by Tracy Weber and Charles Ornstein

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.

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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.

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. 

• Call the Washington VA 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/.

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.

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.

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.

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.

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]

Dr. Palmer

Two Seattle researchers who study the role the immune system has on the development of Type 1 diabetes have won national recognition for their work.

Dr. Jerry Palmer, professor of Medicine at the University of Washington and director of the Diabetes Endocrinology Research Center at VA Puget Sound Health Care System, has been chosen to receive the American Diabetes Association’s 2011 Physician/Clinician of the Year award for his nearly four decades of work conducting research into the causes and treatment of diabetes and for providing care to patients with the disease.

Dr. Palmer will receive the award at the Association’s annual meeting in June.

Dr. Sanda

Dr. Srinath Sanda, a clinical investigator at Benaroya Research Institute at Virginia Mason, has been awarded the first JDRF Mark Pescovitz Early Career Patient-Oriented Diabetes Research award, which includes a five-year, $700,000+ grant to study immune modulation in type 1 diabetes.

In type 1 diabetes, the immune system mistakenly attacks the insulin-producing cells of the pancreas, gradually destroying the body’s ability to make enough insulin to control blood glucose levels.

Typically, when people first develop symptoms of Type 1 diabetes, they still have some surviving insulin-producting cells. While they do, their diabetes is often easier to manage and they have fewer complications.

The goal of Dr. Sanda’s work is to see whether it may be possible to preserve those remaining insulin-productin cells by slowing or blunting the immune system’s attack.

To learn more:

• Visit Dr. Palmer’s webpage.
• Visit Dr. Sanda’s webpage.
• Visit the National Library of Medicine’s MedlinePlus webpage on Type 1 Diabetes.