Friday, March 7, 2014
By Ronald G. Thurston
FALMOUTH — For the umpteenth time Maine policymakers and providers sit around a table and “study” what we are going to do with our ballooning population of old people.
Most people want to stay in their homes and receive only as much care as they need. The present system, however, often forces them into the most expensive and high-tech facilities that dominate end-of-life care.
Ronald G. Thurston of Falmouth is a member of the board of Seventy-Five State Street residence in Portland.
As one now myself, I have more than a passing interest in the subject – as someone who has been around health care and long-term care policy since 1965 perhaps I have something to contribute to the discussion.
Only the most committed ideologue would suggest we can tax our way out of our financially strapped state and federal government.
In short, we are broke at the state and federal level. A broke government leads to broken policy choices.
Rate freezes, benefit reductions and across-the-board cuts become the weapons of choice. Broke government leads then to bankrupt providers and services and current government policy requires receivership and hired management, requiring the drawdown of more state dollars, not fewer – a vicious circle in a downward spiral.
PARTNERS IN CARE
In my view of the world, government and providers partner to provide services to those who cannot afford to pay for their own care.
In a true partnership the payer recognizes the impact of its policy choices on the financial viability of its partner provider.
Being broke doesn’t usually allow for more payment, but in a fair and intelligent world it does require close examination of those regulatory demands put by the government on the provider that add costs and do not contribute substantially to the accomplishment of the mission.
At the same time while the provider works to reduce his own costs government has no less an obligation to examine and reduce its costs, and search for a better way to promote quality and efficiency.
Payment reform, regulatory reform, and services reform are all demanded within a private public partnership in a world of diminishing resources and increasing and ever accelerating demand.
During recent years there have been two major efforts launched that focus on what we now call rebalancing the health care system.
The first was stimulated by a book called “My Mother, Your Mother,” written by Dennis McCullough who has a geriatric practice in Hanover New Hampshire.
McCullough’s basic premise is called “slow medicine,” which he modeled after the slow food movement and it calls for conversation, listening more and slower decision making around issues of elder care, particularly for those over the age of 85, now Maine’s fastest growing age cohort.
McCullough also uses the phrase slow medicine to contrast it with high-tech intrusive emergency room and intensive care that dominates end of life care.
The other major national effort toward rebalancing the system has Maine origins and is detailed in a book written by Allan “Chip” Teel called “Alone and Invisible” and subtitled “Averting Disaster in Aging America.” Teel is a family physician in Damariscotta and has developed some remarkably innovative approaches to keeping elderly and disabled Maine citizens at home and out of the medical care system.
Teel speaks very candidly about the problems he encountered along the way with the MaineCare regulatory and payment system.
In the book, he notes that residential care has come a long way from the scandals of elder neglect and overt fraud that characterized the conditions of the poor farms, the almshouses and some of the nursing homes of the 1960s and 1970s.
TOO MUCH REGULATION
The advent of assisted living offered the promise of a significant departure from the pitfalls of the nursing home world. But the regulatory jungle that is now the standard of care threatens elders just as profoundly.
The dollars and time consumed in such wasteful oversight takes valuable local resources away from providing the care, comfort and companionship that should be the primary focus of our elder residences.”
Teel also illustrates the challenges to reform we face. He says, “I have given no fewer than a 100 presentations over the last five years ... but ironically the idea of saving someone money is not very well received.”
Several state agencies feared that incorporating our ideas and dramatically reducing the cost of care of their clients would reduce the state or federal dollars coming to their organizations.
Providers were concerned that blazing a new trail would require too much reform of the regulatory and payment system that governed their world. Doing more with less just did not compute.
This year I hope it will be different. The time for study is over – The time for leadership, planning and doing is now.
— Special to the Telegram