Duke Hospital, one of the most respected medical centers in the nation, has a new program that cuts health care costs with a novel use of ‘Home Care.’

Recently a University of California study has demonstrated how Home Care reduces health care costs: By keeping elderly people in their homes and out of more expensive Nursing Homes, by reducing the number of Emergency Room visits, hospital stays - and now with ‘Home Infusion Therapy.’

For years Medicaid has had a bias in favor of institutional care – for instance, by law states must provide Nursing Home Care but not Home Care. But today that’s changing – as part of a new Medicaid program twenty-nine states are embracing Home Care to improve the quality of care, reduce costs – and make patients happier.

Unfortunately, our state’s Medicaid policy remains tilted in favor of sending patients to Nursing Homes. In fact, the state just cut rates to Home Care providers, saying it would save money. But, in fact, the state is being ‘penny-wise and pound-foolish.’ Cutting Home Care rates means fewer providers, which means more patients have no choice but to go into Nursing Homes for care – which costs a lot more. It also means more ER visits. And more hospital stays. All of which lead to higher – not lower – health care costs.

It doesn't make sense: Other states are moving people out of Nursing Homes, back into their own homes - while our state can't move people into Nursing Homes fast enough. 

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As part of a new Medicaid Program twenty-nine states are moving people out of Nursing Homes and into Home Care. A recent article in the New York Times about Walter Brown – a former Nursing Home patient – explains how the program works.  

Mr. Brown, who lives in Philadelphia, had a stroke two years ago and went into a Nursing Home.

“It was,” he told the Times, “like being in jail.”

Now he’s out.

Because  Pennsylvania – as part of the new program – is “reaching out to people like Mr. Brown, who have been in nursing homes for more than six months, aiming to disprove the notion that once people have settled into a nursing home, they will be there forever.”

For years the Times reports, “Medicaid practically steered people into nursing homes.”

“Medicaid,” says Gene Coffey, an attorney with the non-profit National Senior Citizens Law Center, “has had an institutional bias in favor of nursing homes. Federal law requires states to provide nursing home services. But not home or community based services.”

But, now, Pennsylvania is moving patients like Mr. Brown out of Nursing Homes and back into their own homes, where they receive Home Care.

The final savings aren’t clear but a recent study by the University of California found home care costs taxpayers $44,000 a year less than nursing home care.

North Carolina policy still tilts toward sending patients to Nursing Homes – but wouldn’t it be a pleasant change to open the newspaper and read a story like this, where a patient left a Nursing Home and returned to his own home. It could cut health care costs. And make patients – like Mr. Brown – happier. 

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Tim Rogers – the Director at the Association of Hospice and Home Care – has taken his life in his hands and tackled Craigan L. Gray, MD, MBA, JD and Director of the Division of Medical Assistance at Department of Health and Human Services head on.  

Rogers wrote Doctor Gray to explain how Gray’s letter to elderly Medicaid patients (see blog below) about losing their home care has caused a lot of upheaval – and urged Dr. Gray to send another letter to clear the air. Gray’s answer was, ‘Thank you for your input. Let’s talk about it sometime’ – which sounds kind of like a polite sandbag, but, whatever it is, hardly solves the problem.

It turns out Doctor, Lawyer, MBA Gray made a couple of other mistakes in his letter. First, he wrote every Medicaid patient in the state they had to undergo an ‘independent assessment’ to see if they should continue to receive home care. But, in fact, the new ‘independent assessments’ only apply to patients applying to receive home care for the first time – not patients whose doctors have already placed them in care and who’ve been receiving it with DHHS approval for years.

Gray also wrote the elderly patients and told them not to talk about the care they need to home care providers. That looks like he misunderstood another new provision of the law. More to the point: Not talking to the person providing your care creates a pretty obvious practical problem.

Doctor Gray’s one of the most powerful men in state government – except for Secretary Lanier Cansler he has more say in who gets care than anyone. He controls millions of dollars in state contracts and spends hundreds of millions of taxpayers’ money.

Right now he’s struggling with the mess the legislature left him with the budget, trying to figure out how to cut care to patients who’re legally eligible – and need – care.

His letter may be a first step in that direction – and a misguided step. There was no need to send elderly patients letters that intimidated – at least part of – them. And, beyond that, folks in America sort of like to practice freedom of speech and, generally, more good comes of it than harm. 

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Craigan Gray, the head of the Division of Medical Assistance at the Department of Health and Human Services, is a well educated man. He signs his official letters Craigan L. Gray – MD, MBA, JD, Director. He’s a doctor, an MBA, and an attorney. That makes you kind of wonder why (with a medical degree and a law degree) he’s working in state government – even if he is making more than the Governor. It must also be tough for his boss Lanier Cansler, who’s only a CPA, when it comes time for the two of them to sit down and argue health care policy.  

But there’s also always a possibility someone with Dr. Gray’s education might lose the common touch.

Imagine, for instance, an eighty year old woman living on $160 a week, whose health is failing. She gets forgetful now and then, and can’t take care of her everyday needs like cooking, bathing and walking on her own – but that’s okay because she’s got home care from Medicaid to help her get by.

Then one morning she receives an official letter – that sounds a lot like it came from the IRS –telling her she’s about to be evaluated to determine if her home care ought to be eliminated and she ought not to discuss it with the people who care for her. It’d scare the willies out of her – right?

Craigan L. Gray signed and sent that letter to every eighty year old lady on Medicaid home care in North Carolina.

It’s fine that Craigan L. Gray is so well educated but somewhere along the way he missed (or forgot) what nurses and aides learn and relearn everyday – that a lot of medical care involves a virtue they don’t give a degree for – TLC. 

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