Another Massachusetts radiation therapy CON application filed

As reported earlier by HealthBlawg (here and here), October 1 was the application filing date for new CONs (or, as we call them here in Massachusetts, DONs) for radiation therapy.  Another application rolled in yesterday from St. Anne’s Hospital, bringing the total to three applications for expansion units (to be considered outside the eight-unit cap on new services).  To the surprise of many observers, only six applications for new services were filed (applicants listed here).

Today’s Boston Globe story notes that most existing services are in Boston, and most of the pending applications are to develop services out in the suburbs. 

It will likely be months before these applications are reviewed.

CDC data on EDs provides great baseline for future study

The CDC has posted a study collecting vast amounts of data on 2004 emergency department visits in hospitals across the country.  While there are no big surprises here — patients are triaged and seen according to severity of illness/injury, there are fewer EDs than there used to be, Medicaid and SCHIP beneficiaries tend to use the ED more than others — this study provides a detailed baseline which may be used in future studies to plan and evaluate modifications to the prehospital and ED care systems.

Will the IRS be the spoiler in hospital-financed EHR and e-prescribing software distribution?

Not-for-profit hospitals have been none too quick in rolling out cost-sharing programs for physician office EHR and e-prescribing tools.  As Modern Healthcare reports this week, they are concerned about being second-guessed by the IRS, and having improper motives imputed to them, which could lead to sanctions.  Given the scrutiny that tax-exempt hospitals have come under recently (see earlier post on this topic), this is probably not an excess of caution. 

Explicit guidance on the issue from Congress or the IRS would be welcome, so that the health care system at large may reap the anticipated benefits of broader dissemination of EHR and e-prescribing systems.

GAO finds CMS data security practices wanting

A GAO report made public yesterday finds that Medicare patient data transmission is insecure.  The AP/Washington Post story on the report says:

Security weaknesses have left millions of elderly, disabled and poor Americans vulnerable to unauthorized disclosure of their medical and other personal records, federal investigators said yesterday.

The Government Accountability Office said it found 47 weaknesses in the computer system used by the Centers for Medicare and Medicaid Services to send and receive bills and to communicate with health-care providers.

The agency oversees health-care programs that benefit one in four Americans. Its data are transmitted through a computer network that is privately owned and operated.

The CMS did not always ensure that its contractor followed the agency’s security policies and standards, according to the GAO.

"As a result, sensitive, personally identifiable medical data traversing this network are vulnerable to unauthorized disclosure," the federal investigators said.

CMS’s response stated that there had been no actual security breaches, and also noted (p. 12 of the report):

CMS has moved aggressively to implement corrective actions for the reported weaknesses and that corrective action or new compensating controls had already been completed for 22 of the 47 weaknesses. An additional 19 weaknesses are scheduled for closure. The remaining six weaknesses are under review to determine what additional resources are needed and their financial impact.

This comes on the heels of another GAO report which highlighted privacy breaches among subcontractors administering aspects of Medicare, TRICARE and Medicaid programs, the lack of consistent reporting mechanisms and the fact that some data was stored offshore, potentially beyond the reach of HIPAA enforcement.

We all know that reliance on digitized data and the global economy has created these potential problems.  The GAO reminds us that a little extra vigilance will go a long way towards ensuring that we do not lose control over access to sensitive data.   

Massachusetts radiation therapy CON applications filed

The recently revised Massachusetts DON guidelines stated that there is need for eight additional radiation therapy units statewide, and applications for eight additional units were filed on the October 1 filing date.

Two applications are for expansion units — Cape Cod Hospital and Massachusetts General Hospital at Newton Wellesley).

Six applications are for new providers — Southcoast (in Fairhaven), Carney and Milton Hospitals, as Mass Bay Radiation Services (at Carney), Cambridge Health Alliance (at Whidden, in Everett), Dana Farber at Milford, Brigham and Women’s at Hawthorn Medical in Dartmouth, and New England Radiosurgery (an affiliate of an existing MRI and PET provider).

Expansion applications may be filed any business day, so additional applications may well be filed in the near future by other existing providers.   

Green House model of nursing facility spreads nationwide; how will it be financed?

Smaller units, more personalized care planning, and greater autonomy for elders are three hallmarks of the Green House model of care, identified by the Robert Wood Johnson Foundation last year as a model worthy of support so that it may be propagated across all 50 states.  The RWJF awarded a $10 million grant to help make this vision a reality.  Today, three Green Houses are open — in Mississippi, Michigan and Nebraska — and a couple dozen more are on the drawing board nationwide. 

The Boston Globe recently ran an article describing the model, the original project in Tupelo, Mississippi, and a project underway in Massachusetts, composed of ten 10-unit Green Houses.  The article reads in part:

Each of the 10 Green Houses will be managed by the residents and two primary caretakers on each day shift, one of whom is "devoted to loving cooking," [Chelsea Jewish Nursing Home executive director Barry] Berman said. The caretakers will also do light housework and help residents with bathing, grooming, and dressing.

The residents in each Green House will determine their own daily routine, menu, and activities. Meals generally will be served family-style, around one long table, with staff and visitors joining in. Residents can volunteer to help keep the household running by doing chores like cooking, folding laundry, and accompanying the cook to the grocery store.

"That’s a more important activity for some residents than anything we could provide," Berman said.

One nurse will serve two 10-resident Green Houses, but medical trappings will be kept to a minimum.

The Green Houses typically cost no more to run than traditional homes, even though there are more caretakers per resident, because they have less waste and do not need such infrastructure as dietary departments. As at conventional homes, most of the bills will be paid by the Medicaid program for low-income seniors and the disabled .

State regulators support the Chelsea project, and have waived some regulations to allow innovation, Berman said.

A two-year study that compared the Tupelo Green Houses with two traditional nursing homes [see abstract here] found that quality of life was better in the Green Houses, with residents saying they had more dignity, privacy, meaningful activity, relationships, and autonomy, according to Rosalie A. Kane, a professor at the University of Minnesota School of Public Health.

Kane said the Green Houses provided small benefits in the quality of care — residents showed less depression, less incontinence, and less of a decline in the ability to feed themselves.

"It’s impressive and worthy of replication," said Kane. "It defies people’s idea of what a nursing home is."

Staff turnover, which averages 71 percent annually in nursing homes, fell to just 10 percent, according to the Green House national staff.

Sounds promising, and sounds consistent with the trends in government and industry trying to create more homelike models of long-term care.  The Globe article reports that one in six Massachusetts nursing facilities plan to implement programs incorporating some elements of the Green House approach.  The issue that may stop others from implementing these plans is lack of funding.  Since Massachusetts Medicaid payments to nursing facilities are no longer even designed to reimburse providers for their reasonable capital costs, the design and construction or renovation of facilities to accommodate new models of care has become cost-prohibitive.  Creative financing will be pursued by a few providers (the Chelsea facility’s approach mixes tax credits and philanthropy), but rolling out any improvements on a system-wide level — whether it’s the Green House model or simply renovation or replacement of the aging physical plants of many nursing facilities — requires either the continued large-scale commitment of public funds, or the maturation of alternative models of long-term care financing.  Unfortunately, neither seems to be on the horizon.

I invite your comments on whether or how the health savings accounts and consumer-directed health initiatives of the Bush administration may be translated to the long-term care arena, or on other means to the worthy end of further disseminating the Green House model.