Investigating The Health Care Industry At A Local Level

by Ike Crumpler Nov 2017 Also on Digital Edition

Although a stroke put Thomas Frawley Jr. in a wheelchair and made him unable to talk, his wife knows how well simple gestures enhance his frequent therapy sessions.

“For being in his health situation, he’s experienced so many wonderful caretakers at VNA, Martin Health and Martin South,” Jane Frawley says. “They’re cheerleaders. They just work hard. Tom is always motivated by a smile.”

Today, Thomas gets just that from a surprise guest who understands firsthand the persistency and positivity it takes to endure the long and difficult road to recovery after an injury.

U.S. Rep. Brian Mast, who as an elite Army ordnance disposal tech lost both legs and a finger from an IED in Afghanistan, accompanied the Visiting Nurse Association of Florida on patient visits in Palm City. In these quiet home environments, away from the noisy Washington posturing and maneuvering on health care, he could observe caregivers in the field, speak with patients, their families and providers, and hear about how the biggest issue in the nation impacts the most important service any of us will ever use.

“I’ve seen struggle played out in a number of ways with a number of people,” Mast says. “None of us expect a struggle. But it’s that moment that we get to step up. It can define us. For all of us, it can become our chance to participate.”

Mast looks at Thomas, who nods a bit and smiles.

“I can see it in your eyes and your smile,” Mast says, “that you choose to participate.”

SEPARATE DIRECTIONS

Health care is at a compelling nexus. The industry’s advances in research, technology, medications and therapies continue to astound, gaining much-deserved credit for breakthrough treatments, surgeries and practices that defeat diseases, restore or replace vital organs, reverse once-considered irreversible conditions, and extend overall life expectancy and quality. The process of paying for health care, in all its coverage forms, however, inspires a lot less awe. More likely, it incites anxiety.

In fact, the health care issue—steeped deeply in the political realm and dominating the news cycle—is engulfed in a great multitude of uncertainties, save one: that it will cost users significantly. We spoke with leading health care providers to better understand how they navigate this byzantine regulatory environment while remaining focused on what counts most: high-level patient care.

“Anything that happens in Washington regarding Medicare generally has a tremendous impact on our hospital,” says Chuck Cleaver, senior vice president and chief financial officer of Martin Health System. “We’ve all read about drug costs. The cost of caring for patients has gone up drastically. That’s a big challenge we face.”

Nick Borello, nurse manager at Martin Medical Center and Cynthia Silva, Martin Health director of Interventional Services

“ Anything that happens in Washington regarding Medicare generally has a tremendous impact on our hospital.”

- Chuck Cleaver

ELASTICITY OF MEDICAID

The minimal increases in the amount of money Medicare reimburses to health care providers—contrasted with the climbing costs of medication and treatment—is an institutional challenge for the industry; it’s practically baked into the Medicare-provider dynamic. Even still, it makes the reams of ever-evolving regulatory requirements from the federal government, which can be complicated by political jousting from state policymakers, all the more cumbersome.

When Congress passed the Affordable Care Act (ACA) under the Obama administration, the law controversially included a large expansion of new enrollees in Medicaid. Leery of a substantial increase in entitlements and the cost mandate escalating over time, the Florida Legislature refused to fully budget for a mass expansion.

LIP SERVICE

In 2017, almost every state participating in the healthcare.gov state exchanges saw enrollment decline by an average of five percent. There was one exception: Florida. The Sunshine State’s enrollment in the federal exchange program increased by one percent to 1.76 million people according to healthinsurance.org, which reports on the state marketplaces.

“We’ve had a lot of people come out who qualified and signed up,” Cleaver says. “So, our Medicaid numbers in Florida went up, even though [the state] didn’t expand [funding for] the program. Then, a lot of these ACA patients end up with bad policies that have very high deductibles.” For its refusal to expand Medicaid eligibility, Florida saw the state’s low-income pool (LIP) fund, which provides match money for reimbursements, reduced by the Obama administration from $1 billion to $608 million.

In late April, the Trump administration increased the federal side of the reimbursement fund to $1.5 billion. But the political seesaw keeps going up and down. By May, the state legislature cut the fund by more than $500 million, with statewide cuts as high as $650 million planned for fiscal year 2018. Less money in LIP means fewer match dollars available for federal reimbursements to hospitals for charitable services rendered, Cleaver explains.

“Right now,” he says, “the hospitals are all working together to figure out how we can match any part of that money.”

Martin Health Neurosurgeons John K. B. Afshar, M.D., John R. Robinson Jr., M.D., John J. Viola, M.D., FACS, and Oszkar Szentirmai, M.D.

MONEY BACK? NO GUARANTEE

On the reimbursement scale, not all hospitals carry equal weight. First-tier hospitals such as Jackson Memorial Hospital in Miami, UF Health Shands Hospital in Gainesville, Tampa General Hospital, among others, serve as safety net hospitals. Such status enables increased local funding, usually through hospital taxing districts.

By contrast, Martin Health System is a community hospital, “where the county government actually pays for some of their residents’ care,” Cleaver says.

While the amount budgeted for community hospital care varies, it’s currently $1.5 million a year. There’s a push, Cleaver says, “to see if those counties will send that up to the state to use as a match for the federal money. You can imagine how difficult that discussion is around the state in a one-on-one basis with hospitals and county commissioners.”

Moreover, Cleaver adds, “They have not figured out a way within the waiver of the federal government to ensure that every county that sends [money] back up to the state will get a match back.”

Martin County allocates $0.25 million for indigent care and related needs. The total fund, which includes not only hospitalization but even funeral services, currently tops out at around $3 million. The county plans to make such funds available to the state, but not before forging an agreement that seeks to bind the state to repayment.

“We hope that the state would honor this agreement,” says Taryn Kryzda, county administrator. “We’re putting in any assurance we can to protect what we’ve collected before we start sending money to the state. That’s the best we can do.”

Accompanying the Visiting Nurse Association of Florida on a patient home visit to learn more about the impacts on health care legislation on providers and patients, U.S. Rep. Brian Mast speaks with John Gelke of Palm City about his family and upbringing, as well as his treatment and recovery from a stroke.
Photo by Hobie Hiler

EXCHANGING HEALTH PLANS

The impact of the issue isn’t only on the indigent. Employer health care plans, Cleaver explains, generally pay higher reimbursement rates to providers than Medicare. With the prospect of government picking up the bulk of the tab, ACA enticed some employers to raise the employee’s portions of the cost, or stop offering health plans all together.

“With the Affordable Care Act, a lot of traditional employers canceled health care and had employees sign up with the exchange,” Cleaver says. “We have people who used to have really good coverage who now have these exchanges.”

The more enrollees in Florida for Medicaid, which lacks LIP matching funds for reimbursements, the greater the odds Martin Health System will end up providing services that it will never see full payment on. Over time, that means greater costs on the provider, which eventually find their way to the patient who can pay.

Karen Purkiss, Martin Health pharmacist

HEALING STARTS AT HOME

It’s no secret that the costs of extended hospitalization run exorbitantly high. Lesser known is that if a patient is re-hospitalized for the same condition within 30 days of treatment, the hospital may not receive payment.

Enter home health care, which provides a vital link between the healing and cost-savings process. Visiting Nurse Association of Florida ranks among the top five percent of home-health agencies in the nation for preventing hospital readmission.

And yet, “It’s a full-time job trying to keep up with what we’re supposed to do based on today’s regulations,” says Jennifer Crow, vice president of marketing and communications.

RETROACTIVE REVOCATIONS

“Today’s regulations” include Zone Program Integrity Contractors (ZPIC), whose mission for fighting fraud and finding ways to save money is “needed and noble,”Crow says. But ZPIC’s range of retroactive regulatory power can prove particularly problematic.

A ZPIC contractor, for example, can contact patients up to 18 months after they’ve received care and question them about their homebound status, which is essential to establishing their need for treatment at home.

“Homebound” doesn’t mean non-ambulatory; it means difficulty leaving the house. Oftentimes, when a contractor questions a senior as to if they were indeed homebound following a medical procedure performed months or even nearly a year earlier, the tendency, Crow says, is to shrug it off or even bolster their ability to get around. Admitting anything less is to reveal a vulnerability most seniors, who are guarded about preserving their independence, are understandably uncomfortable sharing with a stranger.

“If you ask them, they think they’re quite capable of doing a whole lot of things,” Crow says. “And anyone can misremember how they felt during a difficult recovery time 18 months earlier.”

But if the contractor hears any discrepancy, payment for services long-since rendered can be revoked. The contractor, meanwhile, is typically rewarded a percentage of the denied payment. Little wonder industry advocacy organizations such as Home Care Association of Florida describe some contractors in their literature as creating “time consuming and costly administrative burdens” and “disrupting access to care for beneficiaries.”

PRE-CLAIM TO INFAMY

In spring, home-health agencies in Florida braced for implementation of the Pre-claim Review provision put on by Centers for Medicare & Medicaid Services (CMS). Introduced in Illinois, the demonstration—a trial regulation enacted without congressional approval—was unfurled to disastrous effect. At its start, Medicare beneficiaries received letters from CMS stating their claims would be denied. Although not exactly accurate, it actually proved somewhat prescient.

Normally, when a home-health agency receives a patient referral from a physician, treatment quickly follows. Claims for reimbursement are submitted to Medicare, reviewed and paid according to services provided. Pre-claim Review relied, however, on CMS contractors. In Illinois’ Pre-claim Review demonstration, CMS contractors—before agreeing to cover care—reviewed claims for approval, along the way amassing a backlog of paperwork, which often delayed needed care.

Concerned about Pre-claim Review’s unintended impacts, home-health agencies mobilized political support. Florida’s congressional representatives, seemingly powerless to halt a CMS demonstration that they never even voted on, still responded favorably, with both senators and all but two Florida congressmen signing a letter arguing to postpone implementation. It was finally scrapped, but only because someone realized that a demonstration could only be voluntary, Crow says.

MORE TO COME

Still, there are more regulatory hoops on the horizon, Crow says. Changes anticipated for 2019 include, among others, scaling back the traditional 60-day episode of care to 30 days, which will require resubmittal of the time-consuming approval process if care is needed beyond that period. Another projected change is removing therapy from reimbursements eligibility.

“That includes speech therapy,” Crow says, “which teaches stroke patients how to swallow.”

SOLUTION-MINDED RESPONSES

Undeterred in their commitment to high-level patient care, providers are increasing collaboration, communication and proactive engagement across professional lines, Crow says.

“We’ve worked with local hospitals for many years,” Crow says, as VNA of Florida is in its 41st year in business. “There’s an important period of time after someone gets discharged where they might not go into some needed home-health treatment. So, we’re continually working to create the best possible programs to meet the specific needs of patients as they come out of the hospital.”

The combination is better for both patient and provider, Cleaver says.

“We work very closely with the VNA and plenty of other home-health agencies, as this segment of the industry is absolutely going up,” Cleaver says. “You don’t want the patient going back into the hospital. You want the patient at home, getting well.”

Through its latest initiative, Treasure Coast Integrated Healthcare, Martin Health System aims to unite providers across the region in creating a “value proposition to improve the health of our community and provide better care at a lesser cost for Medicare patients,” Cleaver says.

The idea of bundling the costs of care for select procedures, such as hip replacements and emphasizing preventative treatments, is one of the CMS mandates that health care professionals embrace.

“This network goes a step further as it’s working with that patient over the course of the year,” Cleaver says. “About 20 percent of patients make numerous trips to the ER, and if you can help them, you can stabilize those costs. We’re a part of this community and we want to take care of its health care needs. That’s one thing that won’t ever change.”

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