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.   

Universal health care: What will make it work?

A tip of the hat to Tom Mayo at HealthLawBlog, who posted yesterday’s news on the Arnold’s unsurprising veto of the California universal health care bill (link to story on the bill from my earlier post here), and the release of a Congressional study on health care access and affordability, laying out a five-year plan for improvement.  Under the law that called for this report, the president has 45 days to respond with recommendations for legislative and administrative changes.

Tom asks what differentiates Massachusetts — where a universal health care plan is getting up and running, with some fits and starts — from California, where the idea turns out to be a nonstarter.

There is an interesting series of articles published this month by Health Affairs as a web exclusive that includes a wide range of analysis and prognostication.  One of the articles, co-authored by John McDonough of Health Care For All and A Healthy Blog notes that Massachusetts was pushed or pulled into this "third wave" of health care reform by the threatened loss of almost $400 million a year in federal dollars made available under a Medicaid waiver.  The money had previously been directed straight to the state’s two biggest disproportionate share hospitals, and the feds wanted to see the money directed to Medicaid beneficiaries rather than institutions.  The Massachusetts plan redirected the money to the satisfaction of the feds, who approved the plan and renewed the waiver.  There are other pieces to the plan, of course, but this was one key element that galvanized the support needed.   

There are many challenges on the road to full implementation of the Massachusetts plan but, thus far, while some compromises have been made, the general thrust of the plan remains intact.  We’ll see if any bills proposing significant overhauls or repeal are filed for the coming legislative session.

AHA finally supports federal price transparency legislation; the states are taking the lead

This month, the American Hospital Association has made an about-face and is now supporting a bill in Congress that promotes price transparency.  The information made available under such a scheme would clearly be a boon to consumer directed health plans (see HealthBlawg posts on CDH), including plans making use of health savings accounts (see HealthBlawg posts on HSAs).  The realities of the marketplace have pushed the AHA in this direction.

Modern Healthcare reports: 

The move is remarkable considering how vehemently the AHA has fought previous disclosure proposals that have been bandied about on Capitol Hill.

Though political realities in Washington almost ensure the bill won’t see a vote anytime soon, it’s the first shot across the bow from the AHA in a battle over what kind of pricing information hospitals should provide.

And given the AHA’s role in the bill, it’s perhaps not surprising that the bill doesn’t draw a hard line. The bill, H.R. 6053, would require states to enact laws that require hospitals and insurers to make known how much they charge for certain inpatient and outpatient procedures. The bill also would give insured individuals a cost-estimate for certain procedures and calls for a study from the Agency for Healthcare Research and Quality to determine what kind of pricing information is most relevant to the consumer.

A couple dozen states already have some form of price transparency laws on the books.  The challenge will be to link price information with quality information (see recent HealthBlawg post on IOM report regarding P4P). 

As an example of one state’s journey along this road, consider the Massachusetts experience.  The state’s universal health care law calls for publicizing both cost and quality information (see Boston Globe article published today, and links to the law and related information on the Massachusetts legislature’s home page).  Some data is already available on the state’s Division of Health Care Finance and Policy website.  It’s a work in progress.

CMS puts out second, parallel, gainsharing RFP

Shortly after issuing an demonstration project RFP under MMA 646 (see earlier post), CMS finally issued its RFP for gainsharing demonstration projects under DRA 5007.  Up to six projects will be approved, and the applicants are to be hospitals, working with physicians.  Applications are due November 17, 2006.

IOM recommends P4P for Medicare

The proverbial 800-pound gorilla of health care seems poised to jump on the pay-for-performance (P4P) bandwagon.

Last week, the Institute of Medicine released a report recommending that Medicare start moving in that direction — though in a measured, gradual way, acknowledging that there’s still precious little data on P4P programs, no truly standardized metrics, and a need to support providers with the IT infrastructure necessary to measure and report performance.  The press release noted:

"Medicare beneficiaries are not getting the highest possible quality of care because the program’s payment system encourages volume rather than efficiency and quality," said committee chair Steven A. Schroeder, Distinguished Professor of Health and Health Care, University of California, San Francisco.  "The urgency of the situation demands that steps be taken now to encourage health care institutions and clinicians to improve their quality.  Pay for performance has demonstrated sufficient promise based on early experience that it should be pursued, albeit cautiously and in a manner that allows for learning and adjustment as needed. And we should remember that pay for performance is just one part of the solution; other interventions will be needed to achieve the level of quality that Medicare patients deserve."

The IOM panel recommends implementing this approach with no new dollars, which means base compensation for providers would be reduced.  This yielded the expected calls for new funding for bonus pools from the American Hospital Association and American Medical Association (see AP/Yahoo story).

The provider lobby is not wrong — providers as a group will see lower base compensation if and when these proposals are implemented.  (. . . And even if they aren’t; coming reductions in Medicare payments to providers have been the subject of several HealthBlawg posts — including those here, here and here.)  What P4P offers, though, is an opportunity for providers to distinguish themselves based on outcomes, compared against a standardized set of measures.

In theory, this approach dovetails nicely with the consumer-directed health policies espoused by the current administration, and holds out a glimmer of hope that not only may providers be held more accountable for patient outcomes (measured over a large population of cases), but provider selections by consumers may be made on the basis of meaningful, consumer-friendly data — and not on the basis of provider likeability or other factors unrelated to quality of care (see recent RAND study).

While neither providers nor patients like serving as test subjects for investigators trying to prove a theory like this, P4P programs focused on paying for outcomes rather than process are the wave of the future, and providers would be well advised to continue developing the means to provide and measure what payors are prepared to pay for.  

Free money for emergency care provided to undocumented aliens? Many providers say no thanks

The $1 billion in Federal dollars set aside for this program (see earlier post on the subject) is largely untouched — only about 15% of available monies have been claimed.  Reasons cited in a Chicago Tribune story range from lack of interest in complying with onerous documentation requirements for a 33-cents-on-the-dollar payment, to concern that asking undocumented aliens to document that they are undocumented will scare them away from the health care system, to opposition to diverting U.S. health care dollars away from U.S. citizens and a desire to avoid becoming a magnet for uninsured patients.  Hospitals also end up eating the cost of an inpatient stay longer than necessary for stabilization.

It seems to me that the government contractor should be encouraged to streamline the administration of the program and offer further training on confirming eligibility without scaring off patients.  Could we design a better health care financing system if we were starting from scratch?  Sure.  But this program can be useful both to its intended beneficiaries and the providers serving their needs.

What do you think?