Tuesday, November 7, 2017
Here's the introduction to the guide:
An important part of the practice of many elder law attorneys is assisting clients to receive and then benefit from Medicaid home and community-based services (HCBS). In March 2014, the Centers for Medicare and Medicaid Services (CMS) published the first ever regulations establishing standards for the settings in which HCBS are provided.1 These regulations will impact the services, quality of life, and rights of HCBS care recipients, as well as the environment in which they receive those services. Each state must develop and implement a plan for how it will come into compliance with the HCBS rules. The involvement of advocates, including elder law attorneys, in influencing the plan and monitoring its implementation is critical. This guide is designed to provide elder law attorneys with a better understanding of the HCBS settings rule and how they can advocate for a strong, effective system that achieves the spirit and intent of the rule.
The report notes that the reason for "HCBS Medicaid services is to be an alternative to institutional settings." Thus, the rule's main reason "is to define the qualities that make a setting a home that is truly part of a larger community." Additionally, the rule is designed to confirm that those recipients really are part of their community. Last, but not least, the rule is intended to make the lives of these folks better as well as getting them more choice and protections. The report can be downloaded here.
Wednesday, November 1, 2017
This week, the last session I was able to attend at LeadingAge's annual meeting was a panel talk on "Legal Perspectives from In-House Counsel." As expected, some of the time was spent on questions about "billing" by outside law firms, whether hourly, flat-fee or "value" billing was preferred by the corporate clients.
But the panelists, including Jodi Hirsch, Vice President and General Counsel for Lifespace Communities with headquarters in Des Moines, Iowa; Ken Young, Executive VP and General Counsel for United Church Homes, headquartered in Ohio; and "outhouse" counsel Aric Martin, managing partner at the Cleveland, Ohio law firm of Rolf, Goffman, Martin & Long, offered a Jeopardy-style screen, with a wide array of legal issues they have encountered in their positions. I'm sorry I did not have time to stay longer after the program, before heading to the airport. They were very clear and interesting speakers, with healthy senses of humor.
The topics included responding to government investigations and litigation; vetting compliance and ethics programs to reduce the likelihood of investigations or litigation; cybersecurity (including the need for encryption of lap tops and cell phones which inevitably go missing); mergers and acquisitions; contract and vendor management; labor and employment; social media policies; automated external defibrillators (AEDs); residency agreements; attorney-client privilege; social accountability and benevolent care (LeadingAge members are nonprofit operators); ACO/Managed Care issues; Fair Housing rules that affect admissions, transfers, dining, rooms and "assistance animals"; tax exemption issues (including property and sale tax exemptions); medical and recreational marijuana; governance issues (including residents on board of directors); and entertainment licensing.
Whew! Wouldn't this be a great list to offer law students thinking about their own career opportunities in law, to help them see the range of topics that can come up in this intersection of health care and housing? The law firm's representative on the panel has more than 20 lawyers in the firm who work solely on senior housing market legal issues.
On that last issue, entertainment licensing, I was chatting after the program with a non-lawyer administrator of a nursing and rehab center in New York, who had asked the panel about whether nonprofits "have" to pay licensing fees when they play music and movies for residents. The panelists did not have time to go into detail, but they said their own clients have decided it was often wisest to "pay to play" for movies and videos. Copyright rules and the growing efforts to ensure payments are the reasons.
The administrator and I chatted more, and she said her business has been bombarded lately by letters from various sources seeking to "help" her company obtain licenses, but she wanted to know more about why. For the most part, the exceptions to licensing requirements depend on the fairly broad definition of "public" performances, and not on whether the provider is for-profit or nonprofit.
It turns out that LeadingAge, along with other leading industry associations, negotiated a comprehensive licensing agreement for showing movies and videos in "Senior Living and Health Care Communities" in 2016. Details, including discussion of copyright coverage issues for entertainment in various kinds of care settings, are here.
November 1, 2017 in Current Affairs, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Legal Practice/Practice Management, Medicaid, Medicare, Programs/CLEs, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)
Tuesday, October 10, 2017
A recent story reports on the Florida governor's statement calling on a state Constitution Revision Commission "to include provisions to protect residents of nursing homes and assisted living facilities." Scott Wants Nursing Home Rules In Constitution reports that the Florida Governor is calling on the Commission "to consider adding 'permanent measures to put patient safety first.'" The constitutional amendments will be voted on in the November, 2018 election.
Meanwhile, the nursing home in Hollywood Florida where the deaths occurred filed suit challenging the state's moratorium on admissions as well as suspension from the state's Medicaid program. Broward Nursing Home Expands Lawsuit Against State explains that the facility is seeking an injunction.
Stay tuned, there's a hearing on the facility's motion before the end of the month.
Sunday, October 8, 2017
Justice in Aging has released a new issue brief focuses on the emergency readiness of nursing homes. Why Many Nursing Facilities Are Not Ready For Emergency Situations explains the situation in the executive summary:
Nursing facility residents can be particularly at risk during natural disasters, as has been demonstrated yet again during Hurricanes Harvey, Irma, and Marie. The hurricanes resulted in death and injury in nursing facilities across the region, including twelve deaths in one Florida facility.
These deaths and injuries, and the desire to prevent harm in the future, have directed renewed attention on emergency preparedness. This issue brief discusses existing federal and state law, and makes recommendations to address gaps in current law.
Federal regulations on nursing facility emergency preparedness were issued in September 2016, and are scheduled for full implementation in November 2017. The regulations address five primary areas: emergency plans, facility procedures, communication plans, training and testing, and emergency power systems.
Unfortunately, these new regulations are inadequate to protect residents, in part because some of the regulatory standards are excessively vague, and in part because the regulations only govern nursing facilities and cannot mandate the broader coordination that would be advisable for community-wide emergency preparedness. Federal, state, and local governments should take additional steps to ensure adequate preparation for the natural disasters that inevitably will envelop nursing facilities and other health care providers in years to come.
The issue brief offers 7 recommendations including requiring (1) emergency generators, (2) prior coordination between government, healthcare providers and nursing homes, (3) arrangements for emergency evacuations, (4) local governments to keep the pertinent information "on an ongoing, community-wide basis", (5) governments or providers to create resources designed to help in drafting the emergency plan, (6) governments to mandate outside review of the facilities' emergency plans and (7) federal surveyors to impose appropriate sanctions for those facilities that don't comply with the emergency plan.
Thursday, September 28, 2017
On Tuesday, September 26, 2017, at the same time that there was much sound and fury, but no vote, on the Graham-Cassidy Senate effort to repeal Obamacare, the U.S. Senate quietly approved on a voice vote Senate Bill 870, titled "Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017"or "CHRONIC Care" for short.
The vote sends the bill on to the House for any next step of action. In press releases after the vote, sponsors welcomed Senate passage as a sign of bipartisan support for "strengthening and improving health outcomes for Medicare beneficiaries living with chronic conditions," noting:
“This bill marks an important step towards updating and strengthening Medicare’s guarantee of comprehensive health benefits for seniors,” said [Oregon's Senator Ron Wyden,] the ranking Democrat on the Senate Finance Committee. “Medicare policy cannot stand idly by while the needs of people in the program shift to managing multiple costly chronic diseases,” Wyden said. “This bill provides new options and tools for seniors and their doctors to coordinate care and makes it less burdensome to stay healthy.”
The bill that passed the Senate on Tuesday was co-sponsored by Senate Finance Committee Chairman Orrin Hatch (R-Utah), as well as Sens. Johnny Isakson (R-Ga.) and Mark Warner (D-Va.)
Initial review of the modestly ambitious bill shows that if passed in full by the House, the legislation would extend by 2 years the "Independence at Home Demonstration program," now in its 5th year, with funding otherwise set to run out at the end of September. Additional provisions address "telehealth" services and direct studies or accounting reports on Medicare Advantage plans.
The Independence at Home Demonstration program seems worthy of additional operation and tracking, as at least on paper it trends towards what most people seem to want, i.e., better health care access while still at home, rather than waiting for facility-based services. For more on preliminary outcomes from the Demonstration program, see "Corrected Performance Results" from Year 2, released in January 2017.
On the other hand, it is difficult to resist the irony that a great deal of work seemed to go into crafting the acronym, "CHRONIC," which also happens to be the street name for "very high-quality marijuana."
My special thanks to my newest Dickinson Law colleague, Professor Matthew Lawrence, who comes to us with fabulous experience in health care law, for helping identify this active piece of legislation.
Tuesday, September 26, 2017
Check out this updated policy brief, Policy Brief: Requirements for Reporting to Law Enforcement When There is a Suspicion of a Crime Against a Nursing Home Resident. The Long Term Care Community Coalition (as an aside, take a look at their cool url) released this updated brief with information about changes and 2017 updates
1. The potential fines for violations of the law are subject to adjustment for inflation. The fines indicated below are current as of September 2017.
2. New CMS guidelines for these (and other) requirements are in effect as of November 28,
2017. A summary of the guidelines for reporting can be found at the end of this brief. The
full federal Guidance can be found on the CMS website:
The overview explains that
The law broadens and strengthens the requirements for crime reporting in all long term care
facilities (including Nursing Facilities, Skilled Nursing Facilities, LTC Hospices, and Intermediate Care Facilities ...) that receive $10,000 or more in federal funds per year. The facility must inform the individuals covered under the law - its employees, owners,
operators, managers, agents, and contractors - of their duty to report any "reasonable
suspicion" of a crime (as defined by local law) committed against a resident of the facility. After forming the suspicion, covered individuals have twenty-four hours to report the crime to both the State Survey Agency and to a local law enforcement agency. If the suspected crime resulted in physical harm to the resident, the report must be made within two hours.
The brief explains the policy requirements and offers recommendations for consumers, state agency folks and long term care facilities. There is also a summary of the regs as well as definitions of commonly used words.
The brief can be downloaded as a pdf here.
September 26, 2017 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare, State Cases | Permalink | Comments (0)
Monday, September 25, 2017
Video: Elder Law Attorney Uses Her Experiences to Explain Why Graham-Cassidy Repeal of ACA Isn't Right Answer
In a 3-minute YouTube video, Texas Elder Law Attorney Jennifer Coulter explains how the Affordable Care Act has affected her clients -- and herself -- in a positive way. She makes a principled, compelling case for why "getting it right" on health care is far more important than political sound bites and rushed repeal measures.
Tuesday, September 12, 2017
CMS released State Medicaid Director Letter #17-002, Implications of the ABLE Act for State Medicaid Programs. The letter is designed to give guidance to state Medicaid programs on implementing ABLE. The letter includes background on the ABLE Act, explains who is eligible to have an ABLE account (including an explanation about the use of the word "qualified" in the statute)), how funds in the ABLE account are treated, contributions by the beneficiary or a 3rd party, distributions, post-Medicaid eligibility treatment of income and transfers of ABLE money to a state and estate recovery.
Wednesday, September 6, 2017
The National Center on Law & Elder Rights has announced an upcoming free webinar on Medicaid 101.
Here is the info about the webinar
Understanding Medicaid is a key to understanding the health and long-term care delivery system for older adults. Every year, over 6 million older Americans rely on Medicaid every year to pay for necessary health services. Over two-thirds of all older adults who receive long-term care at home or in a nursing facility, participate in the Medicaid program.
This free webinar, Legal Basics: Medicaid 101, will provide participants with a basic primer on the Medicaid program. It will explain the formation of Medicaid, Medicaid funding, key Medicaid protections, and Medicaid’s role in paying for health and long-term care for older adults.
The webinar is set for September 12, 2017 at 2:00 p.m. edt. To register, click here.
Tuesday, September 5, 2017
The National Center of Law & Elder Rights has announced an upcoming free webinar on Managed Care for Dual Eligibles and Medicare Coordination Programs on September 20, 2017 at 2:00 p.m. edt. Here's a description of the webinar
Dual eligible individuals, those with both Medicare and Medicaid coverage, represent the most medically needy and costly population for both Medicare and Medicaid. In an effort to improve health outcomes and reduce healthcare spending, the Centers for Medicare and Medicaid Services (CMS) has been testing financial alignment demonstrations in thirteen states to better coordinate and integrate care for dual eligibles.
What has been learned from these demonstrations so far? What are the take-aways for states that did not participate? This webinar will provide an update on these dual eligible demonstrations and review early evaluations of the programs. The webinar will also cover other recent efforts by CMS to address issues unique to dual eligible including issues around access to durable medical equipment.
Following the training, the audience will have a better understanding of the two models being tested in the demonstration, the fully capitated model and the managed fee-for-service model. They will also know about challenges and innovations during the almost four years since the demonstrations were launched and what further evaluation is being planned.
This is an advanced webinar. Legal service attorneys and aging and disability network professionals who work with dual eligibles are encouraged to attend.
Click here to register.
Thursday, August 10, 2017
The GAO has issued a report that examines various federal programs for low-income individuals. Federal Low-Income Programs: Eligibility and Benefits Differ for Selected Programs Due to Complex and Varied Rules offers the following findings
Six key federally funded programs for low-income people vary significantly with regard to who is eligible, how income is counted and the maximum income applicants may have to be eligible, and the benefits provided. In fiscal year 2015, the most current data available, the federal government spent nearly $540 billion on benefits for these six programs—the Earned Income Tax Credit (EITC), Medicaid, the Housing Choice Voucher program, Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income (SSI), and Temporary Assistance for Needy Families (TANF). The target population for each of these programs differs, for example, people who are elderly or disabled or who have dependent children. Further, some programs have conditions for continued eligibility, such as participation in work activities under TANF. The six programs also vary in what income is and is not counted when determining an applicant's eligibility. For example, certain programs, such as SNAP, disregard a portion of earned income, while others do not. The maximum amount of income an applicant may have and still be eligible for benefits, which is determined for some programs at the federal level and for others at the state or local level, also differs significantly. As of December 2016, this amount ranged from $5,359 per month for one state's Medicaid program to $0 per month in one state for TANF cash assistance, for a single parent with two children. Benefit levels also differed across the six selected programs, with average monthly benefits for these programs ranging in fiscal year 2015 from $258 for SNAP to $626 for Housing Choice Vouchers, and four of the six programs adjust benefits annually.Legal, administrative, and financial constraints pose challenges to efforts to streamline varying eligibility rules for federal low-income programs, according to GAO's current and previous work. A key challenge is that the programs are authorized by different federal statutes enacted at different times in response to differing circumstances. Other laws, such as appropriations laws, can also have an impact on federal programs and their rules. As a result, streamlining eligibility rules would require changing many laws and coordination among a broad set of lawmakers and congressional committees. A further challenge is that a different federal agency or office administers each program GAO reviewed. For some of these programs, such as TANF, state governments also establish some program rules, making it more difficult to streamline rules at the federal level within or across these programs. Finally, financial constraints may also affect efforts to streamline program rules. For example, if rule changes raise the income eligibility limit in a program, more people may become eligible and that program's costs may increase. Despite these challenges, Congress, federal agencies, and states have taken some steps to streamline program administration and rules, such as by making greater use of data-sharing where permitted by federal law and aligning programs' applications and eligibility determination processes. For example, SSI recipients in most states are automatically eligible for Medicaid, and GAO previously reported that some states have integrated the SNAP eligibility process with other low-income programs, such as through combined applications and common eligibility workers.
Friday, July 21, 2017
In the latest chapter of an ongoing dispute between a specialized care facility, Melmark, Inc., and the older parents of a disabled adult son, Pennsylvania's intermediate Superior Court of Appeals has ruled in favor of the parents.
The July 19, 2017 appellate decision in Melmark v. Schutt is based on choice of law principles, analyzing whether New Jersey's more limited filial support law or Pennsylvania's broader filial law controlled. If applied, New Jersey law "would shield the [parents] from financial responsibility for [their son's] care because they are over age 55 and Alex is no longer a minor." By contrast, "Pennsylvania's filial support law...would provide no age-based exception to parental responsibility to pay for care rendered to an indigent adult child."
The parents and the son were all, as stipulated to the court, residents of New Jersey. New Jersey public funding paid from the son's specialized care needs at Melmark's Pennsylvania facility for some 11 years. However, when, as part of a "bring our children home" program, New Jersey cut the funding for cross-border placements, the parents, age 70 and 71 year old, opposed return of their 31-year old son, arguing lack of an appropriate placement. Eventually Melmark returned their son to New Jersey against the parents' wishes, with an outstanding bill for unpaid care totaling more than $205,000, incurred over his final 14 months at Melmark.
Both the Pennsylvania trial and appellate courts ruled against the facility, concluding that "the New Jersey statutory scheme reflects a legislative purpose to protect its elderly parents from financial liability associated with the provision of care for their public assistance-eligible indigent children under the present circumstances." The courts rejected application of Pennsylvania's law as controlling.
This is a tough case, with hard-line positions on the law staked out by both sides. One cannot expect facilities to provide quality care for free. On the other side, one can empathize with families who face limited local care choices and huge costs.
Ultimately, I anticipate these kinds of cross-border "family care and cost" disputes becoming more common in the future for care-dependent family members, as the impact of federal funding cuts trickle down to states with uneven resources of their own. Some of these problems won't see the courtroom, as facilities will likely resist any out-of-state placement where payment is not guaranteed by family members, old or young.
July 21, 2017 in Consumer Information, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Housing, Medicaid, Social Security, State Cases, State Statutes/Regulations | Permalink | Comments (0)
Thursday, July 20, 2017
In early July, the Governor of Hawai'i signed into law the Kupuna Caregivers Act, According to a story about the law, Hawaii Passes Law to Ease Responsibility of Elder Care, the law "provides qualified caregivers with a voucher of up to $70 per day that can be used toward services that they would otherwise perform themselves, including adult day care and assisted transportation." The first law of its type in the U.S. rather than benefitting the recipient of care, the law benefits the caregivers: by paying "working family caregivers, who can be caring for family members who are above the Medicaid eligibility threshold. While the amount provided does not cover the entire cost of care families need, it does allow them to provide more hours of in-home care and other services...." The text of the law is available here.
Wednesday, July 19, 2017
Governing ran a recent story about how states will pay for in-home care for their residents who are elders. As Demand for At-Home Care Grows, States Debate How to Pay for It considers that aging Boomers may not want to reside in nursing homes and if they stay at home, they will need care at home. With a likely greater demand for inhome care, how will it be delivered and who will pay?
[F]iguring out how to pay for more home-based care is mostly left up to the states. Medicaid is the primary payer for home- and community-based care, although states can decide whether or not they’ll offer the coverage. All 50 states and the District of Columbia do have home- and community-based programs of some type, but most states have waiting lists for their programs. Meanwhile, 59 percent of Medicaid funding goes to nursing homes, where about half of those in long-term care receive their services. “Nursing home institutions are a powerful player in the health-care setting, so there’s long been political pressure to not pay for more home health care,” says [Kevin] Prindiville [, executive director of Justice in Aging].
The article highlights California and Washington state, at opposite ends of the spectrum in handling this issue. Waivers may help, or shifting money through legislation that gives flexibility.
Tuesday, July 18, 2017
I read this article last week in the New York Times (also published by the Kaiser Health News), the topic of which is something we should consider seriously. Poor Patient Care at Many Nursing Homes Despite Stricter Oversight discusses Medicare's Special Focus status.
While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to an analysis of federal health inspection data. Of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.
The article highlights some individuals' experiences, with the basis of the article concerning the Special Focus program.
Special focus facility status is reserved for the poorest-performing facilities out of more than 15,000 skilled nursing homes. The Centers for Medicare and Medicaid Services, or C.M.S., assign each state a set number of slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.
More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts. This year, the $2.6 million budget allows only 88 nursing homes to receive the designation, though regulators identified 435 as warranting scrutiny.
The article also discusses lapses by those facilities once on the watch list, how a facility earns its way off the watch list and how long it typically takes to do so and the staffing ratios in such facilities.
Background information about the special focus initiative can be found on the CMS website. You can find the list of special focus facilities on CMS website. For example, here is the one published in June of 2017.
Friday, July 14, 2017
Justice in Aging has released a new issue brief for July about Medicare Savings Programs (MSP). Proposed Cuts to Medicaid Put Medicare Savings Programs At Risk explains the importance of the MSP for many Medicare beneficiaries, including paying their premiums. If the MSP program were cut or eliminated, many beneficiaries may no longer be able to afford Medicare.
Many low-income older adults are only able to participate in Medicare because Medicare Savings Programs help with their Medicare premiums, deductibles and co-pays. These critically important programs reach over 7 million people with Medicare, including 1.7 million older adults who are too poor to be able to afford Medicare but do not qualify for other Medicaid programs.1 With $772 billion in Medicaid cuts, the Better Care Reconciliation Act now being considered in the Senate could knock many older adults and people with disabilities off these programs, making Medicare unaffordable. As a result, those with the greatest needs will lose access to Medicare benefits because they will be unable to shoulder Medicare costs.
The brief explains QMBs, SLMBs, and QIs. It also explains the relationship between MSP and "Extra Help". Regardless of the Senate vote (maybe this week) on repeal and replace, the information in the brief about MSP and the other programs is really helpful. Check it out!
Sunday, July 9, 2017
Medicaid has been in the news frequently of late, as Congress debates the repeal of the Affordable Care Act. Kaiser Family Foundation released a new infographic on the relationship of Medicaid and veterans. Medicaid’s Role in Covering Veterans explains how Medicaid works as a safety net for veterans, helps with coverage for vets with complex medical issues, and provides federal matching funds (which may be affected by the repeal of the ACA). The infographic provides demographic data, lists the conditions of veterans (by percentages) on Medicaid and explains what would happen if Medicaid funding were reduced.
Thursday, June 29, 2017
The National Council on Aging (NCOA) posted a story on its blog explaining per capita caps and the impact on elders. Straight Talk for Seniors®: How Medicaid Caps Would Impact Seniors explains how Medicaid per capita caps would work.
Medicaid is funded jointly by the federal government and the states. Today, the federal government gives states matching funds to cover a percentage of their actual Medicaid costs. This keeps Medicaid affordable for states.
Under per capita caps, the federal government would limit, or cap, its contribution to the states based on a preset formula. This means states would be left paying the true cost of care for people in need. Many predict that states would face severe funding gaps and have to cut back on services to make up the difference.
If this is implemented, 5 states in particular would be hit hard as far as home and community based services funding, including my state of Florida. Those 5 states, besides Florida, are Alaska, Arizona, Georgia, and Nevada. The impact can be severe, as the article notes:
Medicaid per capita caps would hurt seniors in all states, but some states would fare worse than others. Here’s why.
First, the caps would be set based on each state’s 2016 Medicaid costs. This means states that were efficient and kept their costs low that year will be locked into a lower federal contribution. North Carolina, California, Nevada, Georgia, and Florida are examples of states that fall into this category.
Second, the caps would not adjust for an aging population. This means states whose 65+ population is growing faster than the national average will be locked into a smaller federal contribution that will not keep pace with growing costs. In fact, the caps would begin when baby boomers start turning 80. People aged 85+ are more likely to need long-term services and supports, and the cost of their care is 2.5 times more than people aged 65-74.
Monday, June 26, 2017
This week is a big one for the Senate as they consider the Republican version of a health care bill to "repeal" the Affordable Care Act. Now I confess that I've only skimmed portions of it, and I suspect that there will be some "deal making" going on to amend the proposal in an attempt to gather the necessary votes for it to pass. I don't intend this to be a political post, although the title probably makes you think I do. But depending on what happens, couldn't a crisis be looming as a result, at least for those individuals in nursing facilities whose stays are covered by Medicaid? Whether per capita caps or block grants, the potential remains that there may be less money to cover long term stays in nursing homes, right?
What got me thinking about this post was an article in the New York Times on June 24, 2017. Medicaid Cuts May Force Retirees Out of Nursing Homes asks the question, what happens if Medicaid cuts are enough to affect coverage for long term nursing home care? "Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage." One expert interviewed for the story suggested that even if the ACA isn't repealed, Medicaid is still an attractive target for cuts and don't forget that long term nursing home care makes up a significant amount of Medicaid spending, "long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them." The article considers the possibilities of cuts and the impact both on the facilities and the residents.
Justice in Aging released a blog post, issue brief and fact sheet focusing on the impact the Senate version of the bill will have on elders. The Fact Sheet, discussing Caps lists 5 downsides to the states and 3 ways elders will be harmed. Since the Times article was focused on nursing facility coverage, here's what the Justice in Aging Fact Sheet says about that: "Losing Coverage for Nursing Home Care. 62% of nursing home residents rely on Medicaid. For the vast majority of these 850, 000 nursing home residents, Medicaid coverage is provided through an eligibility category that is "optional" under federal Medicaid law. As states face insufficient funding, they will look for optional categories to cut, putting nursing home residents at particular risk." Both the Issue Brief and the Fact Sheet fail to take into account the aging of America by tethering the cap to "baseline years". As the Brief notes
[T]he fourth problem is that the Senate bill’s per capita cap fails to recognize how increasing age corresponds to a greater need for health care. In 2011, for example, persons aged 85 and over incurred average Medicaid costs that were 2.5 times higher than the average costs incurred by beneficiaries aged 65 to 74.35
Assume that a state currently has a large percentage of Medicaid beneficiaries in their early 70s. The base rate for that state will be weighted heavily towards the average health care needs of persons in their 70s, and that weighing will affect the cap amounts imposed in 2027, when the large group of beneficiaries will be in their early 80s — with different and more extensive needs for health care. Notably, such a shift in population from the young-old to the old-old is more likely than not, given the overall aging of America’s population. From 2025 and 2035, approximately two-thirds of the states will experience a rise in the share of seniors who are 85 and older. In most cases, the increase will be at least 25%. (citations omitted).
If these folks in nursing homes need a level of care that can't be provided by their families (if they even have families) and Medicaid is cut, what's the answer? Right now, all we can do is wait and see what happens with the Senate this week. Right now, the vote is projected to take place on Thursday.
Tuesday, June 20, 2017
Consider those who need home health care but say no. Kaiser Health News recently ran a story on this very topic. Some Seniors Just Want To Be Left Alone, Which Can Lead To Problems explain that the percentage of those who want to be left alone is higher than you may think. "As many as 28 percent of patients offered home health care when they’re being discharged from a hospital — mostly older adults — say “no” to those services, according to a new report." The report is from a roundtable that was sponsored by the Alliance for Home Health Quality & Innovation and United Hospital Fund. The report, I Can Take Care of Myself: Patients' Refusals of Home Health Care Services runs 23 pages.
Here are highlights of the report (found on page 1):
Medical care is moving from hospitals and other institutions into the community, which for most people means care at home, where they want to be. With shorter hospital stays and more complex post-discharge needs, the importance of home health care services, including skilled care and personal care, in discharge planning and transitional care is increasing.
Some studies show that patients who receive home health care after hospital discharge are less likely to be readmitted. Other studies show that patients who receive home health care report better quality of life.
Although data are limited, approximately 6-28 percent of patients eligible for home health care refuse these services, for a variety of reasons.
Even less is known about the process by which hospital staff identify patients for referral to home health care, how they explain these services, and how well they address the full range of patients’ and family caregivers’ transitional care needs.
Patients and their family caregivers have similar goals but may have different needs and attitudes about home health care.
Policy and system barriers to accessing services include inflexible criteria for eligibility, inadequate payment for home health care agencies’ services for patients with complex conditions, and shortages of trained workforce.
Recommendations from Roundtable participants include interventions that improve communication about care challenges and home health care services, qualitative and quantitative research on all aspects of home health care refusals, policy changes to increase access and coordination, and continuity across providers and care settings.