. SASH is now operating in 7 counties, and will be statewide by the end of 2012.  The program’s partners include all five state Area Agencies on Aging, Visiting Nurse Associations, and PACE Vermont, as well as every hospital in the seven counties currently participating.  Each participating housing organization commits one person to the SASH site. For example, the community’s Area Agency on Aging would commit one case manager to one SASH hub site; she is the point person for all AAA clients at the hub site.

When SASH rolls out to the planned 112 sites and their neighborhoods, the new projects will include public and non-profit housing programs and their catchment areas, with the aim of reaching out to the entire community. Affordable housing sites are widely dispersed throughout Vermont, and bringing the core SASH services to very rural areas is a key element of the program. Eldridge says they are “using that core as a platform to integrate with other work. For example, we are helping with the use of CDC tobacco cessation funds as a way to convert all of these properties to smoke-free facilities.”

In another collaborative program, Cathedral Square is working with the housing collaborative and other stakeholders to support a broadband initiative, one that would get connectivity into affordable housing sites, making them anchor sites for free fiber optic networks. This helps to advance goals around health information exchange. “If we start looking at the system, and we approach problems in long-term care, we find we can raise many boats. We don’t benefit only the elderly, but families and the housing network as well.”

To read the full innovation report, go to http://www.innovations.ahrq.gov

To learn more about Cathedral Square, and to see a video about the SASH program, visit http://cathedralsquare.org/

Key words: care transitions, supportive services, SASH, AHRQ, innovation