Wednesday, April 22, 2015
LTCCC press release says new study assesses nursing home citation rates nationwide, finds little or no punishment when nursing homes fail to provide care that meets the standards they are paid to achieve, even when such failures result in significant suffering.
Widespread and persistent nursing home problems, including serious deficiencies in care, result in unnecessary harm to thousands of vulnerable residents every day. Deficient and worthless services also cost taxpayers hundreds of millions of dollars a year. The nursing home industry frequently complains that it is one of the most highly regulated in the country. But what does that mean when so many nursing homes are consistently paid to provide care that fails to meet those standards?
LTCCC’s new report, , presents a comparative overview of every state’s (50 states + DC) performance on several key criteria. LTCCC assessed overall state citation rates, number and amounts of fines that each state has imposed in the last three years for violations of minimum standards and the rates at which the states identified resident harm when they found deficiencies. In addition to reviewing state citations as a whole, the study focused on three criteria important to quality care – pressure ulcers, staffing and antipsychotic drugging.
“While no data are perfect, we felt that assessing overall citation and penalty rates, as well as citations for three critical quality criteria, would together provide valuable insights into State Survey Agency performance and the extent to which important problems are being addressed in each state” said Richard Mollot, LTCCC’s Executive Director and author of the report.
1. Resident Harm. States only find harm to residents 3.41% of the time that they cite a deficiency. California and Alabama tied for lowest in the country, finding harm only 1.14% of the time.
2. Inappropriate Antipsychotic Drugging. The nationwide average antipsychotic drugging rate is 18.95% while the average citation rate for inappropriate drugging is 0.31%. This indicates that there is a significant amount of inappropriate antipsychotic drugging that is not being cited by the states.
3. Pressure Ulcers. Pressure ulcers (bed sores) are a problem for over 86,000 nursing home residents. Though they are largely preventable, states cite nursing homes the equivalent of less than 3% of the time that a resident has a pressure ulcer. When states do cite a facility for inadequate pressure ulcer care or prevention, they only identify this as harmful to residents about 25% of the time.
4. Sufficient Care Staff. Insufficient care staff is one of the biggest complaints made by nursing home residents and their families. Studies have repeatedly identified it as a serious problem in a majority of US nursing homes. Nevertheless, insufficient staffing is rarely cited by the states. The annual rate of staffing deficiencies per resident is infinitesimal: 0.042%. Less than 5% of those deficiencies are identified as resulting in harm. Twenty one states never connect insufficient care staff to resident harm in their states.
The report is available on LTCCC’s dedicated nursing home website at http://www.nursinghome411.org/articles/?category=lawgovernment. The website includes interactive charts showing key rates for each state as well as national averages. They include state rankings on criteria identified as important to nursing home resident care and the protection of taxpayer funds that pay for the majority of nursing home care. These charts can be used to gain insights into the strengths and weaknesses of quality oversight in any state.
Tuesday, April 21, 2015
If you haven't had a chance yet to read the new law, you should take a look. Medicare Access and CHIP Reauthorization Act of 2015 was signed by the President on April 16, 2015. Among some of the provisions to note is section 211 which provides for a permanent extension of the QI program (which had expired effective April 1 and had been reauthorized a year at a time), a change to Medigap plans (section 401) and a change to the income-related premium increases for higher income beneficiaries for Part B and D (section 402). These last 2 are part of the offsets in the bill. For the Medigap plans, effective in 2020, those newly eligible for Medicare won't be able to buy a gap plan to cover the Part B deductible. The changes to the income-related premium adjustments take effect a little earlier (2018) and those beneficiaries affected by the change will be paying more for their Medicare coverage.
Monday, April 20, 2015
Whenever I look at national programs on "hot topics" in healthcare law, I'm seriously impressed by the number of offerings on regulatory compliance issues connected to Medicare and Medicaid payments. There are abundant reasons for this emphasis. Each year the Department of Justice touts its statistics on "recoveries" for False Claim Act cases. For the fiscal year ending September 30, 2014, the DOJ enthusiastically reported its "first annual recovery to exceed $5 billion" in a single year. No wonder health care law is a hot field. And remember, much of the money is connected to senior care in all of its guises.
A recent $1.3 million settlement on a Medicare-related False Claims Act case might seem like small potatoes at first glance. But, I was struck by the fact that it was a DOJ settlement with a (non-profit) Continuing Care Retirement Community. I don't usually think of CCRCs as being a major target of False Claim Act allegations. Details are a bit sparse, but the size of the payment seemed pretty hefty when you consider that Asbury Health Center near Pittsburgh, PA actually "self-disclosed" its violation of Medicare regulations. The DOJ press release on April 15 explains:
"For post-hospital skilled nursing care, Medicare regulations require that a facility obtain a physician certification at the time of admission or as soon thereafter as reasonable and practical. The facility must also obtain a physician recertification within 14 days of admission and every 30 days thereafter. Based on information provided by Asbury, the United States alleged that it had civil claims against Asbury resulting from Medicare payments for post-hospital skilled nursing services that were not supported by physician certifications and recertifications."
The 2015 White House Conference on Aging held two more regional forums, one in Phoenix and one in Seattle. There are two regional forums left, one in Cleveland on April 27 and one in Boston on May 28.
As well, the WHCOA will be sponsoring a webinar on April 23 on retirement security. The website offers the following information about the webinar
With Americans living longer, pension options changing, and fewer workers spending careers with a single employer, the sources of retirement security are also changing. This webinar will provide an overview of best practices to help ensure greater opportunity and ability to enjoy a financially secure retirement. Speakers will include officials from the U.S. Treasury Department, the Women’s Institute for a Secure Retirement, and Harvard University. Registration is required and open until April 22nd.... This is the third in WHCOA’s webinar series designed to raise awareness of the challenges and opportunities for older adults in the U.S. We hope you will join us for this engaging discussion of best practices for a secure retirement.
The webinar is free; registration is required. Click here to register.
Thursday, April 16, 2015
The U.S. Department of Labor has released a new proposed rule intended to protect consumers from conflicts of interest among an array of folks who want to give advice about how and where to invest 401(c) and IRA retirement funds. The new rule would impose a "fiduciary duty" standard on those advisors, rather than the current, lower "suitability" standard for investment advice.
A DOL press release explains the goal:
"This boils down to a very simple concept: if someone is paid to give you retirement investment advice, that person should be working in your best interest," said Secretary of Labor Thomas E. Perez. "As commonsense as this may be, laws to protect consumers and ensure that financial advisers are giving the best advice in a complex market have not kept pace. Our proposed rule would change that. Under the proposed rule, retirement advisers can be paid in various ways, as long as they are willing to put their customers' best interest first."
Today's announcement includes a proposed rule that would update and close loopholes in a nearly 40-year-old regulation. The proposal would expand the number of persons who are subject to fiduciary best interest standards when they provide retirement investment advice. It also includes a package of proposed exemptions allowing advisers to continue to receive payments that could create conflicts of interest if the conditions of the exemption are met. In addition, the announcement includes a comprehensive economic analysis of the proposals' expected gains to investors and costs.
The New York Times covers the new rules in "U.S. Plans Stiffer Rules Protecting Retiree Cash," and notes the history of opposition to this kind of reform from -- surprise, surprise -- the "financial services industry." There is a 75-day window for public comments on the latest proposal.
Perhaps my biggest surprise was the remarkably "consumer friendly" presentation of the proposed change by the Department of Labor on its webpage, beginning with this simple video describing conflicts of interest.
Tuesday, April 14, 2015
The Washington Post reminds us that changes to federal law for government-backed reverse mortgages, adiopted in 2014, are about to kick in:
"Interested in a reverse mortgage without a lot of hassles? Better get your application in fast. As of April 27, the federal government is imposing a series of extensive 'financial assessment' tests that will make applying for a reverse mortgage tougher — much like applying for a standard home mortgage.
[D]uring the years of the recession and mortgage bust, thousands of borrowers fell into default because they didn’t pay their required property taxes and hazard insurance premiums. On top of that, real estate values plunged, producing huge losses on defaulted and foreclosed properties for the FHA. The losses got so severe that the Treasury Department had to provide the FHA with a $1.7 billion bailout in 2013, the first in the agency’s history since its creation in the 1930s.
All of which led to the dramatic changes coming April 27. Applicants are now going to need to demonstrate upfront that they have both the 'willingness' and the 'capacity' to meet their obligations. Reverse-mortgage lenders are going to pull borrowers’ credit reports from the national credit bureaus, just as they do with other mortgages.illion bailout in 2013, the first in the agency’s history since its creation in the 1930s."
For more details see the full Post article at Window Is Rapidly Closing to Get Hassle-Free Reverse Mortgage.
Friday, April 10, 2015
ElderLawGuy Jeff Marshall alerted us to this week's ruling by the Third Circuit Court of Appeals, affirming the conviction of Eugene Goldman, M.D. for several counts of taking "kickbacks" for referral of Medicare and Medicaid patients for hospice services. Dr. Goldman's sentence of 51 months, followed by three years of supervised release during which he is barred from practicing medicine, was affirmed. The facts, as set forth in the opinion, are interesting:
"Goldman had a geriatric medicine practice in Northeast Philadelphia. In December 2000, he secured the position of Medical Director of Home Care Hospice ('HCH'). Alex Pugman served as Director of HCH, and his wife, Svetlana Ganetsky, was the Development Executive, responsible for marketing HCH to doctors and other healthcare professionals. According to his contract, Goldman was responsible for quality assurance, consultations, and the occasional meeting. In reality, his job was to refer patients to HCH.
Goldman was paid for the number of patients he referred to HCH and the length of their stay. Early in his relationship with HCH, Goldman was paid $200 per referral. By 2011, he received $400 per referral, with an additional $150 for each patient who stayed longer than a month. Ganetsky paid Goldman each month by check. Between 2002 and 2012, Goldman referred more than 400 Medicare patients to HCH and received approximately $310,000 in return.
In 2006 the FBI and Department of Health & Human Services began investigating HCH for Medicare fraud. The FBI followed up in 2008 by obtaining a search warrant and seizing over 500 boxes of documents and information from HCH’s servers. Shortly after the raid, Ganetsky and Pugman approached the FBI and agreed to cooperate in the investigation. Ganetsky then recorded several meetings at which she paid Goldman for his referrals. Ganetsky made these payments with funds drawn from an account opened by the FBI for the investigation."
Thursday, April 9, 2015
On February 27, Pennsylvania's new governor, Tom Wolf, issued Executive Order 2015-05 regarding "participant-directed home care services."
The order reportedly reflects the Governor's interest and support for home care for seniors and persons with disabilities, while also recognizing potential issues such as low wages or absence of benefits, high turnover, inconsistent quality or lack of standards. The order:
- Creates a Governor's Advisory Group to advise the administration on "ways to improve the quality of care delivered" through publically funded home care service programs;
- Recognizes a "representative for Direct Care Workers for the purpose of discussing issues of mutual concern," while also authorizing a procedure for "election" of the representative; and
- Establishes a "Direct Care Worker List" of all workers paid through state programs, and further permits "an employee organization that has as one of its primary purposes the representation of director care workers" to petition the state to represent a particular unit of direct care workers.
As set forth in recent media reports, the Executive Order has met with resistance from some quarters, including those who are challenging the order as unlawfully permitting "unionization" of home care workers. On April 6, 2015, a complaint seeking injunctive relief from implementation of the executive order was filed in the Pennsylvania Commonwealth Court by a home care worker and his long-time client, a "quadriplegic adult with muscular dystrophy receiving care from the [state administered] Attendant Care Services Act.." The complainants are reportedly represented by "The Fairness Center, a conservative public-interest law firm."
April 9, 2015 in Current Affairs, Discrimination, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Tuesday, April 7, 2015
St. Louis University's Journal of Health Law and Policy has recently released a theme issue, focused on "Health Care Reform, Transition and Transformation in Long-Term Care." A great line-up of articles and authors, including:
- Home & Community-Based Long-Term Services and Supports: Health Reform's Most Enduring Legacy? by Marshall B. Kapp
- Care Coordination for Dually Eligible Beneficiaries, by Katie M. Dean and David C. Grabowski
- The Challenge of Financing Long-Term Care, by Judy Feder
- Rationalizing Home and Community-Based Services Under Medicaid, by Laura D. Hermer
- The Broken Promise of OBRA '87: The Failure to Validate Survey Protocol, by Malcolm J. Harkins III
In addition, there are two relevant Notes written by SLU students:
- Short-Stay, Under Observation. or Inpatient Admission? How CMS' Two Midnight Rule Creates More Confusion and Concern, by Rachel A. Polzin
- Disclosure for Closure? Why the Self-Referral Disclosure Protecol Process Paired with the 60-Day Overpayment Rule Creates More Headaches than Solutions, by Peter J. Eggers
April 7, 2015 in Discrimination, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Social Security, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (1) | TrackBack (0)
Monday, April 6, 2015
According to an informational bulletin from CMS on April 1, the traditional medical assistance program (TMA) and the QI program ended. The QI program had been extended until March 31, 2015, so both programs ended effective April 1, 2015. As a result of the end of the QI program and "[i]n the absence of an extension, states will not be required to discontinue their payment of Part B premiums for QI beneficiaries, but these payments will no longer be eligible for federal reimbursement from CMS unless and until the program is reauthorized" The informational bulletin is available here.
Saturday, April 4, 2015
When it becomes impossible for a loved one to stay at home without help, one decision that families made need to face is whether to use an agency, or hire one or more individuals outright. Agencies are usually more expensive (at least on paper). But direct hires of home aides can raise other questions, including how to handle state and federal income taxes and documentation, insurance, transportation (read: more insurance questions), coverage for holidays, sick leave, overtime, and more. You start off thinking this is short term help; the reality is it can last much longer....
But there is still one more question that may not be on the family's radar screen, until it is too late.
If the informal home care arrangements eventually don't suffice, perhaps because of increasing frailty and care needs, what happens when the individual's money is gone and there is a need for Medicaid-paid care?
As explained in a recent Michigan Court of Appeals case, "informal" arrangements for home care may trigger ineligibility for Medicaid-paid care based on state rules or policies implementing federal law.
April 4, 2015 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Wednesday, April 1, 2015
On Tuesday, March 31, the Supreme Court in a 5-4 decision rejected "private" rights of action for services providers to challenge under-funding of Medicaid programs by states. The ruling potentially impacts availability of services to all Medicaid-eligible beneficiaries, if doctors, home care agencies and similar private health care providers decline to participate in Medicaid funded service programs. The decision in Armstrong v. Exceptional Child Center, was delivered by Justice Scalia, joined in part by Justices Roberts, Thomas, Alito and Breyer. Justice Sotomayor dissents, joined by Justices Kennedy, Ginsburg and Kagan.
This one is going to take a bit of time to digest.
Here is the Washington Post coverage of the opinion.
Here is Kaiser Health's News Links to early reactions.
Tuesday, March 31, 2015
In DeCambre v. Brookline Housing Authority, decided by a federal district court in Massachusetts on March 25, the issue was whether a disabled adult living in Section 8 housing becomes ineligible for the housing subsidy because of disbursements to her from a special needs trust, funded as the result of a personal injury settlement.
Although the court affirmed the Bureau of Hearings and Appeal ruling on her income and expenses, thus disqualifying her for public housing benefits, the court also called for clearer federal guidelines to permit better planning for needy beneficiaries:
"[This case demonstrates the serious problem that beneficiaries of irrevocable trusts face; in particular, those that seek to pour lump-sum settlement funds into irrevocable trusts. But until the rules and regulations are clarified, public housing authorities should provide clear guidance and instruction for potential tenants with regard to their financial planning and spending. A more thorough and thoughtful analysis is required by public housing authorities when determining Section 8 eligibility, until further guidance is provided by the HUD."
Wednesday, March 25, 2015
In advance of his appearance and in preparation for his focus on "Special Needs Planning," Stephen Spano, who is board certified as an elder law attorney by the National Elder Law Foundation (NELF) and whose firm concentrates its practice on elder law, estate planning and special needs planning, asked the students to watch two very interesting -- indeed inspiring -- Ted Talk videos.
Here is his first assignment -- and I look forward to seeing how he uses both videos with our students:
His second assigned video "homework" is from Aimee Mullins, who talks about "My 12 Pairs of Legs."
A new book about Social Security has been getting some buzz since its release last month. Get What's Yours: The Secrets to Maxing Out Social Security is published by Simon & Schuster and authored by Laurence J. Kotlikoff, Phillip Moeler & Paul Solman. Here is an excerpt from the publisher's website
Learn the secrets to maximizing your Social Security benefits and earn up to thousands of dollars more each year with expert advice that you can’t get anywhere else. Want to know how to navigate the forbidding maze of Social Security and emerge with the highest possible benefits? You could try reading all 2,728 rules of the Social Security system (and the thousands of explanations of these rules), but Kotlikoff, Moeller, and Solman explain Social Security benefits in an easy to understand and user-friendly style. What you don’t know can seriously hurt you: wrong decisions about which Social Security benefits to apply for cost some individual retirees tens of thousands of dollars in lost income every year. How many retirees or those nearing retirement know about such Social Security options as file and suspend (apply for benefits and then don’t take them)? Or start stop start (start benefits, stop them, then re-start them)? Or—just as important—when and how to use these techniques? ...
The New York Times ran an article about this book on March 13, 2015. The Social Security Maze and Other U.S. Mysteries discusses the book as well as the intricacies of Social Security. Those of us elder law profs who cover Social Security in our classes know how complex it can be. As the article illustrates, it is more complicated than even we thought.
Given that there are 2,728 core rules and thousands more supplements to them according to the authors, it pays, literally, to seek out a guide...
The book’s success is also, however, symptomatic of something that we take for granted but should actually disgust us: The complexity of our financial lives is so extreme that we must painstakingly manage each and every aspect of it, from government programs to investing to loyalty programs. Mr. Kotlikoff’s game has yielded large winnings for his friends and readers (and several dinners of gratitude), but the fact that gamesmanship is even necessary in the first place with our national safety net is shameful.
The lead author explained how he came to this point "[s]oon, Mr. Kotlikoff was developing a computer model for various payouts from the government program and realized that consumers might actually pay to use it....From that instinct, a service called Maximize My Social Security was born, though it wasn’t easy to do and get it right. 'We had to develop very detailed code, and the whole Social Security rule book is written in geek,” he said. “It’s impossible to understand.'” The article goes on to illustrate some complexity by using as example health savings accounts and discuss why a well-intentioned law has become so complicated.
We all know it is a complicated program, so it's great to have another resource available to help explain everything. The book is available in hard copy or as an e-book either from the publisher or other book sellers.
Friday, March 20, 2015
Have you seen the number of articles that have been released about ABLE accounts? Here's a chance to learn more: the ABLE National Resource Center has announced a free webinar on ABLE on March 26 from 2-3:30 edt. This is a collaboration between ARC, National Disability Institute, Autism Speaks, National Down Syndrome Society, and the College Plan Savings Network. According to the website, Understanding ABLE will cover the facets of ABLE, implementation updates and time for Q&A. To register, click here.
Thursday, March 19, 2015
The National Academy of Elder Law Attorneys (NAELA) recently submitted detailed formal comments to proposed VA rules affecting asset tests for eligibility for Veterans benefits. They begin:
NAELA welcomes the effort to try to make the eligibility criteria for pension and other benefits administered by VA objective and transparent, but we believe that these proposed regulations, if implemented, would cause substantial harm to wartime Veterans, their spouses, and dependents and will not solve the serious issue of unscrupulous organizations taking advantage of potential beneficiaries by selling inappropriate annuities or trusts.
In addition, we express the serious concern that the proposed rule’s 3-year look-back period and transfer of assets penalty exceed statutory authority, opening up VA to future litigation and causing additional uncertainty for Veterans and their families.
For the full NAELA submission, see here.
Wednesday, March 18, 2015
The IRS has released a notice about a proposed regulation for ABLE accounts. Notice 2015-18 notes that some states are already moving forward with setting the framework for ABLE accounts and the notice acknowledges
The Treasury Department and the Internal Revenue Service (IRS) have been advised that several state legislatures currently are in the process of enacting enabling legislation in order to ensure that their citizens may create ABLE accounts during 2015. While the Treasury Department and the IRS currently are working on section 529A guidance, it is anticipated that ABLE programs may be in operation in some states before such guidance can be issued.
Not wanting to delay the states' progress, the notice allows the states to move forward
The Treasury Department and the IRS do not want the lack of guidance to discourage states from enacting their enabling legislation and creating their ABLE programs, which could delay the ability of the families of disabled individuals or others to begin to fund ABLE accounts for those disabled individuals. Therefore, the Treasury Department and the IRS are assuring states that enact legislation creating an ABLE program in accordance with section 529A, and those individuals establishing ABLE accounts in accordance with such legislation, that they will not fail to receive the benefits of section 529A merely because the legislation or the account documents do not fully comport with the guidance when it is issued.
The notice notes that a grace period will be provided to those states where ABLE accounts are being used to make any needed changes to comply with the IRS guidance. The notice goes on to explain how the IRS expects the ABLE guidance will differ from those for 529 plans.
In particular, the Treasury Department and the IRS currently anticipate that, consistent with section 529A(e)(3), the guidance will provide that the owner of an ABLE account is the designated beneficiary of the account. In addition, the Treasury Department and the IRS currently anticipate that the section 529A guidance will provide that, with regard to the ABLE account of a designated beneficiary who is not the person with signature authority over that account, the person with signature authority over the account of the designated beneficiary may neither have nor acquire any beneficial interest in the account and must administer that account for the benefit of the designated beneficiary of that account.
Wednesday, March 11, 2015
Julie Childs, Project Manager for the U.S. Department of Justice's Elder Justice Website shared with us the resources now available to researchers, students and advocates. Some of the highlights:
Here, victims and family members will find information about how to report elder abuse and financial exploitation in all 50 states and territories. Simply enter your zipcode to find local resources to assist you.
Federal, State, and local prosecutors will find three different databases containing sample pleadings and statutes.
Researchers in the elder abuse field may access a database containing bibliographic information for thousands of elder abuse and financial exploitation articles and reviews.
Practitioners -- including professionals of all types who work with elder abuse and its consequences -- will find information about resources available to help them prevent elder abuse and assist those who have already been abused, neglected or exploited.
This website is intended to be a living and dynamic resource. It will be updated often to reflect changes in the law, add new sample documents, and provide news in the rapidly evolving elder justice field.
It will be interesting to watch this site develop.
March 11, 2015 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, State Statutes/Regulations, Statistics | Permalink | Comments (1) | TrackBack (0)
Tuesday, March 10, 2015
In Draper v. Colvin, petitioner sought judicial review of SSA's denial of her application for SSI benefits. Her claim was sympathetic, as "[e]ighteen-year-old Stephany Draper suffered a traumatic brain injury in a car accident in June 2006."
In an admittedly "hard line" ruling on March 3, the 8th Circuit rejected her argument that her parents' intent to establish a valid third-party-settled special needs trust, using proceeds from a settlement of a personal injury suit on her behalf, should permit her to claim SSI.
The ruling means that over $400,000 will be treated as "available resources," thus requiring spend down before she would be eligible for benefits. The court explained (minus citations):
Admittedly, some evidence in the record supports Draper's claim that her parents intended to act in their individual capacities. Draper's parents identified themselves individually as settlors and trustees, and the trust document explicitly states that it was established “pursuant to 42 U.S.C. § 1396p(d)(4)(A)," a provision which notes that a third party, such as a parent, must create the special needs trust for the benefit of the disabled person. Nevertheless, as discussed [earlier in the opinion], other facts provide substantial evidence to support the conclusion that Draper's parents acted using the power of attorney when establishing the trust.
The Court continued on to its tough bottom line:
March 10, 2015 in Cognitive Impairment, Estates and Trusts, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Property Management, Social Security, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)