Where Have All The Good Times Gone?

Fin de regime? Financial analysts are worried, après moi, le deluge… (Art courtesy fine folks at WikiMedia Commons.)

 

Good morning, ProviderNation. Political economy has long been known as “the dismal science.” But some things are true even if Lord Halifax says they are, and a great many of those who follow the economics of long term and post-acute care are asking themselves, “Where have all the good times gone?”

Despite a record fourth quarter for mergers or acquisitions, “it looks as if M&A fever may have broken,” the fine folks at Irving Levin Associates say, gloomily, in their latest report. “This could be the start of something small.”

We’ve covered some of the concerns about a demographic dip at length in this space. Another factor, though, is that old Washington bugbear (which we’ve also covered at length), regulatory certainty. It’s not so much the scale of changes that are happening—it’s the pace.

Regulatory Squeeze

“I didn’t think it could get worse, but it’s going to do,” says Irving Stackpole, a veteran analyst and my own, private Eeyore. “It’s going to get worse because of pressure by CMS to move from volume-based payments to value-based payments.”

It’s notorious, Stackpole and others say, that providers have built their businesses around a large Medicaid population, subsidized by a lower Medicare population with higher turnover. Now, though, the margins are being squeezed from both ends.

Just last month, a key congressional committee passed a bill that would reduce the amount states can collect in provider taxes. It could cost up to 20 states more than $8 billion in Medicaid revenue (because of the various perversities of the current system).

Meanwhile, regulators are speeding through their massive Rules of Participation rulemaking, and Congress is weighing even further value-based purchasing bill for Medicare. The Rules of Participation alone could cost care centers up to $75,000 apiece, advocates at the American Health Care Association say.

Well, now, say all the dismal scientists, that’s how the game works—some win and some lose. Except, for Stackpole and others, those who are bound to lose are those who don’t have much to begin with.

“The SNFs that are serving the most vulnerable populations, those SNFs are going to go bust,” Stackpole tells me. “We’re going to see even more closures, more beds come offline.”

Small/Independent Jeopardy

Stackpole is not on an island here, either. AHCA’s own James Michel, who it must be said is not easily ruffled, says he’s worried, too.

“We are particularly concerned about access in smaller and rural communities where there may only be one or a handful of facilities operating. CMS’ new payment models are rooted in risk-bearing models that make it very difficult, if not impossible, for smaller and independent facilities to participate successfully while keeping their autonomy,” Michel tells me in an email.

“While highly competitive markets can bear some degree of consolidation and constriction of the market, because the demand can be absorbed by the competition,” he adds, “smaller and rural markets with fewer providers certainly cannot. And even if they could, that isn’t necessarily a good thing. There is a growing area of research on the relationship between provider and payer consolidation, and increasing health care costs. In its attempt to constrain growing health care costs, CMS inadvertently may be promoting payment and delivery models that reward consolidation and force the closure of smaller facilities, thereby increasing overall costs and creating access problems for our most vulnerable populations.”

But don’t worry too much, because it can get worse, Michel adds.

‘Silver Tsunami’

“All of this is happening as we teeter on the edge of the ‘silver tsunami,’ where we are set to experience a rapid growth in the number of older Americans who will need long term care,” Michel says. “Are we shooting ourselves in the foot by adopting payment and delivery models that will result in a constriction of our long term care infrastructure at a time when we are going to most need it?”

The regulatory trends are frightening enough. But consider, again, the apparent cooldown in Wall Street’s ardour for seniors housing. What we’re all witnessing is money fleeing a sector from all sides. And that’s before we even consider the seismic shakeup we may be facing as younger adults wake up to their own history.

“If you have a 25-plus-percent under- or unemployment rate among millennials, redistribution will happen around invested capital. What would come out of the system is the capital invested in the insurance sector—a huge amount of the $2.7 trillion that’s spent goes into the pocket of some very well-heeled insurance companies—and that’s where the pushback comes from,” Stackpole says. “How could that surprise you?”

‘A Race To The Bottom’

All of this is completely predictable, but rather dismal, to contemplate, Stackpole says.

“Consolidation is the hallmark of a mature business life cycle,” he says. “And that’s where we are. You could not find a better example of a business cycle moving from its early maturing to its late decline than skilled nursing. You’ve got consolidation, you’ve got closure, you’ve got growing awareness in the market—these are all hallmarks of a profession in late decline.”

But the rubber, inevitably must meet the road.

“The people who really need that nursing center are the families of people who have neurological disorders, the families of people who have Alzheimer’s and dementia, and the people who really need a cardiac or a pulmonary rehab,” Stackpole says. “What they’re going to have to do now is drive 65, 70 miles. Does that matter? Maybe not to some guy at CMS in Baltimore, but to the rest of those people, it sure as hell does.”

So, if you happen to bump into Irving at some conference or other, make sure you buy him a drink or two. He could certainly use it.

“It’s a race to the bottom,” he says. “An absolute race to the bottom.”

Mad Props Dept.

On that cheery note, a couple/three bouquets to throw out.

First, to the fine folks at It’s Never 2 Late, who this week have entered their 2,000th care center.

Second, to the good people at Benchmark Senior Living, who’ve just been named the Boston area’s healthiest employer.

Finally, to Delaware’s own Susan M. Levy, MD, who has just been named president of AMDA—The Society for Post-Acute and Long-Term Care.

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

 

 

What Isn’t Happening In AL Regulation…

Our author, wearing his Serious Face, searching for evidence of things not seen… (Photo courtesy Andrew Harnik.)

Bill Myers

Good morning, ProviderNation. Sorry to distract you from all the mesquite and margaritas down Texas way,* but the fine folks at the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services (say that 10 times, real fast) have done some thinking on state regulations of assisted living centers.

The short version seems to be: There’s a lot of them. The full report is here and the executive summary is here.

Most folks agree that the business of elder care is in its revolutionary age (and many assisted living advocates see their sector as the vanguard of that revolution), so it’s interesting to note what isn’t happening even as the profession grows.

Regulatory Certainty

In many other areas, as the businesses grow and diversify, it’s reasonable to expect that at least some of the bigger players advocate for federal regulations. The shibboleth here is, of course, “regulatory certainty,” in which bigger players argue simplifies political economy for everyone. Take whatever you like about the argument, what’s fascinating is the extent to which you just don’t see that kind of advocacy from assisted living providers.

Part of it, a Royal Smart Person tells me, is that, having taken a look a good look at what “regulatory certainty” means for their skilled nursing cousins, many assisted living providers offer a polite, “No, thanks.” (There’s also the fact that, however large assisted living companies have grown, no single player—or even combination of players—is big enough to warp the market.)

But part of it goes to the very revolutionary character of the profession, the smart person adds. Assisted living providers pride themselves on person-centered care, above all else. However you define person-centered care, the essence of it is flexibility. Therefore, any effort to govern from On High jeopardizes the very innovation, dynamism, and rapid-fire responsiveness that many advocates feel defines assisted living.

Alphabet Soup

Speaking of the alphabet soup of regulatory agencies, the good people of CMS and the National Coordinator for Health Information Technology have released final rules that backers say will “simplify requirements and add new flexibilities [cq] for providers to make electronic health information available when and where it matters most and for health care providers and consumers to be able to readily, safely, and securely exchange that information.”

CMS’ version of the rules is here and the coordinator’s rules are here.

*And, if you’re not following all of the white-hot, provider-on-provider action as reported by our Managing Editor, the Formidable Jackie Oberst, on Twitter, well,  you go to penalty box…

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

Up To A Point, Lord Copper…

The second oldest profession… (Photo courtesy the fine folks at Wiki Media Commons.)

Bill Myers

Washington, D.C.—Hello, ProviderNation. One of the greatest minor characters in all of literature is Mr. Salter in Evelyn Waugh’s glorious “Scoop.”* So terrified is he of his terrifying, press baron boss that poor Salter can only answer in the affirmative by saying, “Definitely, Lord Copper” and in the negative by saying, “Up to a point, Lord Copper.”

But you’ll just have to forgive AHCA’s Dan Ciolek if, dealing with the media reaction to yesterday’s inspector general’s report on Medicare’s therapy margins, he feels that the Salter character is an outrage of his own copyright.

For the past 36 hours or so, Ciolek has had conversations that go something like this:

Reporter: The OIG says that skilled nursing centers made 29 percent profit margins on therapy in fiscal 2012, right?

Dan: Definitely, Lord Copper.

Reporter: The OIG also says that high RUG charges cost Medicare $1.1 billion in fiscal 2012 and 2013, right?

Dan: Definitely, Lord Copper.

Reporter: So we need across-the-board cuts to Medicare therapy rates, right?

Dan: Up to a point, Lord Copper.

As OIG itself noted, AHCA (in the form of Ciolek and others) has been up front in arguing that Medicare has to stop rewarding volume and start rewarding value. So it’s a little bit more than irritating to see some folks read the inspector general’s report—in essence, proof that volume-based payment is flawed—to argue that the only solution is to reduce the amount of payments, regardless of outcomes.

“We have been supportive of a shift away from the volume of service,” Ciolek tells me. “We want to be paid based on what we do in our centers, and in good outcomes. The challenge is to get data on quality and outcomes. That’s why we supported IMPACT and have been developing outcome measures as part of our quality initiative.”

The problem with OIG’s report is that “it doesn’t say whether the quality of the care or the outcomes were better, worse, or indifferent.”

“We care about outcomes,” Ciolek says. “The discussion should be, is the therapy valuable or not? We shouldn’t pay for what is done in rehab, we should pay for the results of rehab.”

Poor Ciolek is trying to thread a needle in the middle of a hurricane. He makes (or tries to make) the following points:

• That, first, the far-famed Omnibus Budget Reconciliation Act of 1987 requires skilled nursing centers to help residents “attain and maintain [their] highest practicable physical, mental, and psychosocial well-being.”
• That, second, federal regulators themselves have acknowledged, in the Jimmo settlement, that therapy services can’t arbitrarily be withheld for folks of any age of condition… “even when a chronic, progressive, degenerative, or terminal condition exists.”
• That, third, regulators are already gathering the kind of data, under IMPACT, that will answer all sorts of questions about value and quality.
• That, fourth, you can’t kinda be data-driven. If it emerges that Medicare is spending too much for therapy without demonstrating value, then the data will answer that definitively.
• That, fifth, until the data comes in, any precipitous moves are also premature.

“The core issue is that beneficiaries need services to get stable, to get better, and to get home, quickly,” Ciolek says. “A lot of the focus is on the margins and the actuarial stuff. The system needs to get rid of minute-driven models. But don’t lose sight of the fact that these folks need care.”

So,  Ciolek’s measured, thoughtful approach will get the media to rewrite the standard-issue, hackneyed narrative about “nursing homes gaming the system,” right?

Up to a point, Lord Copper.

*Your Humble Correspondent, having served as a foreign correspondent, will take his oath that there is nothing satirical about “Scoop.” It is an understated work of pitiless realism.

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

 

A Series Of Tubes…

 

The Interwebs will be busy this week, our Humble Correspondent reports (Photo courtesy fine folks at Wikimedia Commons.)

Bill Myers

Washington, D.C.—Good morning, ProviderNation. The fine folks at AHCA/NCAL are taking to the Interweb Thursday for one of those elephant-in-the-room conversations about workplace violence.

As AHCA/NCAL’s Divine Adrienne Riaz-Khan points out*, nearly 70 percent of workplace assaults occur in health care settings, and the fine folks at OSHA have taken a harder look at the problem. The Webinar will be held at 2 p.m. EST and will feature Jackson Lewis P.C. superstar Nickole Winnett.

Very, Very, Very (&c.) Important

Speaking of Thursdays and people who are Very, Very, Very, Very, Very, Very Important, Your Humble Correspondent is looking forward to his grand entrance at Unique Residential Care Center’s Fifth Anniversary Gala, wherein the fine folks will celebrate their whole shelf of awards here in our nation’s capital.

Mazel tov, kids. Mazel tov.

Minnesota’s North Stars

Meanwhile, the fine folks at the Sabo Center for Democracy and Citizenship and Bipartisan Policy Center will host a Webinar of their own (why didn’t I copyright this whole Webinar thing?) next Thursday, Sept. 24, from 1 p.m. EST until 5 p.m. EST.

They’ve got themselves a star-studded lineup, including former Sen. Byron Dorgan (D-S.D.), former U.S. Rep. Martin Sabo (D-Minn.), and former U.S. Rep. Vin Weber (R-Minn.), who’ll wrestle with the policy challenges of an aging population.

MedPAC Recycling

Whatever else one thinks of the fine folks at MedPAC, let’s give them credit for reducing their carbon footprint by their willingness to recycle ideas. The group’s next congressional report is due next summer, but this week they released some initial data. AHCA/NCAL’s unsinkable Dianna Dorman quotes MedPAC as follows:

“… the Commission has long been concerned that the existing payment system does not encourage quality care and creates wasteful spending, noting there is substantial overlap of patients across settings, skilled nursing centers have incentives to encourage unnecessary therapy services and avoid certain patients, and a common assessment tool does not exist…”

Why does Your Humble Correspondent have this sinking feeling that MedPAC is going to harp on skilled nursing’s Medicare margins, and recommend even more managed care?

*I recognize that she’s dealing with workplace violence, but if you do not kneel before Adrienne, I will fight you.

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

 

Obamacare, SCOTUSCare, Chevron And You…

Hello, ProviderNation. By now, you’ve read (or read about) the Supreme Court’s decision, in King v. Burwell, protecting Obamacare’s health insurance subsidies across the country. As the fine folks at AHCA/NCAL point out, the decision has very little immediate economic impact, since small-business owners had already been subject to the insurance mandate beginning this year; next year, bigger businesses will have to pony up.

“The SCOTUS ruling is a clear signal that the ACA is here to stay, at least for now,” AHCA/NCAL’s inestimable Dianne De La Mare has it. “In other words, it is ‘business as usual’ in all exchanges, whether those exchanges are state-run or federally run. Currently, 34 states rely on federally run marketplaces. Another 13, plus Washington, D.C., have their own state-run exchanges, and three others have state marketplaces but use HealthCare.gov to determine subsidy eligibility. The court’s decision clarifies that subsidies will continue to be available to any individual who purchases insurance through any exchange (state-run or federally run), and earns between 100-400 percent of the federal poverty level. That means those individuals who previously had tax-credit subsidies in federally run exchanges will keep those subsidies to the extent that they continue to satisfy the subsidy requirements. Those same individuals also will stay insured.”

If some business owners think that Burwell’s endorsement of Obamacare (or, as a rather disgruntled* Justice Scalia put it, “SCOTUSCare”) means the sky is falling, some advocates for front-line care workers clearly see Burwell as manna from heaven. The average direct-care worker earns about $17,000 per year, PHI’s Matthew Ozga writes. That’s way less than the 400 percent of the federal poverty line threshold that would qualify workers for Obamacare subsidies. If owners see Obamacare as bad for business, there might still be a silver lining: Workers who can obtain health care might  just be more willing to stay in their jobs.

Chevron Deference

There’s one other potential message-in-a-bottle from Burwell. You’ll see in reading Justice Roberts’ opinion for the 6-3 majority a reference to the two-pronged Chevron test. Roberts rejects the Chevron logic, but it might be worth exploring the reference because health care observers are likely to hear about it a lot more in the future.

In 1984, energy giant Chevron appealed a lower court decision in favor of a lawsuit originally brought by the National Resources Defense Council. NRDC had gotten the lower court to agree that Reagan-era revisions to EPA’s Clean Air Act regulations were illegal. Chevron appealed to the Supreme Court. In what is a little-known but widely felt decision, the court held that, in instances where legislation was ambiguous, the courts should focus on two questions: first, whether the regulatory action directly contradicts the intent of Congress, and, if not, whether the agency’s action “is based on a permissible construction of the statute.”

“If this choice represents a reasonable accommodation of conflicting policies that were committed to the agency’s care by the statute,” Justice Stevens wrote for the majority, “we should not disturb it unless it appears from the statute or its legislative history that the accommodation is not one that Congress would have sanctioned.”

Ever since, “Chevron Deference” has been the shibboleth of the lobbying American community here in Washington.

*You may think it unfair to refer to Scalia as “disgruntled.” Can we agree, at least, that he was far from being gruntled?

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

What, Me Worry?

Why America slept: SeniorCare.com’s findings are worrisome.

Good afternoon, ProviderNation.

The numbers are in, and they aren’t encouraging. The fine folks at SeniorCare.com crunched survey data and found that Americans are woefully under-prepared for their aging future. In separate surveys, 37 percent of respondents said they thought they would need long term care in the future; as it happens, though, 69 percent of Americans are actually expected to need long term care.

“It’s time for a senior care reality check,” SeniorCare.com says, in what may count as one of the understatements of our millennium.

More than half of Americans will spend at least some time in nursing homes, according to SeniorCare.com’s projections. Another 19 percent will use assisted living. Most people—86 percent—are predicted to use informal caregivers at some point (the numbers overlap).

But nearly three-quarters of people who need long term care will have to pay out-of-pocket, because Medicare will only cover about 12 percent of the nation’s long term care needs and only 30 percent of people qualify for Medicaid, SeniorCare.com reports.

If you think that’s bad, don’t worry, it gets worse. Because almost three-quarters of people surveyed haven’t bothered to have “The Talk” about long term care options with their loved ones, SeniorCare.com finds.

So what’s to be done? SeniorCare.com asked a few dozen professional thought leaders. AHCA/NCAL’s own Tom Burke urges families to take it slowly.

“Have several talks over time,” he says. “Avoid one-and-done scenarios. Go slow. Be patient with your mom or dad. Know that this is a scary topic.”

Dr. Bill Thomas, who is taking his show on the road as we speak, says the numbers speak to a larger problem with aging in our culture.

“We need to change the narrative surrounding aging in general,” he says. “Your topic is actually just one (very tangible) example of the toll we pay for living in a deeply ageist society. Fixing this problem requires us addressing ageism head on.”

Thomas puts the preparedness crisis bluntly. Age free, or—well, you know. “People who are prepared,” he says, “get to choose the kinds of care they will receive and who will deliver that care. People who are not prepared get care that is chosen by someone else.”

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

Death and The September Night…

The unmentionable odour of death

Offends the September night…

—W.H. Auden, “September 1, 1939”

Good morning, ProviderNation. Maybe it’s a seasonal thing—here in the decadent capital, the leaves are doing their lustrous wonders, the mercury sinks in the mouth of a dying day, and twilight comes earlier and earlier—or maybe it’s psychic convergence.

In any case, death is in the air.

It’s about time.

Shanda Fur Die Goyim

You’ll have seen our little effort to make sense of death, dying, and grief in the September issue. I remain proud of the work, but I have to admit that John Morley and the fine folks at JAMDA have wiped at least some of the smug off my face. No sooner had I let slip the September cover, feeling peacock proud of having dealt with a matter that so many providers had consigned to the shanda fur die goyim bin, when I see that Morley and Angela Sanford had stolen a march: Their essay in the August issue of JAMDA, “The God Card: Spirituality in the Nursing Home” is brilliant enough on its own, but it’s accompanied by an op-ed and an original study on palliative sedation in nursing homes.

And just as I’m recovering from my vertigo of watching Morley and company scoop me, the Institute of Medicine releases, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” Meanwhile, AHCA super-lobbyist Clif Porter (and all-around decent chap) gives us an interview for the October issue of Provider in which he tells us that providers ought to look to hospice as a model for building goodwill with the public and with lawmakers.

So it appears that providers are more willing to talk openly about death and dying and grief than I had given them credit for.

‘Good Death’ Aspiration

Still, no one will claim that this refreshingly morbid September closes the conversation. And however much the Big Public may hymn the virtues of “a good death,” the attitude still seems aspirational.

“I wish there were a way we could get out into our communities,” says Robin Hillier, owner and operator of Lake Rehabilitation and Nursing Center in Conneaut, Ohio. “Having these discussions about what we want for ourselves at the end of life is something that we need to have throughout our lives. We all talk about estate planning, and tax planning, but not enough people do enough about end-of-life care.”

Robin Hillier

Hillier has acquired a grim expertise on grief and mourning. Not only does her center care for and treat the elderly, but it also has a pediatric unit.

“One of the biggest rewards for my staff is working with those people, because they have an opportunity to develop lifelong relationships,” she says. “But one of the problems is when one of those residents dies, it’s much harder. You’re sad when someone who’s older died, but you can celebrate a long life, well lived: It’s just much harder when someone young dies.”

That’s why The Talk starts early and continues often at Lake Pointe, Hillier tells me.

“We take that seriously, we talk about it clearly, and we want to provide you with the support you need to deal with it,” Hillier says at every new staff orientation (and beyond).

Family Values

Staff grief is only one mountain to climb, though. The biggest one is often families of the dying. (In fact, an earlier study in JAMDA found that nearly three-quarters of staff reported family members as a hindrance to offering quality end-of-life care.)

Debbie Meade

“We have to balance between a resident and families, often,” says Debbie Meade of Health Management, in Georgia. “The resident is tired. They’re tired of the fight. And there are times when they’re just ready to go. And they know it.”

For families, though, it’s often hard to “let go,” Meade says. The guilt, the sense of betrayal, the fear of loss all overwhelm families at what is literally the last minute. (But even the Supreme Court sometimes seems to struggle with teasing out the difference between letting someone die and actually killing them.)

“That’s where we miss the boat,” Meade says.

‘Your Mom Is Not Here Anymore’

Meade says that these are the moments where providers must find their voices.

“I had a resident—the flesh was literally rotting off her body. And the family had a feeding tube in her,” she recalls. “I sat down with the family and said, ‘I’m sorry, I can’t let you do this anymore. Do you understand that your mom is not here anymore?’”

The reasons so many providers balk at such blunt talk are easy to understand, Meade says. The fear of lawsuits, the fear of honesty—it’s all human, all too human. “They think they’ve given up on them, and they think they’re not doing what’s right,” she says.

But the consequences of human failure are absolutely inhumane, Meade says.

“We don’t sit down and have those honest conversations. And that’s when the resident suffers, when you watch the family not having enough love and courage to let them go to that better place,” she says. 

‘Granny Wants To Go’

Like so many in her line of work, Meade has dearly won experience. She had to help her beloved grandmother die. A vivacious, vibrant woman, “Granny” had been up and about until one more stroke drew a curtain down on her. Meade instantly moved her grandmother into Health Management’s skilled nursing center.

“I was trying to feed her, and she closed her mouth and shook her head, No. I said, ‘You don’t want to eat?’ She shook her head. No. I called my Dad and said, ‘Granny wants to go.’

“I know I did what she wanted,” Meade says. “She just looked me in the eyes and shook her head. And I knew what that meant.”

It took seven days for Granny to die. But she did so peacefully, and on her own terms. Meade says she misses her grandmother every day, but regrets nothing. She hopes that she and other providers can find ways to pass on what they’ve learned.

“It’s something that we need to talk about more,” she says. “It’s something we need to share.”

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

 

 

 

 

 

 

 

 

 

 

Aloha, National Nursing Home Week

Joe DeMattos

As AHCA/NCAL’s National Nursing Home Week draws to a close, Hawaii-native Joe DeMattos brings us all a little closer to Hawaii with some insights about the word “aloha” and its true meaning.

Good Morning, ProviderNation.

Aloha is among the best-known words in the world. Most people know it as the traditional way to say “hello” and “good-bye” in Hawai’i.

But aloha means so much more. When you say “aloha” to someone, you are saying that love flows between you.

“Aloha au iā ‘oe” means “I love you” in ‘Olelo Hawai’i, the language of Hawai’i.

This year, the theme of National Nursing Home Week is “Living the Spirit of Aloha.” When one lives with the aloha spirit, one lives with, and is, an agent of it. In this sense, aloha is a noun, and it is a powerful verb of action.

To hold the idea, the noun of aloha and all that it means in the thousands of years of proto-Polynesian and Hawai’i history is to believe and value right thought, right action, respect for others, forgiveness, kindness, compassion, empathy, and love. Aloha is the description of the ultimate world-view of abundance.

Putting aloha into action as a verb means acting on its values in how you treat yourself and in how you view and treat others.

“Living the Spirit of Aloha” in health care assumes the best of yourself and of those with whom you interact—family, patients, residents, colleagues, and even opponents.

Interestingly, the “hand shake” of Hawai’i is to look into the eyes of the person you are greeting, to embrace, touch foreheads and noses, and to exchange the breath of life, the spirit of aloha.

Here in Maryland, 233 skilled nursing and rehab centers provide over 9 million days of care each year to Marylanders in need.

Many in care are “kupuna,” our treasured elders; some, increasingly more, are younger.

As we celebrate and create new living examples of the meaning of aloha, we have an opportunity to double our efforts to “Live the Spirit of Aloha” with all in care, young and elder.

Here are seven simple steps to “Live the Spirit of Aloha” every day:

• Love yourself in a positive way.
• See the best in yourself and others.
• Self-right any of your wrongs.
• Seek and offer forgiveness openly and often.
• View and act as your best possible self and view others the same.
• Work as a team—the flowing love always implies relationship—with others and your highest self.
• Make it your mission to help all with whom you interact to be their best self.

Aloha au iā ‘oe.

Born and raised in Hawaii, Joe DeMattos is chief executive officer of the Health Facilities Association of Maryland, which represents most of the state’s 233 skilled nursing and rehabilitation centers. He can be reached at: jdemattos@hfam.org.

Please the Court…

ACHA/NCAL is wading into a legal challenge of Medicare’s observation stay policies.

Good morning, ProviderNation.

The legal eagles at AHCA/NCAL are soaring into a potential class-action suit challenging federal observation stay rules. Here’s the background: 14 Medicare patients sued the government alleging that their due process rights were violated when they were put on observation status. Last September, a federal District Court in Connecticut dismissed the case, saying that a previous decision by the 2^nd Circuit Court of Appeals means that when Kathleen Sibelius uses a word, it means just what she chooses it to mean—neither more nor less.

The plaintiffs here are appealing their dismissal (back with their old friends in the 2^nd Circuit). The plaintiffs are arguing that the feds should be required to give written notice when they’re placed on observation status, what it will cost, and whether they can challenge the status. The plaintiffs are also arguing that they should have the right to appeal observation status administratively under the Medicare statute.

In an Amicus brief filed to the circuit, AHCA lawyer Mark G. Arnold says that the current rules are expensive and dangerous for Medicare patients.

“The private interest here is clear: the ability to obtain necessary, often life-saving, medical treatment in a timely fashion,” Arnold says in the brief. “Of at least equal importance is the prospect that the absence of full Medicare benefits prevents the beneficiary from obtaining necessary medical care at all. One of the named plaintiffs … had to depart from the [skilled nursing center] despite her need for such services because she could not afford its costs.”

Given that the 2^nd Circuit has already ruled on the matter the odds against the plaintiffs seem long. But, after all, one only gets what one negotiates for.

On “Mr. Bainum”…

Good afternoon, ProviderNation.

Every hack lives in fear of burying the lede.

But, “transparency” is a big word in Washington (even if it’s one of those words that people mean it only to mean what they mean it to mean). So, in the interest of self-criticism, Your Humble Correspondent admits that he goofed. Big time.

Last week, we dipped the flag in salute to Mr. Stewart Bainum, the founder and longtime chief of Manor Care. We hit all the usual notes that you’d expect in an obit: hard-scabble youth, hard work, pioneering spirit, rise to the top, personal generosity, etc.

What we didn’t tell you is just how deep his generosity went. And we didn’t tell you that someone who knows his generosity best is AHCA/NCAL’s own Martece Yates.

She wants you to read her story, and I do, too.

In 1988, Martece was just wrapping up elementary school. She lived in Southeast D.C., which is the same as saying that she lived in a free-fire zone. (This was the nadir of the War on Crack, and Southeast D.C. was shameful host to most of the District’s homicides: 225 citywide in 1987, 369 in ’88, 434 in ’89, 479 in ’90 and—still a record—482 in ’91.)

In her own view, Martece wasn’t poor. Her parents worked hard and they had food on the table and clothes on their backs. (Martece, precocious and bright, with the grades to prove it, favored “Harvard” gear.) Middle school was coming and—like most of the “promising” kids in her neighborhood—Martece hadn’t give a thought to her local school, Kramer,  other than a shudder. (Kramer, then, was one of the worst in the city, which easily made it one of the worst in the country.) Like many such kids, Martece was prepared to schlep across the city to Ward 3’s Alice Deal.

And then a man in a tie knocked on her house. He was a recruiter for something called the “I Have a Dream” project and told Martece and her family that she would get help with college tuition if she agreed to attend Kramer.

“We didn’t believe the guy,” Martece recalls, laughing. “It was like Publishers’ Clearing House—someone just knocking on your door like that?”

It turned out that the project was bankrolled by Stewart Bainum, who had just retired from running his business empire. He and his wife, Jane, had started a foundation in the late 1960s, but it wasn’t enough for him. He wanted to put his mouth where his money was.

For Martece, it was the beginning of a lifelong relationship with a mentor whom she still refers to as “Mr. Bainum.”

“It was something,” she says. “What made this man want to do this?”

Whatever it was, Martece decided early, it wasn’t ego.

“You never got the feeling that he thought it would move him up to some higher level if he helped all these little black kids from Southeast,” she says.

In fact, for a multi-millionaire, Bainum was self-effacing, even innocent.

“He had this pure honesty and candor,” Martece says. “He had no problem asking, ‘What kind of shoes are those?’”

At fourteen, Martece had her first job—working at Manor Care. Unlike a lot of kids’ jobs, though, Martece was put to work. She started in the employee relations department and was bounced to the legal department and back again, learning the business inside and out.

There, she met a woman called Phyllis Edmunds, the first African-American lawyer that Martece had seen outside of television. “It was really nice to see someone who was in charge of her own department that looked like me,” Martece says.

As ever, there was Bainum, who was full of questions for his young protégé.

“He would say, ‘How’s everything going?’” Martece recalls. “Is everybody treating you right?”

What mattered most was that Bainum took care without being condescending, Martece says.

Oh, and there was his estate out in Middleburgh, Va. Horses, swimming pools, tennis courts (she learned how to score the game there), the works. “You’ve only seen something like this on T.V.,” Martece says.

Each summer, Martece and the other “Dreamers” were invited down to the estate for a day. They had the run of the place and Martece remembers, especially, the long walks she took in the woods, enjoying the silence—the real, peaceful silence—of the countryside.

Like some of her classmates, Martece’s life took a detour. She started college in DC (paid for by Bainum), but after her son was born, she dedicated herself to her best job—being a mom. She hasn’t forgotten the promise she made to herself (and, indirectly, to “Mr. Bainum.”) In a scant few months, she’ll have wrapped up her bachelor’s in nursing.

In the meanwhile, Bainum’s foundation has produced a documentary about the Dreamers.

Anyway, Death be not proud. (Bill Myers, senior editor, Provider)