HBO's Will Scheffer takes on CMS, hospice revenue: A must-watch for healthcare finance leaders

The first time I saw the dark HBO comedy "Getting On," every single healthcare policy synapse lit up in my brain. That one 30-minute episode explored the Centers for Medicare & Medicaid Services' policy on payments for treating patients with congestive heart failure, handwashing compliance programs, and introduced a storyline about maximizing revenue from the Medicaid hospice program.

Just those references would be enough to suggest "Getting On" is as exciting as a revenue cycle seminar on the closing afternoon of a Healthcare Financial Management Association conference. But not only is it funny and poignant, it explores the drivers that make the U.S. healthcare system the most expensive on earth with a wit and intelligence no other scripted hospital show has come close to matching.

The stunning season finale, which aired on Sunday, outlined a hospital finance executive's worst nightmare: A qui tam lawsuit, the feds freezing accounts and ordering an audit, and a looming disqualification from the Medicare program.

Although it has received largely positive reviews, "Getting On" has not gotten a significant amount of media attention. Only 12 episodes have been produced to date, and it is purposely among the least glamorous television shows ever broadcast. It takes place in a geriatric unit (slyly named after the late and somewhat obscure Hollywood composer Billy Barnes) based at a down-in-the dumps hospital in Long Beach, California. The photography is dim, washed out and tinted blue by ever-present fluorescent light fixtures.

Three of the four principal cast members are varying degrees of obese. Most of the featured players are warts-and-all old, and little makeup is used. Remarkably enough, it is still brighter, neater and more attractive than the BBC version that ran from 2009 to 2012 and inspired this American counterpart (all episodes are available for streaming at hbogo.com; season one is available on Amazon.com).

The relative obscurity of "Getting On" and its wonkier-than-average storylines may have been among the reasons why show co-creator Will Scheffer--best known for the celebrated HBO series "Big Love" he launched with his professional and life partner Mark Olsen--was willing to speak with me on relatively short notice. Olsen is an attorney by training, and Scheffer credits him with performing the research that brings so many healthcare finance angles into the show.

Below is my exclusive interview with Scheffer, pictured, condensed and edited for space and clarity.

FierceHealthFinance: I have noticed that the British version of "Getting On" treats the National Health Service as sort of a dotty but benign relative who may take the longest route imaginable to a destination but still does its job. By contrast, the U.S. version seems to view the healthcare system as something that either contains oppressive rules or loopholes intended to be exploited for financial or personal gains. What made you decide to take this point of view?

Will Scheffer: Our entry into the show was much more from a geriatric point of view, rather than a bureaucratic point of view. Our mothers had been going through end-of -ife issues; we had gone through many years with many healthcare issues ... and that was our initial attack on the material. There was a kind of intention to expose what it was like to be in the system, and that's part of the lingua franca of the show.

The first season focused on the administration and the comedic issues that could arise, and that was based in part on our research into financing. We were attempting to skewer that whole management style (the first season has an on-running gag about using the Disney approach to healthcare services).

The hospice storyline that has been part of the second season is part of the fact that both our mothers had been through hospice, and our research into corporate hospice services. We hope to further that storyline, discussing the whole use of scatter beds. It is really is interesting in terms of how they play into hospice care and death rates at hospitals.

FHF: Dr. Stickley (the hospital administrator) makes passing reference to the fact that geriatrics is a loss leader for hospitals, which is indeed true. The fall from grace of Dr. Jenna James (played by Laurie Metcalf) at Mt. Palms Hospital is illustrated by her being shuffled over to the geriatrics unit and the clutter and blight in her office. It is the lowest-paid medical specialty--even lower than family medicine-- and the number of doctors entering it is in decline. Yet at the same time the U.S. population is aging rapidly and demand for such services is going to rise. Why do you think we're so conflicted about providing care to aging patients and providing the money to do so?

Scheffer: Americans are terrified of aging, death and dying, and we as a country really haven't advanced that dialogue or made any progress. Hospitals remain places you don't want to be at, and in that context it makes sense that geriatrics would be the least well-paid job.

And as the population ages, and more of us have aging parents, we thought the time was right to look into this topic some more ... and wouldn't you rather go and told it could be fun, a way of safely navigating that world, and having some catharsis? We had plenty of bad experiences with our mothers in geriatric care, particularly in rehab, but their ends were really, really great, and we both thought what a privilege it was to be there. I think we wanted to give that message.

But in this current state of affairs, with this divided government and class warfare, whether there will be a big appetite to spend money on an aging population is a big question.

FHF: What materials do you use for research?

Scheffer: We use everything. That's our philosophy for research. We use firsthand accounts of our own experiences, going to hospitals and studying the environments. We also use journals, and online forums for nurses where they talk about the work they're doing (three of the main characters are nurses). We also use management books. We were interested in all of the ways we could make this particular institution specific to what was going on in healthcare.

FHF: The Medicaid hospice benefit and how it can be abused is another healthcare finance issue explored by you (working with a for-profit hospice operator, Dr. James uses just about every available scatter and swing hospital bed for hospice patients, and the geriatric unit uses the additional revenue to conduct research and buy televisions for the patients). It's a troubling double-edge not only because of the clinical dishonesty involved in placing people in hospice just for monetary reasons, but also because it's entirely possible someone who's not terminally ill could wind up missing out on potentially lifesaving care specifically because they're in hospice. Is that dilemma going to be explored further down the line?

Scheffer: Clearly, Dr. James' enthusiasm for the hospice program came out of her own character flaw, and her intentions of doing no harm while bringing in more money quite appears that she is gaming the system. Basically, we're dealing with a very difficult healthcare situation that is also profit-based, and we try to bring voice to the fact that the more you try to clean things up, the more things you wind up having to clean up.

It's also complicated by (the Affordable Care Act). It's an improvement, but a complication, and an opportunity for hospitals and administrators to find other ways around things.

FHF: You snuck in a reference to death panels in the end credits of the last episode of the first season, but the strongest critique of the way healthcare is being delivered is made by a Swedish national trying to rescue his mother from undergoing a cardiac procedure she obviously does not need and cannot afford. And a doctor replies deadpan that U.S. hospitals have much better amenities, which in the case of Mt. Palms is a bird bath-style fountain with purple lights and what appears to be a shower door masquerading as a waterfall. There are a lot of Americans who are in thrall to the notion that theirs is the best healthcare system in the world. Did you feel you had to use an outside point of view to try and prove otherwise?

Scheffer: It's an interesting question, but it wasn't a conscious decision to bring it into the story line in that specific manner, but we are interested in seeing it in action. We would likely be exploring it further through having some foreign doctors visit the hospital.

FHF: Have you been renewed for another season?

Scheffer: We're hopeful that HBO will give us a chance to continue. We're just passionate about the show and have much more to say about healthcare and geriatrics.- Ron (@FierceHealth)

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