Category Archives: VA Puget Sound

Health news headlines – October 24th

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Silhouettes of U.S. Soldiers at night in Iraq

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Veterans’ needs ‘should drive where they get their care,’

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On Capitol Hill, lawmakers resume work this week to resolve differences over legislationaimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times.

Five senior VA leaders – including former department secretary Eric Shinseki –have resigned in the past six weeks.

Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.

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Dr. Kenneth Kizer

Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outsideproviders for medical care.

Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.

An edited transcript of that interview follows. Continue reading

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Poll: Americans bristle at penalties in ‘wellness’ programs

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By Jordan Rau
KHN

Workers believe employer wellness programs should be all gain but no pain, according to a poll released Tuesday.

The poll from the Kaiser Family Foundation found employees approve of corporate wellness programs when they offer perks, but recoil if the plans have punitive incentives such as higher premiums for those who do not take part. (KHN is an editorially independent program of the foundation.)

Wellness programs, which are encouraged under the federal health law, are structured in various ways. In some plans, the worker has to join a particular program, such as an exercise class, while others focus on outcomes, such as the employees’ blood sugar or cholesterol.

Evidence is mixed about whether any substantially improve workers’ health or lower costs to employers and insurers.

The poll found 76 percent of workers thought it was appropriate for employers to offer wellness programs that promote healthy behavior.

But a majority opposed wellness plans that had financial repercussions for workers:

  • 62 percent did not think employers should charge higher health insurance premiums to workers who did not participate, and
  • 74 percent said management should not charge more to those who did not reach health goals.

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The Obama administration is allowing employers to link up to 30 percent of health premiums to wellness programs. Penalties and rewards for participating in a tobacco cessation program can be as high as 50 percent of the insurance plan cost. Continue reading

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Nearly 1,500 hospitals penalized under Medicare quality program

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hospital magnify 300By Jordan Rau
KHN Staff Writer

More hospitals are receiving penalties than bonuses in the second year of Medicare’s quality incentive program, and the average penalty is steeper than it was last year, government records show.

Medicare has raised payment rates to 1,231 hospitals based on two-dozen quality measurements, including surveys of patient satisfaction and—for the first time—death rates.

Another 1,451 hospitals are being paid less for each Medicare patient they treat.

For half the hospitals, the financial changes that started last month are negligible: they are gaining or losing less than a fifth of one percent what Medicare otherwise would have paid. Others are experiencing greater swings.

Gallup Indian Medical Center in New Mexico, a federal government hospital on the border of the Navajo Reservation, will be paid 1.14 percent less for each patient. Arkansas Heart Hospital in Little Rock, a physician-owned hospital that only handles cardiovascular cases, will get the largest bonus, 0.88 percent.

The bonuses and penalties are one piece of the health care law’s efforts to create financial incentives for doctors and hospitals to provide better care. They come at a tumultuous time as the technical problems of the healthcare.gov insurance portal and premium prices are stoking questions about the law’s viability. The incentives are among the law’s few cost-control provisions that have kicked in, but it is too early to tell how effective they will be in making hospitals operate more efficiently.

“This program is driving what we want in health care,” said Dr. Patrick Conway, Medicare’s chief medical officer. He said most hospitals have improved since the program began a year ago. However, even some hospitals that have gotten better are still losing money because they are not scoring as well as others or have not improved as much.

Across the country, hospital executives say they have put renewed focus on excellence in the areas that are judged. Some have clamped down on nighttime noise, one of the questions patients are asked about, by replacing squeaky wheels on food carts and discouraging nurses and workers from chatting on cell phones outside of rooms.

Others have scrambled to ensure heart attack patients always get an angioplasty within 90 minutes of arrival because that is part of the scoring. Some private insurers have adopted similar incentives.

“The thing about the government, if they start paying attention to it, we have to scramble around to pay attention to it,” said Dr. Leigh Hamby, chief medical officer at Piedmont Healthcare, a hospital system in Georgia. “It gets us moving.”

Hospitals in Maine, Massachusetts, Nebraska, New Hampshire, North Carolina, Utah and Wisconsin are faring the best, with 60 percent or more of hospitals getting higher payments, according to a Kaiser Health News analysis.

Medicare is reducing reimbursement rates for at least two-thirds of hospitals in 17 states, including California, Connecticut, Nevada, New Mexico, New York, North Dakota, Washington and Wyoming, as well as the District of Columbia.

How A Hospital Is Rated

Under the program, known as Hospital Value-Based Purchasing, Medicare reduced payment rates to all hospitals by 1.25 percent. It set the money aside in a $1.1 billion pot for incentives. While every hospital is getting something back, more than half are not recouping the 1.25 payment they initially forfeited, making them net losers.

The payment adjustments are applied to each Medicare patient stay over the federal fiscal year that started Oct. 1 and runs through September 2014. The potential bonuses and penalties were higher than they were last year, when the maximum at stake was 1 percent.

To assess quality, Medicare looked not only at how hospitals scored in comparison with each other, but also how much each improved from two years ago compared to other hospitals.

A hospital is judged on whichever score is higher, so some hospitals with subpar quality rankings are still getting more money because they showed vast improvement.

It won’t be clear how much any hospital’s bonuses and penalties amount to in dollar figures until next October because it depends on how much a hospital ultimately bills Medicare.

This year, 45 percent of a hospital’s score is based on how frequently it followed basic clinical standards of care, such as removing urinary catheters from surgery patients within two days to decrease the chance of infections. Thirty percent of the score is based on how patients rate the way they felt they were treated in the hospital, such as whether the doctors and nurses communicated well.

Medicare added its first measure of a medical outcome, looking at death rates of patients admitted for heart attacks, heart failure or pneumonia.Those mortality rates, calculated from the number of Medicare patients who died in the hospital or within a month of discharge, count for 25 percent of a hospital’s score.

The incentive program has received a mixed reception among hospital executives. Some complain that patients’ views sometimes are swayed by the swankiness of the hospital, and that hospitals that treat the very sickest patients often get the worst evaluations.

Physician-owned hospitals that focus on just a few specialties have tended to do particularly well in the program, as evidenced by the Arkansas Heart Hospital’s record bonus this year. Some leaders also object that even if they show improvements, their hospital can lose money if the improvements are not as great as others.

Will Penalties Bring Change?

Researchers are unsure whether the penalties are significant enough to trigger major improvements, especially in areas such as mortality, where there’s no definitive explanation for why some hospitals do such a better job than others in keeping patients alive.

“Shame and penalties, I don’t know if that’s the best way to get organizations to change,” said Leslie Curry, a researcher at the Yale School of Public Health.  Her work has found that hospitals with low mortality rates are the ones where it is a priority of executives and where there is a culture where front-line workers such as nurses and lab technicians feel comfortable raising concerns to doctors and devising better methods.

“The fiscal penalties are nominal, frankly, in the scheme of things,” she said.

Others say even small differences in payments provide strong encouragement for hospitals to improve. “Sometimes institutions may think they’re performing excellently until they see outside data that compares to your peers,” said Dr. Richard Bankowitz, the chief medical officer of Premier, a group that works with hospitals to improve quality. “People are motivated to excel. Nobody wants to be in the bottom quartile anymore.”

The addition of mortality rates into the scores provides hospitals with their biggest challenge yet. Amanda Berra, a consultant at The Advisory Board, a Washington health care consulting firm, interviewed 40 chief medical officers at hospitals about mortality rates.

“They were very split. About half of them said you could not have a more powerful measure. On the other side we heard people who were really unenthusiastic,” she said. “We heard that the data is not super meaningful. They felt they had drastically improved in recent years and have kind of gotten where they could go.”

The average penalty grew to 0.26 percent, up from 0.21 percent in the first year of the program. North Georgia Medical Center in Ellijay is the only hospital besides Gallup to lose more than 1 percent of its reimbursements: it will lose 1.04 percent.  Denver Health Medical Center, a highly respected safety-net hospital, is losing 0.71 percent of its reimbursements.

The hospital that was penalized the most last year, Auburn Community Hospital in upstate New York, reduced its 0.90 penalty, but will still lose 0.55 percent.

The average bonus was 0.24 percent, almost the same as last year’s 0.23 percent. Large bonuses are going to some major teaching hospitals, such as Thomas Jefferson University Hospital in Philadelphia and Duke University Hospital in Durham, N.C. Most are being distributed among smaller institutions, such as Pikeville Medical Center in Kentucky.

“The dollars are less important in terms of impact than the fact that the nation is sending a signal through the payment mechanism that there’s something to be worked on in the care we deliver,” said Nancy Foster, an executive at the American Hospital Association. “It’s a national symbol to health care providers that here is an area where you can do better.”

Many Past Winners Continue To Get Bonuses

Most winners from last year stayed winners and losers stayed losers. But there were some switches. Oaklawn Hospital in Marshall, Mich., improved its score the most from last year. In place of a 0.26 penalty, Oaklawn will receive a 0.65 percent bonus. A number of prominent academic medical centers also turned around their scores.

Vanderbilt University Medical Center in Nashville, Massachusetts General Hospital in Boston, New York-Presbyterian Hospital in Manhattan, Cedars-Sinai Medical Center and Ronald Reagan UCLA Medical Center, both in Los Angeles, and Yale-New Haven Hospital were among the 300 places that went from a penalty to a bonus.

A total of 416 hospitals that won bonuses last year will be penalized this year. Centura Health-St. Thomas More Hospital in Canon City, Colo., dropped from a 0.08 percent bonus to a 0.72 percent penalty, the largest decrease.

This program is one of several Medicare has launched to make hospitals and doctors pay more attention to how their treatments compare with other hospitals, and to be more careful with public money.

Medicare gives bonuses to the private Medicare Advantage insurance plans that score well on quality metrics. In 2015, the health law calls for the government to begin a quality payment program for physician groups of 100 professionals or more, and that is to be expanded to all doctors by 2017.

The goal of all these programs is to replace the current financial incentive in Medicare, in which the only way for a hospital to get paid more is to perform more procedures and take on more patients.

For hospitals, the quality payments come on top of Medicare’s penalties on 2,205 hospitals with higher than expected readmission rates. The agency is doling out a maximum punishment this year of 2 percent.

As a result two out of three hospitals are losing money starting last month from the combined effects of the quality and readmissions programs. Pineville Community Hospital in Kentucky is losing 2.57 percent of its reimbursements, the largest penalty in the country.

Twenty-one other hospitals are losing 2 percent or more. These cuts come on top of reductions in special payments that go to hospitals that treat large numbers of low-income people.

Only 729 hospitals will end up with an increase in payments from the combined readmissions and value-based programs. Maine Coast Memorial Hospital in Ellsworth fared the best, gaining 0.80 percent.

Hospitals that are designated as critical access facilities, certain cancer hospitals and places with too few cases to be accurately measured were excluded from both programs.

Maryland hospitals are exempt because that state has a unique payment arrangement with Medicare.

Medicare relies on information found on hospital bills to determine the quality of care. In judging death rates, Medicare looked at patients admitted from July 2011 through June 2012, and compared those rates with how the hospitals performed between July 2009 and June 2010.

For the clinical and patient satisfaction measures, Medicare assessed hospital performances from April 2012 through December 2012, and compared them with scores during the same months in 2010.

The amount of money at stake increases to 1.5 percent of payments in October 2014, and continues to grow by a quarter percent until it reaches 2 percent.

Medicare is planning to add new measures next year, including comparisons of how much patients cost Medicare at different hospitals and rates of medical mishaps and infections from catheters.

In addition, the maximum readmission penalties grow to 3 percent next year, and Medicare is launching a third incentive program that takes an additional 1 percent of payments away from hospitals with the most patients who suffered injury or infection during their stay.

Combined, these three quality programs have the potential to strip away as much as 5.5 percent of Medicare payments from the worst performing hospitals starting next October.

“We’re moving more toward outcomes measures,” Conway said. “We’re moving away from volume and toward quality.”

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jrau@kff.org

This article was produced by Kaiser Health News with support from The SCAN Foundation.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Jerral Hancock and Stacie Tscherny Portrait

Finally home, injured vets face new lives as VA faces costs

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By Jessica Wilde, News21

This report is part of a project on post-9/11 veterans in America produced by the Carnegie-Knight News21 program.

Jerral Hancock wakes up every night in Lancaster, Calif., around 1 a.m. dreaming he is trapped in a burning tank. He opens his eyes, but he can’t move, he can’t get out of bed and he can’t get a drink of water.

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

Hancock, 27, joined the Army in 2004 and went to Iraq, where he drove a tank. On Memorial Day 2007 — one month after the birth of his second child — Hancock drove over an IED. Just 21, he lost his arm and the use of both legs, and now suffers from post-traumatic stress disorder.

The Department of Veterans Affairs pays him $10,000 every month for his disability, his caretakers, health care, medications and equipment for his new life.

Jerral Hancock and Stacie Tscherny Portrait

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

No government agency has calculated fully the lifetime cost of health care for the large number of post-9/11 veterans of the wars in Iraq and Afghanistan with life-lasting wounds.

But it is certain to be high, with the veterans’ higher survival rates, longer tours of duty and multiple injuries, plus the anticipated cost to the VA of reducing the wait times for medical appointments and reaching veterans in rural areas.

“Medical costs peak decades later,” said Linda Bilmes, a professor in the Kennedy School of Government at Harvard University and coauthor of “The Three Trillion Dollar War: The True Cost of the Iraq Conflict.”

As veterans age, their injuries worsen over time, she said. The same long-term costs seen in previous wars are likely to be repeated to a much larger extent.

Post-9/11 veterans in 2012 cost the VA $2.8 billion of its $50.9 billion health budget for all of its annual costs, records show. And that number is expected to increase by $510 million in 2013, according to the VA budget.

Like Hancock, many veterans returning from Iraq and Afghanistan have survived multiple combat injuries because of military medicine’s highly advanced care. Doctors at Brooke Army Medical Center in San Antonio repaired Hancock’s body with skin grafts and sent him to spinal-cord doctors for the shrapnel that ultimately left him paralyzed. He still has his right arm, but he can only move the thumb on his right hand.

Injuries like Hancock’s likely will lead to other medical issues, ranging from heart disease to diabetes, for example, as post-9/11 veterans age.

“So we have the same phenomenon but to a much greater extent,” Bilmes said. “And that drives a lot of the long-term costs of the war, which we’re not looking at the moment, but which will hit in 30, 40, 50 years from now.”

Veterans like Hancock with polytraumatic injuries will require decades of costly rehabilitation, according to a 2012 Military Medicine report that analyzed the medical costs of war through 2035. More than half of Iraq and Afghanistan veterans are between the ages of 18 and 32, according to 2011 American Community Survey data. They are expected to live 50 more years, the Institute of Medicine reports.

About 25 percent of post-9/11 veterans suffer from post-traumatic stress disorder, and 7 percent have traumatic brain injury (TBI), according to Congressional Budget Office analyses of VA data. The average cost to treat them is about four to six times greater than those without these injuries, CBO reported. And polytrauma patients cost an additional 10 times more than that.

Post-9/11 veterans use the VA more than other veterans and their numbers are growing at the fastest rate. Fifty-six percent of Iraq and Afghanistan veterans use the VA now, and their numbers are expected to grow by 9.6 percent this year and another 7.2 percent next year, according to a VA report from March 2013.

Jerral Hancock Drinking Water

Hancock drove over an IED in Iraq in 2007. Hancock’s stepfather, Dirrick Benjamin, helps him take his medication. He and Hancock’s mother take care of him full time, helping him with everyday tasks like getting dressed and drinking water. (Photo by Jessica Wilde/News21)

 

In response to multiple injuries suffered by Iraq and Afghanistan veterans, the VA established its polytrauma care system in 2005, creating centers around the country where veterans are treated for multiple injuries, ranging from TBI and PTSD to amputations, hearing loss, visual impairments, spinal-cord injuries, fractures and burns.

Post-9/11 veterans make up around 90 percent of polytrauma patients, said Susan Lucht, program manager of the polytrauma center at the Southern Arizona VA Health Care System in Tucson.

Each polytrauma patient costs the VA on average $136,000 a year, according to a CBO report, using VA data from 2004 through 2009. And many of their medical issues will never go away.

One TBI patient at the Tucson center, Erik Castillo, has received speech, physical, occupational, psychological and recreational therapies for all of the paralysis, cognition and memory issues associated with injuries he received in a bomb blast in Baghdad.

But Castillo’s treatment is exactly what medical professionals and economists say could potentially be cost-saving as well as life-saving.

If the VA treats primary injuries early on and creates a community and family support system, it might be able to lower costs later, said Dr. James Geiling, Dr. Joseph Rosen and Ryan Edwards, an economist, in their 2012 Military Medicine report.

“And those are the costs that we’re trying to reduce by giving the care that we do,” said Dr. G. Alex Hishaw, a staff neurologist at the Tucson center.

Castillo has been living with TBI for nine years, and he still goes to the VA three times a week for therapy. “I’ll utilize the VA for the rest of my life,” he said.

The shrapnel that entered Castillo’s brain from a bomb in Baghdad in 2004 burned a portion of his frontal lobe, which had to be removed. Doctors told his parents that he wouldn’t survive and that if he did, he would need care for the rest of his life.

Slowly, Castillo started to re-create himself. He learned to talk again, to eat again, to move his left arm and leg. Now, he is going to college.

“We want them to graduate,” Lucht said. “But they always know that this is their foundation. This space is here. And their needs will change as they age.”

As Hancock and other post-9/11 veterans age, they will need increased medical care and will become more expensive for the VA. The injuries they have now will likely lead to more complicated and expensive medical issues. TBI, for example, may lead to greater risk of Alzheimer’s disease, psychological, physical and functional problems, and alcohol-abuse disorders.

Doctors and economists argue that today’s conversation should not only be about the primary wounds of war, but about the medical issues that are often associated with them. PTSD, for example, is often associated with smoking, substance abuse, depression, anxiety, heart disease, obesity and diabetes. Amputations are associated with obesity, cardiovascular disease, osteoarthritis, back pain and phantom limb pain.

“We should help an amputee to reduce his cholesterol and maintain his weight at age 30 to 40, rather than treating his coronary artery disease or diabetes at age 50,” Geiling, Rosen and Edwards wrote.

“Society is not yet considering the medical costs of caring for today’s veterans in 2035 — a time when they will be middle-aged, with health issues like those now seen in aging Vietnam veterans, exacerbated by comorbidities of post-traumatic stress disorder, traumatic brain injury and polytrauma,” they wrote.

Polytrauma centers have expanded across the country. But that doesn’t mean that all veterans live close enough to access them. In many parts of country, health care is hampered by distance because veterans who use the VA live far away from their closest VA hospital.

For Army Spc. Terence “Bo” Jones, it is more important that he live near his family.

U.S. Army Spc. Terence “Bo” Jones stepped on an IED in Afghanistan in 2012, and lost both of his legs. Now an outpatient at the VA polytrauma center in San Antonio, Texas, Jones is learning to walk on prostheses and drive an adapted car with only his hands. (Photo by Jessica Wilde/News21)

Jones lost both of his legs to an improvised explosive device blast in Afghanistan in 2012. Like Hancock, Jones woke up at Brooke Army Medical Center with his family by his side.

He was 21 when he stepped on the IED. It shot him 10 feet into the air and he landed in a nearby well. He doesn’t remember it, but his friends told him he was conscious and trying to climb out.

Now an outpatient at the VA polytrauma center in San Antonio, Jones is learning to walk on prosthetic legs, provided to him by the VA. The VA also provides adaptive driving equipment for his car, and he is taking driver education to learn how to drive with only his hands. One day, he hopes to get a service dog, and the VA will pay for veterinary care and equipment for the dog to help its owner.

“We can get them anything that they need,” Lucht said.

The VA provides other assistive accommodations for injured veterans — from grab bars and walk-in showers to wheelchairs and specialized seating. And a lot of veterans wear out their prosthetic limbs because they’re active, Lucht said.

When Jones finishes rehab, he plans to move home to Idaho, go to college and open his own shop doing custom cars and motorcycles. But in Idaho, Jones won’t be near a polytrauma center anymore.

One of the most rural veteran populations in the country is served by the Reno, Nev., VA hospital, said Darin Farr, the hospital’s public affairs officer. “We’re actually considered frontier,” he said.

The hospital’s patients come from as far away as 280 miles. More than 29,000 veterans are enrolled in the Reno hospital, staffed by 1,200 employees, only 40 to 50 percent of whom actually provide medical care.

Many VA hospitals fall behind in entering data from private health records or following up with patients, especially mental health patients for whom follow-up care is particularly important, according to VA Office of Inspector General reports.

The VA doesn’t always provide timely mental health evaluations for first-time patients, and existing patients often wait more than the recommended 14 days for their appointments, the OIG reported last year.

Veterans have complained for many years about long wait times to schedule appointments. “Long wait times and inadequate scheduling processes at VA medical centers have been long-standing problems that persist today,” the U.S. Government Accountability Office reported in February. Inconsistent scheduling policies, staffing, phone access and an outdated scheduling system make the problem worse.

Meanwhile, both the GAO and OIG have reported that VA’s data on wait times for medical appointments is unreliable, and some schedulers entered incorrect dates or changed them to meet performance standards.

Farr says the Reno hospital faces unique challenges that might contribute to wait times. The hospital competes with other hospitals for employees who might pay more than the government does.

“We don’t have a lot of space,” he added. The hospital schedules more than 373,000 outpatient visits and 4,200 inpatient visits every year. But it only has 64 hospital beds — 14 psychiatric, 12 ICU and only 38 for general use.

When Terence Jones finishes rehab at the polytrauma center in San Antonio, he hopes adaptive equipment will help him return to a normal life. Jerral Hancock, on the other hand, knows that he never will.

Hancock misses the adrenaline rush of life before his injury. He longs for a wheelchair that will go faster than 5 mph. He described the time he fell out of his hospital bed as exhilarating. He busted his cheek open, but he loved it.

With the $100,000 the Defense Department gave Hancock for his injuries when he was discharged, he bought two mobile homes outside Los Angeles, one for him and his two children, ages 9 and 6, and one for his mother and stepfather, who take care of him full time. Hancock supports all of them with his monthly disability check from the VA.

The VA bought him a wheelchair and put a lift into his front porch. They widened the doors in his mobile home so his wheelchair could fit in and out. They will pay for his medications and all of his medical care for the rest of his life.

When Hancock arrived at his new mobile home, he couldn’t fit his wheelchair in the front door. So he kept one wheelchair inside, and his stepdad carried him through the door and down the steps to a second wheelchair that he paid for himself. It took eight months for the VA to pay him $1,000 for the second wheelchair, and four months to put a lift into his front porch.

“I was stuck in the house for six months over this fight,” Hancock said. “I had a wheelchair upstairs and I had a wheelchair downstairs. And my caretaker carried me up and down the stairs from wheelchair to wheelchair. It was ridiculous.”

The VA also bought Hancock an $85,000 arm that he could attach to his shoulder to use. But he can’t seem to get it to work.

The VA gave Hancock $11,000 toward a car, but his mother said that doesn’t come close to the cost of a handicap-equipped vehicle. Instead, he bought a seven-passenger bus with a lift for his wheelchair.

Even with all of the money that the VA spends on Hancock’s medical and family care, he still lives in a mobile home, and his bedroom has little extra space with a hospital bed and a wheelchair in it. He can’t fit into his kids’ bedrooms. He can’t drink a glass of water on his own. And his air conditioning hardly works, even though he can’t be in the heat for too long because his burns prevent him from sweating.

Hancock’s children also have had to adjust.

“My son watched me walk off — he was going on 3 — and I jumped on a bus with a couple hundred pounds of gear,” he said. “The next time he saw me, I lost 100 pounds … I looked like a skeleton and I had tubes coming out everywhere … My daughter, this is all she knows.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Backlogs for veterans could grow under shutdown

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Purple Heart_ThumbnailBy Pamela M. Prah
Stateline Staff Writer

Veterans, who already face a lengthy backlog in getting help, risk not getting their disability and pension benefits at all next month if the federal government shutdown lasts several weeks.

The Department of Veterans Affairs said it has enough money to process veterans’ claims for pensions, compensation, education and vocational rehabilitation programs through late October, but a prolonged shutdown would suspend those programs once the money runs out.

And while veterans’ medical care is protected, some call centers and hotlines have already been suspended under the budget impasse between Congress and the White House.

“B/c of #shutdown, @VAVetBenefits overtime ends today. After decreasing backlog 30%, we project it will start increasing,” Tommy Sowers, assistant secretary for public and intergovernmental affairs at the VA, tweeted on the first day of the shutdown.

States play a key role in ensuring that veterans receive their benefits. Ever since World War II, each state has developed its own department or agency specifically to manage veterans’ affairs.

Once the state processes a veteran’s pension, compensation and disability claim, that claim is then sent to the federal VA “and at that time, it’s out of our control,” said Robert Horton, spokesman for the Alabama Department of Veterans Affairs, with the federal VA either approving or rejecting the claim.

The federal VA has been widely criticized for the backlog. As of Sept. 28, the VA said there were 725,469 casespending, 58 percent of them for more than 125 days.

State veterans agencies can offer additional programs to veterans. Collectively, states contribute more than $6 billion annually for veterans and their families, according the National Association of State Directors of Veterans Affairs, an organization that dates back to 1946.

“If the federal VA has to lay off employees, then claims won’t be processed and veterans possibly won’t receive their benefits or payments for pension and compensations, but right now there is no effect on the state VA,” Horton of the Alabama VA said.

Which VA Services Are Protected?

All VA medical facilities and clinics will remain fully operational during the federal shutdown, including VA hospitals. In 2009, Congress passed a law to fund the VA one year in advance.

This allows the VA health care system to plan ahead and ensures that VA health care is funded for an additional year beyond the government shutdown, according to a  “Government Shutdown FAQ” from Tom Tarantino, chief policy officer for the Iraq and Afghanistan Veterans of America (IAVA), a nonprofit, nonpartisan organization for new veterans.

Also not affected are VA medical appointments, prescription drug phone lines, home loan processing and veterans’ crisis lines, according to the VA’s “Field Guide to Government Shutdown.”

“While veterans may be more protected than other constituencies, a government shutdown does not bode well for top priorities within the veterans’ community,” Tarantino wrote.

Among the VA services that are affected under the shutdown:

  • Call centers and hotlines related to education and consumer affairs are suspended as well as the Inspector General Hotline (1-800-488-8244).
  • No decisions on claims appeals or motions will be issued by the Board of Veterans Appeals.
  • The VA’s Veterans Benefits Administration will not be able to continue overtime for claims processors.
  • Recruiting and hiring of veterans job applicants will cease with the exception of the Veterans Health Administration.

Bill Allman, project analyst at the Washington state’s veterans benefit enhancement projects, called the shutdown unfortunate. His department has spearheaded a project that has moved nearly 10,000 veterans from the state’s Medicaid rolls to the VA’s health care system using a federal database known as the “Public Assistance Reporting Information System,” or PARIS.

Allman said the federal manager of the PARIS system has been furloughed until a budget resolution can be reached.  “This may drag on much longer than any of us predicted,” he said. “It really drives home the impact that the shutdown has on people’s lives, as well as the additional work that it creates for others.”

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Health law offers veterans new options

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ACA health reform logoBy Michelle Andrews

Military veterans will have more health insurance options under the Affordable Care Act, but some vets, like many Americans, may still struggle to find affordable, accessible care that meets their needs.

Roughly 40 percent of the 22.3 million military veterans receive health-care services from the Veterans Health Administration, which operates a nationwide network of medical centers, hospitals and clinics.

Many veterans are eligible for both VA health care and Medicare, Medicaid or Tricare, the health plan for active and retired military and their families. About half of veterans have private insurance; approximately one in 10 veterans younger than 65 are uninsured.

Veterans who were honorably discharged after being on active duty for at least two years may qualify for VA health services. Since funding for the VA health program is limited, however, priority is given to veterans who have service-related disabilities or low incomes.

Although there are no premiums for VA health care, some veterans may owe co-payments for services. Veterans who return from active military duty are typically eligible for free VA health care for five years.

Under the Affordable Care Act, most people will have to have health insurance starting in January or pay a penalty. Veterans who are enrolled in VA health care won’t have to buy additional coverage, although they can supplement their coverage if they want to.

Mike Sage, 64, a Vietnam War combat veteran, pays $15 per visit for primary-care services and $50 for specialist care at the VA clinic near his home in Monmouth, Ill.

Prescription drugs are $8 for a 30-day supply. But his wife, Kay, like many veterans’ spouses, doesn’t qualify for VA health care. They plan to check out the policies offered on the Illinois health insurance exchange this fall to see if there’s a better option than the catastrophic-coverage plan with a $5,000 deductible that she currently carries.

Sage was relieved to learn that his VA health care counts as coverage under the ACA. “As long as I’m not subject to a penalty [for not having insurance], we’ll do some comparative shopping for her,” he says.

Kay Sage might qualify for a premium tax credit for coverage on the exchange if the couple’s household income is between 100 percent and 400 percent of the federal poverty level ($15,510 to $62,040 for a family of two in 2013), according to the Treasury Department.

The expansion of Medicaid under the Affordable Care Act — which states are currently wrestling over whether to implement — could also affect veterans’ health care. The law allows the expansion of the federal-state program for low-income people to include adults with incomes up to 138 percent of the federal poverty level ($15,856 in 2013).

According to an analysis published by the Urban Institute last month, four in 10 uninsured veterans have incomes below 138 percent of the federal poverty level, potentially enabling them to qualify for Medicaid if their states expand the program. Most of those veterans have incomes below 100 percent of the poverty level.

“For these veterans, it’s critical that their state expand Medicaid,” says Jennifer Haley, a research associate at the Urban Institute who co-authored the report.

In states that don’t expand their programs, veterans whose income falls below 100 percent of the poverty level will generally not qualify for Medicaid, nor for subsidized coverage on the exchanges.

Even though a non-disabled veteran may meet the income threshold for VA health care — nationally, about $34,000, further adjusted by geographic location — he or she may not live near VA facilities or know that VA care is available, according to the report.

At a hearing last month before the House Committee on Veterans’ Affairs, VA officials said they expect a net increase of 66,000 veterans seeking health care through VA facilities when the mandate to have health insurance kicks in next year.

Some veterans will come into the VA system but others will leave to seek coverage on the exchanges or through Medicaid, they said. Those who are eligible for more than one health program may pick and choose, using one program for cheaper prescription drugs, for example, and another for specialist care.

But more choices may not mean better care, says Kenneth Kizer, director of the Institute for Population Health Improvement at the UC Davis Health System.

In an opinion piece published last year in the Journal of the American Medical Association, Kizer, a former VA official, noted that having access to multiple plans can lead to fragmented care, increasing the chances of errors and other complications.

“Tests get repeated, drugs get prescribed that may not be compatible with each other,” he says. “One provider may not realize what the other is doing.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column toquestions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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New online database reveals thousands of hospital violation reports

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Sign for an emergency room.By Christine Vestal
Stateline Staff Writer

Hospitals make mistakes, sometimes deadly mistakes.  A patient may get the wrong medication or even undergo surgery intended for another person.  When errors like these are reported, state and federal officials inspect the hospital in question and file a detailed report.

Now, for the first time, this vital information on the quality and safety of the nation’s hospitals has been made available to the public online.

A new website, www.hospitalinspections.org, includes detailed reports of hospital violations dating back to January 2011, searchable by city, state, name of the hospital and key word.

Previously, these reports were filed with the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid (CMS), and released only through a Freedom of Information Act request, an arduous, time-consuming process.

Even then, the reports were provided in paper format only, making them cumbersome to analyze.

Release of this critical electronic information by CMS is the result of years of advocacy by the Association of Health Care Journalists, with funding from the Ethics and Excellence in Journalism Foundation.

The new database makes full inspection reports for acute care hospitals and rural critical access hospitals instantly available to journalists and consumers interested in the quality of their local hospitals.

The database also reveals national trends in hospital errors. For example, key word searches yield the incidence of certain violations across all hospitals.  A search on the word “abuse,” for example, yields 862 violations at 204 hospitals since 2011.

Once they receive a complaint, federal and state inspectors attempt to discover the cause of a hospital error or violation. For example, poor safety procedures result in thousands of patients slipping and falling each year in U.S. hospitals, and poor sterilization methods cause thousands more to contract infections. Poor administrative procedures can result in patients receiving wrong treatments.

Once the causes of specific problems are determined, federal and state authorities require hospitals to file a plan to correct them.  These plans still remain under wraps, as do inspection reports on psychiatric hospitals and long-term care hospitals.

Also unavailable are the results of complaint-based and routine inspections by the nation’s largest private hospital accreditation organization, The Joint Commission.

Because the commission is a private entity, it is not subject to the Freedom of Information Act.  For this reason, the health care journalism association has launched a new effort to gain the release of these reports on hospital quality and safety.

The commission has rejected two previous requests by the journalism group saying disclosure of the information would hamper its efforts to improve hospital quality.

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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My doctor is taking payments from drug companies – what should I do?

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Dollars for Docs: How to Evaluate Drug Payment Data

by Nicholas Kusnetz
ProPublica

Update: This story has been revised to reflect updated Dollars for Docs data on March 11, 2013.

Drug companies have long kept secret details of the payments they make to doctors for promoting their drugs. But 15 companies have now made some of that information public.

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ProPublica’s Dollars for Docs pulls their disclosures into a single database so patients can easily search for their doctor. We created Dollars for Docs database partly as an educational tool. How can patients use it? Here are some suggestions.

Q. My doctor is on this list. Should I care?

A. If your doctor is listed, it’s because he or she received money from one of the drug companies for promotional activities or consulting.

Payments are legal, so it doesn’t mean your doctor has done anything wrong. But research has shown that drug company marketing can influence what a doctor prescribes, and some experts say it is cause for concern.

Others say the information should carry less weight. They say the amount of money a doctor receives is less important than personal recommendations and the doctor’s training and experience.

One word of caution: Some doctors in our database have the same or similar names, so be sure to confirm with your doctor that he or she is actually the one on the list. Names and addresses on the data are as disclosed by the companies, and they sometimes use variations.

Q. My doctor is not on the list. What does that mean?

A. ProPublica included payments only from the drug companies that have made these relationships public so far. Many doctors do not do promotional work or consulting for drug companies.

Others may receive such payments from companies that haven’t yet disclosed them. So even if your doctor isn’t on the list, experts say it’s worth asking about the issue.

Q. What’s the best way to bring up the issue with my doctor?

A. Although it can feel awkward, some experts say it’s important to ask about potential conflicts of interest. Others say patients should trust their doctors to do what’s right for them.

If you do raise the issue, tell your doctor you want to feel confident the drugs he is prescribing for you are best for the job.

According to a 2010 national survey by Consumer Reports, conducted for this project, 70 percent of adults say doctors should tell their patients about payments they’ve taken from a drug company whose drugs they are about to prescribe.

Ask first if your doctor has any financial relationships with drug companies. If so, ask about what companies are involved, the nature of each relationship and the duration.

Most often, doctors are paid for promotional activities, such as speaking to other doctors about a drug, or for consulting or research.

It’s important to ask whether medications you are taking are made by the companies. If the answer is yes, it’s not necessarily a problem but is worth discussing further.

Q. How can I be sure my doctor is offering unbiased advice about a drug?

A. If your doctor has prescribed you medication made by a company he or she receives payments from, you should ask whether there are any cheaper generic alternatives. How does the drug compare to others in its class? What are the side effects? Are there alternatives with fewer side effects? And importantly, are there non-drug alternatives, such as diet, watchful waiting or physical therapy?

It may be that the drug you are on is the best option. But sometimes a drug company will market a new, more expensive version of an established drug even when the older one is cheaper and effective.

Asking these questions will show your doctor you’re aware of these issues.

Q. Where can I learn more about drugs my doctor prescribes?

A. Searching the Web will bring up a wealth of links and literature. One site that has comprehensive drug and supplement information is MedlinePlus.

Want to know more? Follow ProPublica on Facebook and Twitter, and get ProPublica headlines delivered by e-mail every day.

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Study: PTSD treatment for soldiers improving, but there’s still work to be done

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Photo: U.S. Army)

By Matthew Fleming

When it comes to diagnosing and treating posttraumatic stress disorder among soldiers returning from service in Afghanistan, Iraq and other modern battle theaters, the Veterans Administration and the Department of Defense still have a long way to go to meet the needs of armed service members, according to a new Institute of Medicine study.

In a report released Friday and based on the first phase of a two-part study, the IOM called for more screening and better assessments of PTSD cases – suggesting that screening be done at least once a year when primary care providers see service members.

It also recommends that the VA build on these early identification efforts by improving soldiers’ timely access to evidence-based care.

In addition, the VA should invest in research regarding telemedicine, Internet-based approaches and other technological advances that could help patients overcome barriers to getting help.

Also, military health care providers should take steps to coordinate treatment for PTSD with other health conditions that affect these service members and veterans.

The study estimated that PTSD, which is often triggered by traumatic events that are commonplace in combat life, affects somewhere between 13 to 20 percent of the 2.6 million soldiers who fought in Iraq or Afghanistan since 2001.

Of those veterans diagnosed with PTSD, 50 percent also show signs of other related conditions, such as depressive symptoms and substance abuse.

The absence of support from society and loved ones can increase the risk. In 2010, the VA treated more than 430,000 veterans with the disorder.

The IOM’s research grew out of congressional concern about the incidence of PTSD among returning soldiers. Congress directed the VA and Defense Department to support the project in the FY 2010 National Defense Authorization Act.

In the first phase, the IOM researchers conducted site visits and reviewed available information, but did not look at original data, like the number of soldiers who relapsed after receiving treatment, according to Dr. Sandro Galea, the IOM panel’s chair.

Findings from the study’s second phase, which are scheduled for release in 2014, will involve “examining databases of funding organizations to make systematic assessments of new treatments coming up the pipeline,” said Galea.


This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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VA nurses scrutinized after patient deaths in two states

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by Tracy Weber and Charles Ornstein
ProPublica

After a patient died last year at a Veterans Affairs hospital in Manhattan, federal inspectors discovered nurses in his unit had a startling gap in their skills: They didn’t understand how the monitors tracking vital signs worked.

None of the nurses interviewed could accurately explain what would happen if a patient became disconnected from a cardiac monitor — which allegedly occurred to the patient who died, according to an October 2011 report from the U.S. Department of Veterans Affairs’ inspector general.

The incident followed two deaths in the cardiac monitoring unit at a VA hospital in Denver that raised similar questions about nurse competency.

Earlier this month, a broader review by the VA inspector general of 29 VA facilities found only half had adequately documented that their nurses had the needed skills. Some nurses “did not demonstrate competency in one or more required skills,” but there was no evidence of retraining, the report said.

An outside nursing expert who reviewed the reports at ProPublica’s request called them “troubling” and said the fact that the lapses weren’t caught and corrected “signified much broader problems.”

The inspector general’s findings reveal “a lack of oversight and adherence to accepted clinical and regulatory standards,” said Jane Hirsch, a clinical professor emeritus at the University of California, San Francisco School of Nursing, who previously oversaw nursing at U.C. San Francisco Medical Center.

The April 20 IG report also noted that previous inspections had found nurse competency issues in “dialysis, mental health, long-term care, spinal cord injury, endoscopy procedure areas, the operating room and the cardiac catheterization laboratory and with reusable medical equipment.”

In a response to the inspector general, the VA pledged to create uniform competency standards for its 152 hospitals and to ensure that evaluations of every nurse’s skills are up-to-date. Nurses will not be able to work in areas in which they have not demonstrated competency.

A VA spokeswoman declined further comment.

Nurse competency has increasingly become an issue in medicine. Hospitals and clinics create their own procedures and tests for assessing the skills of nurses, but theiradherence to these policies is spotty.

Outside regulators don’t test individual nurses, but simply check if a sampling of the nurses’ files have the appropriate paperwork certifying competency.

That’s what VA’s inspector general did for the April review. As such, officials acknowledged that they could not verify whether nurses at those hospitals, or others, are providing competent care.

“We did not look at actual care or actual competence,” Julie Watrous, director of the inspector general’s combined assessment program, which inspects each VA hospital every three years, told ProPublica.

Only half the 29 facilities included in the new report had complete nurse skill assessment records that met the hospitals’ standards, inspectors found. Of the 349 nurses whose files were examined, paperwork showed that 58 lacked skills in at least one area. And for 24 in that group, there was no evidence that anything was done in response.

In an interview, however, the IG official who coordinated the report said she was generally pleased with the findings. Although both the VA and its hospitals had room to improve, she said, all of the hospitals had policies in place and at least some proof of skills in each nurse’s file.

“We never found one single site or even person that didn’t have at least components of competency assessment and validation,” said Carol Torczon, associate director of the St. Petersburg, Fla., office of the inspector general. “Where we found the holes was in the paper process.”

Torczon said she believed that the problems identified in Denver and New York were not reflective on the care generally provided by VA nurses in cardiac monitoring units.

Inspectors in the New York and Colorado cases said they could not definitely tie the deaths of the patients to their nurses’ care. But they noted that their lack of training put patients at risk.

Registered nurses assigned to telemetry units typically place cardiac leads, set parameters for the monitors tracking each patient, verify heart rhythms and take appropriate actions if there is an irregularity. They also enter progress notes and inform doctors of any changes.

After the patient in New York died, inspectors quizzed nurses and a biomedical engineer about what would happen if a patient got disconnected. “According to some staff, a ‘red alarm’ would be triggered since a disconnected lead was considered critical,” the report said, “whereas other staff told us that a disconnected lead would trigger a yellow alarm or that it would not trigger any alarm at all.”

Inspectors also found no evidence that the nurses’ competence had been checked. Records showed that one of the patient’s nurses had last received training on the monitors 13 years earlier.

Two years earlier at a VA hospital in Denver, inspectors looked into the deaths of two patients on cardiac monitors. After the first death, the hospital gave nurses a basic test of their ability to interpret monitor readings: only one of 28 passed, according to a January 2010 report. The nurse in charge when both patients died had never received specialized training in cardiac monitors.

Even after the second patient died in 2009, inspectors found “it was unclear who was responsible for telemetry training, and staff were not aware that policies had been updated.”

Both facilities vowed extensive reforms in responses that were included in the IG reports.

Experts say up-to-date competency evaluations are important because they ensure that nurses, who provide the bulk of the frontline care in hospitals, have the skills for their position.

“It would appear that the old adage ‘inspect what you expect’ has most certainly not been taken very seriously in these environments,” said Hirsch, who was chief nursing officer at UCSF Medical Center for nine years.

After reading the New York and Denver reports, Hirsch said her concern wasn’t the incidents themselves as much as that the competency of the nurses hadn’t been documented or evaluated in a long time.

Had she been in charge, the findings would have caused her “to be really nervous and want to jump on it immediately,” she said.

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Washington state program helps vets on Medicaid get their VA benefits

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It is commonly accepted that many poor veterans and their families find themselves on Medicaid, even though, in many cases, they would qualify for more generous benefits from the Department of Veterans Affairs.

The VA’s Aid and Attendance program, for instance, helps wartime veterans receive the care they need to stay in their homes or assist with long-term care expenses.

But many who are entitled to this benefit end up on Medicaid — which has significant implications for the veteran’s family members.

In 2003, the state of Washington began a pilot program to identify veterans who were falling through the cracks. In the years since, the program has served thousands of people who qualified for this assistance.

At the same time, it has helped relieve some of the fiscal pressure placed on the state’s Medicaid program by shifting these costs to the federal VA. Viewed as a win-win, the program has become a model for other states.

KHN asked two state officials invovled in the program’s operations to explain the basics of the Veterans Benefit Enhancement Project — how it came to be and why it is making a difference for both the state’s veterans and its budget.

Bill Allman, who developed and now manages the Washington State Health Care Authority’s program.Alex Deluao of the Washington State Department of Veterans Affairs

Bill Allman: How PARIS is helping veterans in need

About 10 years ago, I first heard about a federal databank called PARIS — the Public Assistance Reporting Information System. I

t was set up to allow both state and federal programs the opportunity to compare public assistance files, primarily to look for cheaters who were double-dipping by drawing the same kind of benefits from different government programs.

Astonishingly, a broader use of such a databank had gone unrealized until I started asking questions, particularly about the military and veteran program information available to the states.

With my background in medical assistance for the state of Washington, I was well aware of the fact that many poor veterans and their families were winding up on the rolls of Medicaid, never realizing that they might also be eligible for richer federal benefits.

For example, the VA will pay elderly/disabled veterans up to $23,396 per year and surviving spouses of veterans up to $12,691 per year.

And, the National Care Planning Council estimates that approximately 11.5 million seniors – about 33 percent of all people older than 65 – could qualify for pension or death pension benefits.

For my part, I am still stunned to realize how many veterans did not realize they qualified for the federal benefits.

It occurred to me that PARIS may offer a way to reverse this reality by pinpointing the many veterans who were seemingly falling through the cracks.

Here’s why: the PARIS data is keyed to an individual’s social security number, and includes information about state welfare and medical assistance billings, as well as that person’s eligibility for civil service benefits; Defense Department programs like CHAMPUS, a health plan for military dependents and surviving spouses; and the TRICARE managed care plan that serves many active duty military and retirees.

Therefore, armed with this databank, I had a way to uncover who was eligible but not receiving these veteran’s health care benefits.

In short, it was exactly what I had been looking for, because I was well aware that being on Medicaid was a disadvantage in another way.

If you know a veteran or family member in Washington State who needs our help, please let the VA know how we can reach them. 

When veterans died on Medicaid, their families usually lost their small estates because long-term-care-related Medicaid clients typically pay for a small portion of the health care they receive, but the programs do require the recovery of those costs if a client dies and leaves any kind of an estate behind.

Thus, the state, in this case Washington, has first claim or lien, through the “estate recovery process,” on a deceased veteran’s home, as well as other property and assets that went untouched while the individual was still alive.

But that’s not true for federal veteran benefits because those are provided in gratitude for the veterans’ service to country. As a Vietnam veteran myself, I was very conscious of what that difference might mean, and I had already begun to seek out ways to counter it.

PARIS was the answer. With a little effort, I found ways to use the federal databank to locate veterans on Medicaid and then help them transition to federal benefits. It had a good payoff for the state, too, which was dealing with budget crunches throughout the decade.

I took what I found to the head of my agency — Dennis Braddock, himself a helicopter pilot in the Vietnam War — and got the go-ahead to set up a pilot program in Clark County, which is located in southwestern corner of the state.

The initiative also has gotten the strong backing of Mike Gregoire, the husband of our current governor and a strong advocate for Washington state veterans.

We began our pilot in 2003, focusing at first on long-term care beneficiaries, most of them in nursing homes. From the very beginning, we worked in partnership with the Washington State Department of Veterans Affairs and other state social action programs.

Since then, we have become a model for many more states, with more than two dozen now beginning to evaluate the PARIS system and set up similar programs.

“Connecting veterans and their families to benefits they earned through their military service is simply the right thing to do,” John Lee, director of the Washington State Department of Veterans Affairs, told me. “This partnership allows us to reach out to veterans and families and let them know we’re here to help.”

For my part, I am still stunned to realize how many veterans did not realize they qualified for the federal benefits. In addition, they didn’t know that Medicaid benefits often aren’t free.

We’ve helped thousands of veterans in the eight years since we got our pilot up and going, and I think it’s fair to say we’ve saved millions of dollars for those veterans. Taxpayers, too, have benefited by some $30 million in cost avoidance as of the end of Fiscal Year 2011.

The program’s successes include not only moving vets onto federal VA health care  programs, but also enhancing some vets’ current benefits and lining up monthly cash payments and dependent benefits.

It’s amazing to me in retrospect that these loopholes exist in our health care system, letting people fall through the cracks when a little bit of forethought can prevent that.

I’m proud of our state for leading the way on this effort. The system we’ve pioneered is now in place to help future vets like those returning from Iraq and Afghanistan. I’m just one person and we’re just one state, but we made a big difference. That thought just knocks me down.

Bill Allman is the manager of the Washington State Health Care Authority Veterans Benefit Enhancement/PARIS Projects. Readers with questions about PARIS or related projects can contact him at William.Allman@hca.wa.gov.

Alex Deluao: Helping low-income veterans maintain the best possible quality of life

As Americans, we feel a sense of gratitude to those who raise their hands and defend our freedoms.

But sometimes, veterans miss out on the benefits they earned, something we often see when it comes to health care and long-term care.

You might be surprised that many people who served in the military either don’t consider themselves to be veterans or are too proud to ask for these benefits. This is especially true for older veterans whose military service is a distant memory, often decades old and sometimes purposefully forgotten.

For the most part, they probably got along just fine without anything from the government. But circumstances can change and sometimes extra help is necessary.

Take, for example, an older couple that recently received the assistance they needed from a veterans’ program.

The husband, a Korean War veteran, served his country, came home, and built a family and a career. He always had enough money saved away for the emergencies that life presented. But after suffering an injury, he knew he needed extra help.

His wife had been caring for him but she too was becoming frail, and he was worried that taking care of him was putting too big a burden on her.

So far, we have helped connect more than 3,300 veterans or their widows to these programs and their benefits.

That’s when the Veterans’ Affairs Aid and Attendance program proved crucial to this couple’s well-being.

This federal program can help wartime veterans remain at home or assist them in paying for long-term care. It’s available to lower-income veterans and their widows, who also qualify for VA pension benefits.

A large number of veterans across the country who qualify for this aid, however, somehow are slipping through the cracks. It leads to this very serious question: How do we connect veterans who are in need and who are eligible to this benefit?

Thanks to the creative thinking of employees at the Washington State Department of Social and Health Services and the Washington State Department of Veterans Affairs, we have found an answer.

In 2003, our agencies joined forces and started a pilot project to match federal VA data with the Public Assistance Reporting Information System.

PARIS, as it’s known, shows us who has applied for Medicaid benefits. When we match that information against the Federal VA’s data, we can identify eligible veterans or their widows, and help them apply for VA Pension and Aid and Attendance.

So far, we have helped connect more than 3,300 veterans or their widows to these programs and their benefits.

It’s one of those rare situations where everyone wins. Veterans receive monthly payments that can be used for in-home care or long-term care, and our state saves millions of dollars with fewer people using the Medicaid program.

Veterans also are able to utilize a benefit they earned through their military service, which, unlike Medicaid benefits, do not have to be re-paid.

There is nothing more satisfying than pioneering ways to help deserving people and we continue to be amazed at how much this partnership has done to help Washington’s veterans.

At WDVA, our goal is to help veterans and their families get connected with everything they earned, and we’re always looking for innovative ways to reach them.

If you know a veteran or family member in Washington State who needs our help, please let us know how we can reach them. Call us at 1-800-562-2308 or visit us online at www.dva.wa.gov. To find another State’s Department of Veterans Affairs visit http://www.nasdva.net/.

Alex Deluao is the manager of the Washington State Department of Veterans Affairs Olympia Service Center.


This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Survey Satisfaction Check List

How does your hospital stack up against the competition?

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Photo: Steve Woods

By Jordan Rau
This story was produced in collaboration with
 

Medicare has begun publishing patient safety ratings for thousands of hospitals as the first step toward paying less to institutions with high rates of surgical complications, infections, mishaps and potentially avoidable deaths.

The new data, available starting last week on Medicare’s Hospital Compare website, evaluate hospitals on how often their patients suffer complications such as a collapsed lung, a blood clot after surgery or an accidental cut or tear during treatment.

The measures also include specific death rates for patients who had breathing problems after surgery, had an operation to repair a weakness in the abdominal aorta or had a treatable complication after an operation.

In addition, Hospital Compare is evaluating rates of some specific medical errors, such as giving patients the wrong type of blood, leaving surgical implements in patients’ bodies during surgery and falls that occur during their stay.

Survey of Patients’ Hospital Experiences

About the survey: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay. Use the results shown here to compare hospitals based on ten important hospital quality topics. Read more information about the survey of patients’ hospital experiences.

The evaluations are part of Medicare’s broad move from paying hospitals a set amount for each procedure. That change was directed by last year’s health care law, which set up new “value-based purchasing program” that will begin in October 2012.

Over time, hospitals with the lowest quality—as judged by a variety of metrics, not just the new patient safety measures—will be at risk to lose up to 2 percent of their regular Medicare reimbursements under the health law.

The new data on patient safety moves Medicare further along toward its ultimate goal, which is to base payments on the actual medical outcomes for patients. To rate hospitals, Medicare is comparing them to the national rates for medical complications and hospital acquired conditions.

For instance, on average, 2.1 out of every 1,000 patients discharged suffered an accidental cut and tear from medical treatment. Out of 100 patients, 4.4 on average died after surgery to repair a weakness in their abdominal aorta.

By looking at how a hospital compares to the national average on this and other complication statistics, Medicare has come up with overall evaluations of how good hospitals are at avoiding complications and hospital-acquired conditions. Medicare is aiming to incorporate the new patient safety data into payments in the second year of the program.

Making this information public has been long favored by patient safety advocates. “This is pulling the curtain back on preventable health care harm to older Americans,” said Rosemary Gibson, co-author of “The Treatment Trap” and editor of a series of articles on overtreatment in the Archives of Internal Medicine. “These are really good things to know. We are really getting into the meat of what can happen to patients in hospitals.”

But the latest data is intensifying objections from the hospital industry and some academic researchers that Medicare is using dubious and unfair measurements in ways that will hurt some hospitals, particularly those with sicker patients. The data is based on billing claims that hospitals submit to the government, not clinical medical records.

One concern held by hospitals and researchers is that hospitals categorize the same things differently when billing Medicare, skewing comparisons.

“Medicare claims data is the thing a lot of people judge from, but it’s a large database and frankly I’ve always wondered if apples and oranges are being mixed,” said Dr. Gerald Healy, a senior fellow at the Institute for Healthcare Improvement, a Massachusetts nonprofit, and past president of the American College of Surgeons.

Hospital officials said their initial review of the new data has exacerbated their concerns that Medicare’s calculations do not fully take into account the fact that some hospitals do more surgeries or treat sicker patients.

“We believe the data is fairly seriously flawed in the way it’s calculated,” said Nancy Foster, a vice president at the American Hospital Association. “When inaccurate data is out there, it both misleads the public and generates a lot of activity that is unproductive in the hospital.”

Atul Grover, head of advocacy for the Association of American Medical Colleges that represents teaching hospitals, said some of Medicare’s measures also make teaching hospitals look worse.

“If you’re not appropriately risk-adjusting on this, you’re already selecting a patient population that’s more likely to die,” he said. “That’s why they come to us, because other people are reluctant to operate on those complex cases.”

Officials at the Agency for Healthcare Research and Quality, which designed many of the measures, referred questions to Medicare. Officials there were not immediately available to discuss the new measures. Dr. Patrick Romano, a professor at the University of California, Davis School of Medicine who helped the government design the measures, said the measures do take the sickness levels of patients into account, although not as thoroughly as Hospital Compare’s existing evaluations of readmissions and hospital-wide mortality rates.

Still, he said the measures were a good addition to the overall view of how well hospitals are doing. “We’re trying to understand a large animal like an elephant or a whale,” he said. “To do that, we take pictures from a variety of perspectives, with different cameras and different techniques.”

Hospital Compare was originally designed to be a helpful consumer tool, but to date it has not been widely used by patients choosing hospitals. Experts caution about drawing dire conclusions from the raw rates of hospitals, as some of the measures are complex and differences not statistically significant.

For some of the measures, Hospital Compare categorizes most hospitals simply as “average,” “above” or “below” the national norm, which experts say is a better way for consumers to know whether a hospital is an outlier.

To find a hospital on the site, type in the city and state, click on the hospital name and then select the “Patient Safety Measures” tab at the left. Hospital Compare also gives patients the option of choosing several hospitals at once. The new data covers the period between October 2008 and June 2010.

Medicare last week also announced 18 more measures it is considering for inclusion in the value-based purchasing program.  Many of these measures look at how hospitals handle stroke patients and what steps they take to protect patients from blood clots. Others are intended to address two bacterial infections that can spread through hospitals: Clostridium difficile and Methicillin-resistant Staphylococcus aureus.

Illustration: Steve Woods Photography

Contact Jordan Rau: jrau@kff.org

 


This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Silhouettes of U.S. Soldiers at night in Iraq

Critical shortage of army neurologists for U.S. troops in Iraq and Afghanistan

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By T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR April 12, 2011, 6:33 p.m.
From reporting by NPR, ProPublica and Frontline, Sept. 8, 2010

The Army is facing a “critical” shortage of neurologists, partly because of recent policy changes designed to improve diagnosis and treatment of mild traumatic brain injuries, according to a new military medical memorandum.

The policies, issued last June [1], require soldiers who have suffered three or more mild traumatic brain injuries in a year to receive a comprehensive evaluation by a neurologist or similarly qualified doctor.

Silhouettes of U.S. Soldiers at night in Iraq

The military also set up a clinic in Afghanistan last year specifically to treat traumatic brain injury and mandated rest periods for soldiers exposed to blasts.

The new initiatives have “increased dramatically” the need for neurologists on the battlefield, according to the memo [2], which was issued in March and obtained recently by ProPublica and NPR.

“The shortage is far more acute than they want to admit,” said one Army doctor, who did not want to be identified for fear of damaging his career. “This is an ideal doctrine which was promulgated but not fulfilled due to a lack of resources.”

Army officials have long complained about a lack of neurologists, neuropsychologists and other medical professionals needed to diagnose and treat mild traumatic brain injuries, also known as concussions.

At a hearing last June [3], Army Gen. Peter Chiarelli, the vice chief of staff, told Congress that the Army had a total of 52 neurologists, though only 40 were practicing — a figure, he said, that included child neurologists. “I have a shortage in neurologists, a tremendous shortage,” Chiarelli told NPR and ProPublica in an interview last year.

Chiarelli said the problem was not a lack of funding, but recruiting neurologists willing to be deployed to war zones. Also, under the military’s system for deploying doctors, some neurologists act as general practitioners, serving as the primary medical officers for combat units sent overseas rather than as specialists.

The new memo aims to stop that practice and funnel neurologists to help troops with brain injuries. “There has always been a shortage of board certified neurologists; neurologists are in short supply in civilian practices as well,” Cynthia Vaughan, a spokesman for the Army’s Surgeon General, wrote in response to questions. “The change was made to ensure we have neurologists who are deployed working as neurologists and available to treat concussive injuries vs. deploying as general medical officers.”

It is unclear whether other military services are having similar trouble finding neurologists to deploy abroad. A spokesman for Central Command, which oversees the fighting in Iraq and Afghanistan, did not immediately return a request for comment.

Official military figures [4] show that more than 155,000 troops have suffered concussions since the beginning of the wars in Iraq and Afghanistan, many of them caused by blasts from roadside bombs, a common insurgent weapon.

Researchers outside the military say the true figure could be at least twice that number. The Pentagon says nearly 50,000 others have suffered more severe brain injuries. Previous ProPublica and NPR stories [5] found studies showing that as many as 40 percent of mild traumatic injuries go undiagnosed.

Such injuries do not leave visible scars and can be difficult to detect. Most concussions heal quickly, usually within a matter of weeks. But civilian studies show that 5 percent to 15 percent of those who sustain concussions may suffer long-lasting cognitive issues, such as problems with memory, reading, doing simple math, or following directions.

Research has shown that the danger of long-term damage increases with the number of concussions. Studies have indicated an increased risk for a dementia-like condition among football players and other athletes who suffered numerous mild head injuries over their careers. Follow on Twitter: @txtianmiller [6]

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