Monday, December 5, 2016
The 1st Annual Report of the White House Legal Aid Interagency Roundtable (WH-LAIR), Expanding Access to Justice, Strengthening Federal Programs was released last month. A fact sheet accompanying the report is available here. According to the DOJ website, the reason for WH-LAIR is
to raise federal agencies’ awareness of how civil legal aid can help advance a wide range of federal objectives including improved access to health and housing, education and employment, family stability and public safety. The Legal Aid Interagency Roundtable’s message included that providing legal assistance to people who cannot afford it can also have substantial economic benefits by preventing outcomes that are harmful to them and expensive for the communities.
WH-LAIR is made up of a number of federal agencies. The fact sheet highlights some of the accomplishments, including an ElderJustice AmeriCorp which provides teams of attorneys and paralegals to help elder abuse victims. This first report covers the 4 years of operation of WH-LAIR. The report highlights the participating agencies' efforts to incorporate legal aid into their programs. policy recommendations to improve access to justice, furthering strategic partnerships, furthering data collection, evidence-based research, and concomitant analysis. The full report has 3 sections: (1) legal aid overview and its correlation to advancing federal priorities, (2) how the agencies have incorporated legal aid into their programs and (3) future opportunities to continue and expand their work.
December 5, 2016 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Legal Practice/Practice Management | Permalink | Comments (0)
Thursday, December 1, 2016
The Administration on Aging (AoA) issued FAQ on the Long Term Care Ombudsman Program. The purpose of the FAQs is " to assist State Agencies on Aging, States’ Long-Term Care Ombudsman Programs, and other entities that work with Ombudsman programs with implementation of the State Long-Term Care Ombudsman Programs Rule." Each FAQ provides extensive explanation as well as cites to the appropriate sections of the CFR.
Monday, November 28, 2016
The National Consumer Voice For Quality Long-Term Care has released a fact sheet explaining the changes to the Federal Nursing Home Regulations. The 15 page fact sheet " provides a brief overview of key changes in the sections on Resident Rights; Freedom from Abuse, Neglect, and Exploitation; and Admission, Transfer and Discharge that will go into effect in Phase 1. The purpose of the summary is to highlight what is different between the prior rule and the final rule." The fact sheet is organized by sections of the CFR and explains what is amended and what is new./ Print this out and save it. It's invaluable!
here.Last month the Commonwealth Fund published an issue brief about the correlation between Medicare beneficiaries with Physical and/or cognitive impariments and the connection to Medicaid and nursing home placements. With all the talk about changes to Medicare and Medicaid, this is a timely topic (but it always is timely), Risks for Nursing Home Placement and Medicaid Entry Among Older Medicare Beneficiaries with Physical or Cognitive Impairment. Here is the abstract:
Issue: More than half of individuals who age into Medicare will experience physical and/or cognitive impairment (PCI) at some point that hinders independent living and requires long-term services and supports. As a result of Medicare’s limits on covered services, Medicare beneficiaries with PCI experience financial burdens and reduced ability to live independently. Goal: Describe the characteristics and health spending of Medicare beneficiaries with PCI and estimate the likelihood of Medicaid entry and long-term nursing home placement. Methods: The Health and Retirement Study 1998–2012 is used to estimate long-term nursing home placement, as well as Medicaid entry. The Medicare Current Beneficiary Survey 2012 provides information on health care spending and utilization. Key findings and conclusions: Almost two-thirds of community-dwelling Medicare beneficiaries with PCI have three or more chronic conditions. More than one-third of those with PCI have incomes less than 200 percent of the federal poverty level but are not covered by Medicaid; almost half spend 10 percent or more of their incomes out-of-pocket on health care. Nineteen percent of individuals with PCI and high out-of-pocket costs entered Medicaid over 14 years, compared to 10 percent without PCI and low out-of-pocket costs.
The brief offers background, data and analysis. For expediency, I've included the conclusion here. I recommend you read the entire brief.
This analysis finds that:
- A third of older adults have PCI in a given year; more than half of adults who age into Medicare will experience PCI over the remainder of their lifetimes. While the majority of older adults with PCI live in the community, they are at high risk for costly, long-term nursing home placement.
- Individuals with PCI often have multiple chronic conditions, resulting in high Medicare expenses and out-of-pocket spending. Those with high out-of-pocket spending as a proportion of income as well as PCI were at greater risk for spending down their resources and entering into Medicaid over a 14-year period, compared to those with PCI but without high out-of-pocket spending.
- The risk for Medicaid entry was greater for those at lower income levels at the beginning of the 14-year period. However, 14 percent of the highest-income group at baseline with high out-of-pocket spending and PCI entered Medicaid by the end of the follow-up period.
Improving financing for home and community-based care would help many beneficiaries with PCI continue to live independently and support families in helping them obtain the care they prefer. Our current health care system, which covers costly institutional services but not social support in the home, distorts the way Americans receive care as they age and die. After people with serious impairment become impoverished and qualify for Medicaid, they are covered for long-term nursing facility care. However, personal care services at home that might have prevented them from needing to turn to Medicaid or enter a nursing home are not covered by Medicare.
Intervening early to prevent nursing home placement and Medicaid enrollment may produce offsetting savings in Medicare and Medicaid. An accompanying brief describes two innovative approaches to providing long-term services and support benefits: a voluntary, supplemental benefit for home and community-based services for Medicare beneficiaries; and an expansion of the Medicaid Community First Choice program for people with incomes up to 200 percent of poverty. Both options show promise of maintaining independent living longer and avoiding costly long-term institutionalization and exhaustion of resources that result in Medicaid enrollment.
The brief is also available as a pdf here.
Tuesday, November 22, 2016
We blogged earlier about the discussion regarding switching Medicaid to block grants. The impact of doing so would be far reaching and the Commonwealth Fund released an issue brief, What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?
Here is the abstract from the issue brief:
Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans. Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee. Methods: Review of existing policy proposals and other documents. Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting “per capita caps” would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.
The article provides history, data and discusses strategies. The Brief concludes that the issue, and the resulting outcomes, are not as simple as may be presented.
As the country’s largest insurer, Medicaid is subject to the same cost drivers that affect all providers of health insurance: population growth and demographic trends that increase enrollment, health trends that influence how often people need care and what kind of care they require, and advances in technology that drive up costs, among other factors. But unlike commercial insurers, government-funded Medicaid, in its role as first responder and safety net, is more vulnerable to these trends and to cost increases. For more than 50 years, Medicaid has been rooted in a flexible federal–state partnership, constantly restructured over time to meet current challenges.
Any attempt to restructure federal financing for Medicaid and replace flexibility with strict spending limits—whether in the form of block grants, per capita limits on spending, restrictions on what counts as state expenditures, or a combination of all three—would divorce funding considerations from the real-life needs that have informed federal and state Medicaid policy for half a century. Crucially, a per capita cap would permit population growth to occur. But the limit of lawmakers’ appetite for continued growth in enrollment is unclear. Given how states responded to the relatively mild and temporary funding reductions the federal government enacted in 1981, sweeping changes like those currently under consideration are likely to produce far more substantial fallout.
The 10 page issue brief can be downloaded as a pdf here.
CMS has released a new handbook, Coordination of Benefits and Third Party Liability (COB/TPL) In Medicaid (2016). The explanation of the Handbook offers a section "About This Handbook": "Purpose: The purpose of the Handbook is to provide an overview of COB/TPL policy on a variety of individual subjects... 2. Intended Audience: The Handbook is intended for CMS Central Office (CO) and Regional Office (RO) staff working on COB/TPL issues, state Medicaid agency staff, and all other parties interested in Medicaid COB/TPL policies... 3. Content: The Handbook contains policy guidance on a variety of COB/TPL topics that is current at the time of publication. .."
The manual is available here for download as a pdf.
Wednesday, November 16, 2016
A colleague yesterday sent me a link to a story about Speaker Ryan's plan to introduce cuts to Medicare (or eliminate it in its current form as we know it). (Of course, this was after the class where we had just finished covering Medicare). All I could think was, not again.... By not again, I meant here is another proposal heading to Congress to change (or eliminate) one of the entitlement programs. We've weathered the proposals to change Social Security (Remember the Commission appointed by President George W. Bush?). Now it's Medicare.
There is information on Speaker Ryan's website about his plan to change Medicare. A series of articles have popped up in the last few days as a result of his recent interview appearing on Fox. In Talking Points Memo, Ryan Plans to Phase Out Medicare in 2017, the transcript of the interview appears. Here's a quote:
What people don't realize is because of Obamacare, medicare is going broke, medicare is going to have price controls because of Obamacare, medicaid is in fiscal straits. You have to deal with those issues if you are going to repeal and replace obamacare. Medicare has serious problems [because of] Obamacare. Those are part of our plan.
The article describes his position as a phase-out of Medicare, although current beneficiaries keep Medicare.
Money magazine also ran an article, questioning the Speaker's assertion that Medicare is going broke. Is Medicare Really Going Broke, Like Paul Ryan Says?
Here’s the thing: Medicare is on an unsustainable spending path, but it’s not going broke. “The idea that we have a crisis is just nonsense,” says Dr. Robert Berenson, a fellow at the Urban Institute, a nonpartisan research organization, and formerly an official at the Centers for Medicare and Medicaid Services. And Obamacare is not the culprit for Medicare’s fiscal woes.
The article notes that his plan proposes
changes [that] generally fall under the terms “privatization,” or “premium support.” While it remains unclear exactly what this would look like, it may mean giving beneficiaries some sort of fixed dollar amount to buy their own private insurance as an alternative to, or even replacement for, original Medicare... Under this type of system, beneficiaries who choose the lowest-cost coverage will stretch their government subsidy the farthest—which ironically, is how Obamacare works today.
The Washington Post ran an article about it, focusing on whether this is an "opportunity" for the Democrats, Paul Ryan’s plan to phase out Medicare is just what Democrats need. The Washington Post article offers a sobering assessment
If Ryan gets his way, Medicare as a universal insurance program will cease to exist. It will be replaced by “premium support,” or vouchers which seniors will use to buy private insurance. If you can’t afford any of the available plans with what the voucher is worth, tough luck. The whole point is to transfer the expense from Medicare to the seniors themselves. Half a century after Medicare brought health security to America’s seniors, Republicans would snuff it out, leaving some unknown number without any coverage at all and breaking the fundamental promise the government made.
Serious bummer folks.
Monday, November 14, 2016
CMS announced the 2017 premiums on November 10, 2016. Since the 2017 SSA COLA is so low, the hold harmless provision will kick in for many. For the Part B premium, most will pay $109.00 because of the "hold harmless" while others will pay $134. The income adjusted part B premium for higher income beneficiaries starts at $187.50 and tops out at $428.60 for a single person. The 2017 annual Part B deductible will be $183.
The Part A inpatient hospital deductible for 2017 will be $1,316, and the SNF co-pay for days 21-100 will be $164.50 in 2017. More of the 2017 figures are available here.
Monday, November 7, 2016
A federal district court in Mississippi has entered an injunction prohibiting the CMS rule against pre-dispute arbitration from taking effect at the end of this month. According to a story on NPR, "[t]he reason for granting the injunction, the court explained in its order, is that it believes the new rule represents "incremental 'creep' of federal agency authority" — in this case the Centers for Medicare & Medicaid Services — 'beyond that envisioned by the U.S. Constitution.'"
The 40 page order is available here.
Monday, October 31, 2016
SSA announced recently that there would be a COLA for 2017, but it is a teensy COLA, actually, a .03% increase. Big gap between Social Security cost-of-living adjustment and retiree inflation offers a critical look at the 2017 COLA compared to inflation and how the government calculates the COLA using the consumer price index. An article in USA Today about the 2017 COLA noted that this COLA won't allow beneficiaries to get ahead, even slightly. Instead, they will likely lose ground, because of the Medicare Part B premium costs
The nation’s 65 million Social Security beneficiaries will receive a paltry 0.3% cost-of-living adjustment to their monthly checks in 2017, the government announced Tuesday. In dollars and cents, it means the average retired beneficiary’s check will rise about $5 to $1,360 per month in 2017.
The even more bitter pill: Many current Medicare beneficiaries won’t be able to spend any of that extra money. Instead, they’ll likely have to send their COLA straight back to Uncle Sam to cover higher Medicare Part B premiums.
Almost a third of Medicare's 56 million beneficiaries could see their premiums jump 22% next year, according to the Medicare Trustees Report, putting the cost at an estimated $149 per month. Those unlucky 30% of beneficiaries include people enrolling in Part B for the first time in 2017, people who are on Medicare but who aren't currently taking Social Security benefits and current enrollees who pay an income-related higher premium.
Sunday, October 30, 2016
The New England Journal of Medicine published a study that shows by region where people spend more time at home at the end of life. Days Spent at Home — A Patient-Centered Goal and Outcome notes that
Being home at the end of one’s life will never be a universal goal, but our experience and academic research suggest that, all else being equal, patients would rather be at home than in health care facilities. When surveyed about their preferences for dealing with a terminal illness, most people (86%) indicated that they would prefer to be at home in their final days. In addition, they would not want to be on a ventilator in order to gain an extra week of life, and they are not opposed to drugs that could improve symptoms but potentially shorten life. These preferences are highly consistent across regions of the country and people’s socioeconomic status.1 Despite this consistency in end-of-life preferences, there is wide regional variation in the intensity of, expenditures on, and locations of care provided during the last 6 months of life.
The Wall Street Journal reported on the study. Where the Elderly Die Can Vary by Region, Study Shows explains that
How much time people spend in hospitals or nursing homes in the final months of life, instead of at home, varies widely depending on where they live, new research shows.
Across the Rockies and regions of the Gulf Coast, the dying spend more than two additional weeks hospitalized or in other facilities, on average, compared with those at the end of life in the Midwest and Montana, researchers reported Wednesday in the New England Journal of Medicine.
In other parts of the country, the picture is more mixed but still differs sharply from one community to another.
The study also looks at the differences in Medicare spending as a result of the regional variations. "Research suggests one reason for the geographical spending swings may be that doctors practice medicine differently in some areas of the country than others, with some doctors doing more despite little difference in results." Even in some instances where the patient's care was supposed to be delivered at home, that didn't occur. "The ... study also found that health-care and hospice services intended to keep people at home perhaps did not do so. Regions where use of home care and hospice were greater also had higher use of hospitals and nursing homes ...."
Thursday, October 27, 2016
The Administration for Community Living (ACL) released on October 26, 2016 the unpublished final regulation for independent living programs (the reg is officially published on October 27, 2016). The rule is effective November 25, 2016.
The discussion section explains the new rule
The federal Independent Living (IL) program seeks to empower and enable individuals with disabilities, particularly individuals with significant disabilities, to exercise full choice and control over their lives and to live independently in their communities. For over 40 years, these aims have been advanced through two federal programs: Independent Living Services (ILS) and Centers for Independent Living (referred to as CILs or Centers). The Workforce Innovation and Opportunity Act (WIOA) transferred these Independent Living programs to the Administration for Community Living (ACL) and created a new Independent Living Administration within the agency, adding section 701A of the Rehabilitation Act, 29 U.S.C. 796-1.
According to the ACL news release, the new regs:
Clarifies requirements surrounding WIOA’s addition of new core services to:
- Facilitate the transition of individuals with significant disabilities from nursing homes and other institutions to home and community-based settings
- Provide assistance to individuals with significant disabilities who self-identify as being at risk of entering institutions so that the individuals may remain in the community
- Facilitate the transition of youth with significant disabilities who are no longer in school and no longer receiving services under section 614(d) of IDEA.
Clarifies several key definitions. For example:
- “Consumer control” adds specificity to definition in the context of individuals to mean that the person with a disability has control over his or her personal life choices, independent living plan and has the right to make informed choices about content, goals and implementation. Prior to the final rule, “consumer” was sometimes interpreted to include the parents or caregivers of the person with a disability
- “Personal assistance services” is now defined to explicitly include assistance with activities outside of employment, such as social activities and parenting.
Addresses the roles and responsibilities of the State Independent Living Council, as defined by WIOA. For example, the final rule:
Includes additional details of what must be a part of the SILC Resource Plan to carry out the functions of the SILC
Addresses the SILC’s authority to conduct resource development activities to support the provision of services by Centers for Independent Living
Clarifies the expanded role of the SILC in the development of the State Plan for Independent Living.
Wednesday, October 26, 2016
DOJ announced recently that it had settled a False Claims case against Life Care Centers of America Inc. (Life Care) and its owner, Forrest L. Preston. The defendants agreed to pay $145 million to settle a case where the Government claimed “that Life Care violated the False Claims Act by knowingly causing skilled nursing facilities (SNFs) to submit false claims to Medicare and TRICARE for rehabilitation therapy services that were not reasonable, necessary or skilled….” In addition, the defendant also signed a Corporate Integrity Agreement with the Office of Inspector General (HHS-OIG) for HHS. Under this 5 year agreement, “an independent review organization [will] … annually assess the medical necessity and appropriateness of therapy services billed to Medicare” by the defendant. The suit was brought pursuant to the whistleblower provision of the False Claims Act.
According to the suit, the defendant put corporate-wide procedures and polices into place that caused a maximum number of “beneficiaries in the Ultra High reimbursement level irrespective of the clinical needs of the patients, resulting in the provision of unreasonable and unnecessary therapy to many beneficiaries.” Further the defendant tried to keep SNF residents longer than needed so the defendant could continue to bill for rehab, even though the therapists concluded therapy should be ended. The defendant kept careful track of the therapy minutes per patient and the patient’s therapy days so that the maximum number of patients were at that “highest level of reimbursement for the longest possible period.”
According to an email I received, the amount of the settlement was partially based on statistical sampling.
Thanks to Laurence Hooper for emailing me.
Friday, October 21, 2016
LeadingAge, the trade association that represents nonprofit providers of senior services, begins its annual meeting at the end of October. This year's theme is "Be the Difference," a call for changing the conversation about aging. I won't be able to attend this year and I'm sorry that is true, as I am always impressed with the line-up of topics and the window the conference provides for academics into industry perspectives on common concerns. For example, this year's line up of workshops and topics includes:
- General sessions featuring Pulitzer Prize winning journalist Charles Duhigg on the "The Science of Productivity," 2013 MacArthur Fellow and psychologist Angela Duckworth on the the importance of grit and perservance for successful leadership, and famed neurosurgeon and speaker Sanjay Gupta on "Medicine and the Media."
- Hundreds of sessions, organized by "interest groups":
October 21, 2016 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, International, Legal Practice/Practice Management, Medicaid, Medicare, Programs/CLEs, Property Management, Retirement, Science, Social Security, State Cases, State Statutes/Regulations, Veterans | Permalink | Comments (2)
Thursday, October 20, 2016
Geripal-a geriatrics/palliative care blog-has started a podcast series. The first one is on bed alarms. The podcasts include links to articles referenced in the podcasts. For the one on bed alarms, the following were discussed:
Barker Anna L, Morello Renata T, Wolfe Rory, Brand Caroline A, Haines Terry P, Hill Keith D et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial BMJ 2016; 352 :h6781
Shorr RI, Chandler AM, Mion LC, Waters TM, Liu M, Daniels MJ, et al. Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial. Ann Intern Med. 2012;157:692-699.
Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., Srulovici, E. and Admi, H. (2011), Low Mobility During Hospitalization and Functional Decline in Older Adults. Journal of the American Geriatrics Society, 59: 266–273
Click here to access the podcast.
Monday, October 17, 2016
We knew it was coming. The American Healthcare Association has filed suit in the federal district court in the Northern District in Mississippi, challenging the CMS rule that prohibits pre-dispute arbitration in nursing home admission contracts, American Health Care Association Files Court Challenge to Arbitration Rule: CMS Exceeds Statutory Authority by Banning Pre-Dispute Arbitration Agreements in Updated Requirements of Participation
The press release explains
The American Health Care Association (AHCA) today filed a lawsuit against the Department of Health and Human Services challenging the legality of a provision of a recently released regulation. The Requirements of Participation final rule, issued by the Centers for Medicare and Medicaid Services (CMS) on September 29, will prohibit skilled and nursing care facilities from entering into pre-dispute arbitration agreements with residents at their centers, no matter how fair or beneficial those agreements may be to residents.against the Department of Health and Human Services challenging the legality of a provision of a recently released regulation. The Requirements of Participation final rule, issued by the Centers for Medicare and Medicaid Services (CMS) on September 29, will prohibit skilled and nursing care facilities from entering into pre-dispute arbitration agreements with residents at their centers, no matter how fair or beneficial those agreements may be to residents.
The suit "request[s] the courts [act] to stop the enforcement of the arbitration portion of the rule after its effective date of November 28, 2016." The complaint is available here.
Wednesday, October 12, 2016
On October 11, 2016, the U.S. Court of Appeals for the D.C. Circuit ruled in PPH Corp. v. Consumer Financial Protection Bureau. Although initially conceived as a "multi-member independent agency" in its final form approved by Congress, the CFPB is "an independent agency headed not by a multi-member commission but rather by a single Director. Because the CFPB is an independent agency headed by a single Director and not by a multi-member commission, the Director of the CFPB possesses more unilateral authority – that is, authority to take action on one’s own, subject to no check –than any single commissioner or board member in any other independent agency in the U.S. Government. Indeed, as we will explain, the Director enjoys more unilateral authority than any other officer in any of the three branches of the U.S. Government, other than the President." The opinion notes the great power held by the director and describes it as "massive in scope, concentrated in a single person, and unaccountable to the President [and thus] triggers the important constitutional question at issue in this case." Examining historical precedent and discussing the lack of checks on the director's power under the current structure which (the court described as a "threat to individual liberty posed by a single-Director independent agency"), the court held "that the CFPB is unconstitutionally structured."
The court looks next at the appropriate remedy, with the Plaintiff arguing the agency should be shuttered. Instead, the court severed the offending language in the statute, to provide "the President ... the power to remove the Director at will, and to supervise and direct the Director." The court goes on at length (and acknowledges this) to explain its ruling, and to also address the Plaintiff's challenge to the fine imposed against it by the CFPB.
The CFPB therefore will continue to operate and to perform its many duties, but will do so as an executive agency akin to other executive agencies headed by a single person, such as the Department of Justice and the Department of the Treasury. Those executive agencies have traditionally been headed by a single person precisely because the agency head operates within the Executive Branch chain of command under the supervision and direction of the President. The President is a check on and accountable for the actions of those executive agencies, and the President now will be a check on and accountable for the actions of the CFPB as well.
The opinion is available here.
Monday, October 10, 2016
Will New Federal Ban on Pre-Dispute "Binding" Arbitration Clauses in LTC Agreements Survive Likely Challenges?
My colleague Becky Morgan provided prompt links and important initial commentary for CMS's recently issued final regulations that are intended to "improve the quality of life, care, and services" in Long-Term Care (LTC) facilities. As we start to digest the 700+ pages of changes and commentary, it seems clear the battle over a key section that bans pre-dispute binding arbitration agreements is already shaping up. This rule, at 40 CFR Section 483.70(n), has an implementation date of November 28, 2016.
The regulatory ban on pre-dispute binding arbitration in covered facilities raises the question of "conflict" with the Federal Arbitration Act (FAA), 9 U.S.C. Section 1 et seq. The 2012 per curium ruling by the Supreme Court in Marmet Health Care Center, Inc. v. Brown, shapes the issue, if not the result.
CMS distinguishes Marmet and presents the rule change as based on authority granted under the Social Security Act to the Secretary of Health and Human Service to issue "such rules as may be necessary to the efficient administration of the functions of the Department," which necessarily includes supervision of all providers, including LTC providers, who "participate in the Medicare and Medicaid programs." CMS points to the long history of regulatory authority over LTC including long-celebrated "patient's rights" legislation adopted in the late 1980s. CMS further explains (at page 399 of the 700 page commentary to the new rules):
Based on the comments received in response to this rulemaking, we are convinced that requiring residents to sign pre-dispute arbitration agreements is fundamentally unfair because, among other things, it is almost impossible for residents or their decision-makers to give fully informed and voluntary consent to arbitration before a dispute has arisen. We believe that LTC residents should have a right to access the court system if a dispute with a facility arises, and that any agreement to arbitrate a claim should be knowing and voluntary. . . .
We recognize that an argument could be made that Medicare and Medicaid beneficiaries can assert in Court the FAA's saving clause if they believe that a pre-dispute arbitration agreement should not be enforced. However, the comments we have received have confirmed our conclusion that predispute arbitration clauses are, by their very nature, unconscionable. As one commenter noted, it is virtually impossible for a resident or their surrogate decision-maker to give fully informed or voluntary consent to such arbitration provisions. That same commenter 402 also noted that refusing to agree to the arbitration clause, in most cases, means that care will be denied.
Furthermore, Medicare and Medicaid beneficiaries are aged or disabled and ill. Many beneficiaries lack the resources to litigate a malpractice claim, much less an initial claim seeking to invalidate an arbitration clause. Rather than requiring Medicare and Medicaid beneficiaries to incur the additional fees, expense, and delay that would be the direct cost of opposing a motion to enforce arbitration, we have concluded that this is precisely the type of situation envisioned by the Congressional grant of authority contained in sections 1819(d)(4)(B) and 1919(d)(4)(B) of the Act authorizing the Secretary to establish "such other requirements relating to the health, safety, and well-being of residents or relating to the physical facilities thereof as the Secretary may find necessary.”
By coincidence, just hours before the final LTC rules issued by CMS, the Pennsylvania Supreme Court enforced pre-dispute arbitration agreements for nursing home residents in Taylor v. Extendicare Health Facilities (decided September 28, 2016).
The LTC industry seems ready to fight, as reported by industry insiders at McKnight's News on September 29, 2016:
Both the American Health Care Association and LeadingAge expressed disappointment in the arbitration ban in statements provided to McKnight's.
“That provision clearly exceeds CMS's statutory authority and is wholly unnecessary to protect residents' health and safety,” said Mark Parkinson, president and CEO of AHCA.
LeadingAge has supported arbitration agreements that are “properly structured and allow parties to have a speedy and cost-effective alternative to traditional litigation,” but believes CMS has overstepped its boundaries with the ban, the group said.
“Arbitration agreements should be enforced if they were executed separately from the admission agreement, were not a condition of admissions, and allowed the resident to rescind the agreement within a reasonable time frame,” LeadingAge added in its statement.
Stay tuned -- but don't hold your breath as the next round is likely to take some time. My special thanks to Megan Armstrong, Class of 2018 at Dickinson Law, for sharing key links with me for our research on this important development.
October 10, 2016 in Consumer Information, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations, Statistics | Permalink | Comments (0)
Sunday, October 9, 2016
The GAO issued a new report regarding the accessibility of SNF expenditure data. Skilled Nursing Facilities: CMS Should Improve Accessibility & Reliability of Expenditure Data was released October 6, 2016. Here is what the GAO found
The Centers for Medicare & Medicaid Services (CMS) ... collects and reports expenditure data from skilled nursing facilities (SNF), but it has not taken key steps to make the data readily accessible to public stakeholders or to ensure their reliability. SNFs are required to self-report their expenditures in annual financial cost reports, and CMS posts the raw data on its website. However, CMS has not provided the data in a readily accessible format and has not posted the data in a place that is easy to find on its website, according to public stakeholders and GAO's observations. In addition, CMS does little to ensure the accuracy and completeness of the data. Federal internal control standards suggest that agencies should make data accessible to the public and ensure data reliability. Until CMS takes steps to make reliable SNF expenditure data easier to use and locate, public stakeholders will have difficulty accessing and placing confidence in the only publicly available source of financial data for many SNFs.
GAO found that, for each fiscal year from 2011 through 2014, direct and indirect care costs were lower as a percentage of revenue, on average, at for-profit SNFs compared with nonprofit and government SNFs. Direct and indirect care costs were similarly lower at chain SNFs compared with independent SNFs. In addition, the median margin, which measures revenue relative to costs, was higher for for-profit and chain SNFs than for other SNFs in each of the 4 years.
The relationship between SNFs' nurse staffing levels (hours per resident day) and their margins varied by ownership type in each fiscal year from 2012 through 2014, the 3 years with complete staffing data. For-profit SNFs generally had lower nurse staffing ratios than did nonprofit and government SNFs. Examining each fiscal year separately, GAO estimated that a SNF's margin had a small, but statistically significant, effect on its case-mix adjusted (that is, adjusted for residents' health care needs) nurse staffing ratios. For example, for each percentage point increase in a for-profit SNF's margin in fiscal year 2014, GAO estimated that the SNF's total nurse staffing ratio (including registered nurses, licensed practical nurses, and certified nursing assistants) decreased by 4.1 minutes per resident day after controlling for other factors. However, in GAO's analyses, these other factors, such as geographic location, were more important predictors of a SNF's case-mix adjusted nurse staffing ratios.
A pdf of the report is available here.
Tuesday, October 4, 2016
The GAO has issued a new report of interest to all of us who read this blog or teach elder law. Elder Housing: HUD Should Do More to Oversee Efforts to LInk Residents to Services was released on October 3, 2016. The 66 page report is available here as a pdf and the highlights are available here.
Here are the findings:
While limitations in the Department of Housing and Urban Development's (HUD) data make an accurate assessment difficult, GAO estimates that roughly half of the 7,229 Section 202 Supportive Housing for the Elderly (Section 202) properties have HUD-funded service coordinators—staff who link residents to supportive services such as transportation assistance or meals. HUD's data indicate that 38 percent of Section 202 properties have a HUD-funded service coordinator, but these data likely underestimate the true number. GAO surveyed a generalizable sample of Section 202 properties not identifiable in HUD's data as having a service coordinator and, on this basis, estimates that an additional 12 percent of Section 202 properties actually had one—bringing the actual total of Section 202 properties with service coordinators to about 50 percent. Federal internal control standards note that it is important for management to obtain relevant data from reliable sources. Properties with service coordinators are subject to additional monitoring, but without accurate information, HUD risks not taking steps to monitor Section 202 properties with service coordinators to help ensure they are connecting residents to supportive services.
Properties without service coordinators connect residents to services in a variety of ways—for example, property managers may serve this function themselves, or they may utilize other local organizations. Several stakeholders told GAO that property managers are well-positioned to know their residents, and have some insight into their needs. Others noted that property managers generally lack the time and expertise to effectively manage this responsibility, and that the manager's role can conflict with that of the service coordinator. Through GAO's survey and site visits, managers of Section 202 properties without service coordinators cited a variety of reasons for not employing them, including lack of funding and having too few units to justify hiring someone to focus on supportive services for the elderly residents.
HUD requires its staff to monitor Section 202 properties' adherence to program requirements. However, HUD lacks written policies and procedures that describe how its staff should monitor the requirement for Section 202 property managers to coordinate the provision of supportive services. Available guidance describes general monitoring procedures for multifamily properties but does not address Section 202 specifically. HUD officials told GAO they plan to develop guidance on monitoring Section 202 properties with service coordinator grants by December 2016. Federal internal control standards note the importance of documenting responsibilities through policies. Without written policies and procedures, HUD cannot be assured that elderly residents are receiving assistance obtaining services. In addition, HUD collects performance data, such as the number of services provided, from Section 202 properties that have service coordinators but does not have policies or procedures in place to verify the accuracy of the data or for analyzing the data collected. Federal internal control standards also note the importance of evaluating data for reliability and processing data into quality information to evaluate performance. Until HUD takes steps to assess service coordinator performance data for reliability and analyze the data reported, its ability to use that information to monitor whether service coordinators are performing effectively and helping to fulfill the goals of the Section 202 program will likely be limited.
Make note that HUD plans to have Section 202 monitoring guidance with grants for service coordinators by December. Stay tuned!