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.
Monday, November 21, 2016
Medicaid block grants...again? Not only is Medicare in the spotlight for revamp, so too is Medicaid. Kaiser Health News reported this in Millions Could Lose Medicaid Coverage Under Trump Plan. The article explains
One major change endorsed by both Trump and House Speaker Paul Ryan (R-Wis.) would transform Medicaid from an entitlement program into a block grant program.
Here’s the difference. In an entitlement program, coverage is guaranteed for everyone who’s eligible. The federal government’s commitment to help states cover costs is open-ended. The states’ obligation is to cover certain groups of people and to provide specific benefits. Children and pregnant women who meet specific income criteria must be covered, for example.
The article notes that this isn't the first time that block grants for Medicaid has been proposed. "Turning Medicaid into a block grant program has been discussed for more than 25 years, but the idea has always met resistance from some states, health providers, health care advocates and Democrats. Even with a Republican majority in Congress and Trump in the White House, the plan would still face an uphill legislative battle."
And don't forget the statements regarding undoing the Affordable Care Act:
The biggest risk for Medicaid beneficiaries comes from pledges by Trump and other Republicans to repeal the Affordable Care Act, which provided federal funding to states to expand Medicaid eligibility starting in 2014. Thirty-one states and Washington, D.C. did so, adding 15.7 million people to the program, according to the government. About 73 million are now enrolled in Medicaid — about half are children.
The article focuses on some of the other options that may be considered in determining whether to make changes to Medicaid.
All these proposed changes are a lot to take in. So hang on and stay tuned.
Sunday, November 13, 2016
As I've spent several recent weeks of my sabbatical in Arizona to be closer to my 90+ year old parents, I watched the run up to the election from this Southwestern vantage point, instead of my usual Pennsylvania location. Not only was I surprised by the result of the Pennsylvania vote, it was a surprise to see Arizona voters -- usually a Republican stronghold with a strong "senior" vote-- struggle with the election choices available to them.
On November 8, Arizona rejected legalization of recreational marijuana (predictable) and approved a significant increase of minimum wage (a closer call, as the business community in Arizona largely opposed that increase). Further, Trump had angered some by throwing shade on 80-year-old Senator John McCain's "hero" reputation. In contrast, Trump's seeming alliance with controversial Sheriff Joe Arpaio, despite the later's pending criminal contempt prosecution, gave other Arizonans pause. Ultimately, 84-year-old Arpaio was voted "out" in Arizona (but, it remains to be seen whether he will be "out" of government at the federal level too). In other words, Arizonans were not voting in support of a "pure" Republican platform.
My mom, a Democrat but a somewhat reluctant Hillary supporter, was glued to CNN for much of the summer and fall, and she accurately predicted the Trump victory despite the pollsters' and commentators' refusal to acknowledge the frustrations driving the Trump tidal. She insisted on voting on election day, rather than taking advantage of Arizona's early vote options.
We know little about how Donald Trump will prioritize and govern once he takes the reins of his very first elected position. That uncertainty makes many nervous even as it makes others hopeful.
What will a Trump Administration mean for aging Americans? Some topics to consider:
- Public Retirement Benefits: Candidate Trump -- rarely one to get into the details of policy issues -- seemed o make a distinction between age-based benefits, including Social Security retirement and Medicare health insurance coverage, and disability-based benefits. Congress may seize on the latter. Trump argued "more jobs, less waste" was a cure for the solvency questions. On the one hand, he says he would support privatizing "some portion" of Social Security savings or investments to allow individuals to self-invest, while on the other hand rejecting "government" in the role of the retirement"investor." He seems willing to consider means testing for payment of retirement benefits. Here's a link to several utterances of Donald Trump on the topic of Social Security.
- Health Care for Seniors: Unlike ObamaCare in general, it will probably be harder for Donald Trump and Congress to displace the fundamentals of Medicare for seniors. But real cost questions attend health care for seniors. At what point will Trump be hit with the reality that all of his campaign plans about immigration, walls, foreign trade and infrastructure pale in comparison to the true challenges facing an aging American on health care?
- Medicaid for Long-Term Care: Candidate Trump has probably not focused on Medicaid as a source of long-term care financing. With Republicans controlling the House and Senate, however, will the old "anti-Medicaid planning" forces feel newly energized?
- Consumer Protections for Older Americans: Candidate Trump will feel the pressure from Republican-controlled Congress to roll back administrative safeguards implemented by President Obama during the last two years. Perhaps here is where seniors may feel the quickest impact from the change in power, including potential rollbacks on consumer protection measures that attempted to bar pre-dispute binding arbitration "agreements" for nursing home residents, implemented fiduciary duty standards for investment advisors, and imposed closer scrutiny on consumer credit companies. Indeed, the most direct threat of the Trump Administration, combined with the Republican Congress, is likely to be to "Elizabeth Warren's Consumer Financial Protection Bureau."
How this all plays out will be "interesting," won't it? The points above are about today's generation of seniors. Perhaps the most important Trump impact will be for "future" seniors, especially if Trump's predicted roll back on environmental protections and his advisors' seeming rejection of climate science hold sway.
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.
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)
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)
Friday, September 30, 2016
Filial Friday: PA Trial Court Rules that New Jersey's Law Controls Outcome of "Reverse" Filial Support Claim
I've been following for some time an interesting "reverse filial support law" case in Delaware County, Pennsylvania. A key issue in Melmark v. Shutt is whether New Jersey parents of a New Jersey, disabled, indigent adult son are liable for his costs of his care at a private, nonprofit residential facility specializing in autism services, Melmark Inc., in Pennsylvania. Since most of the modern filial support claims I see involve facilities (usually "nursing homes") suing children over the costs of their elderly parents' care, I describe cases where the facility is suing parents of an adult child as a "reverse filial support" law claim.
In a September 2016 opinion that followed a June nonjury trial, the Pennsylvania trial court used a "choice of law" analysis to determine which state's substantive "filial support" law controlled the parents' liability. The court ultimately ruled that New Jersey's statutes applied. N.J. filial support obligations are more limited than those affecting families under Pennsylvania law. Under N.J. Stat. Ann. Section 44:1-140(c), the state exempts parents over the age of 55 from support obligations for their adult children (and vice versa). By contrast, Pennsylvania does not place age limits on filial support, either for adult children or elderly parents. See Pa.C.S.A. Section 4603. In the Melmark case, the father was 70 and the mother was 68 years old during the year in question. The disabled son was 29.
The court decided that New Jersey had the "most significant contacts or relationships" to the dispute. That's classic conflict-of-laws analytical language. At issue was more than $205,000, for costs of residential services between April 1 2012 and May 14, 2013.
Wednesday, September 28, 2016
The Federal Nursing Home Reform Act went into effect back in 1987. Those accompanying regs have been in place a long time. Now CMS has issued final rules that revise the LTC regs. The official publication date is Oct. 4, 2016. The regs are being implemented in phases, with phase one going into effect on November 28, 2016. Here is the Federal Register summary:
This final rule will revise the requirements that Long-Term Care facilities must meet to participate in the Medicare and Medicaid programs. These changes are necessary to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. These revisions are also an integral part of our efforts to achieve broad-based improvements both in the quality of health care furnished through federal programs, and in patient safety.
The regs are over 700 pages and are available here. Here are the effective dates: "Phase 1 must be implemented by November 28, 2016... Phase 2 must be implemented by November 28, 2017 ... Phase 3 must be implemented by November 28, 2019 ... A detailed discussion regarding the different phases of the implementation timeline can be found in Section B. II 'Implementation Date.'"
42 C.F.R. 483.10 is updated but CMS is "retaining all existing residents’ rights and updating the language and organization of the resident rights provisions to improve logical order and readability, clarify aspects of the regulation where necessary, and updating provisions to include advances such as electronic communications."
There's a new reg, 42. C.F.R. 483.21, "Comprehensive Person-Centered Care Planning" wherein CMS, among other things, is "requiring facilities to develop and implement a baseline care plan for each resident, within 48 hours of their admission, the instructions needed to provide effective and person-centered care that meets professional standards of quality care."
One of the most watched sections involved the use of arbitration clauses. 42 C.F.R. 483.70 now includes, among other things, the following: "Binding Arbitration Agreements: We are requiring that facilities must not enter into an agreement for binding arbitration with a resident or their representative until after a dispute arises between the parties. Thus, we are prohibiting the use of pre-dispute binding arbitration agreements."
This is just a brief overview of a few provisions. We'll blog about more of them later, but for now, be sure to read the new regs. They're important!
P.S. this post has been updated to correct the publication and effective dates (I was too excited)
Tuesday, September 27, 2016
Kindred Health Care Inc. Hit With Sanctions for Failure to Comply with Federal Settlement Terms on Hospice Care
Kindred Healthcare Inc., the nation's largest post-acute care provider (after acquiring Gentiva Healthcare in 2015) recently paid more than $3 million to the federal government as sanctions for inaccurate billing practices under Medicare for hospice services. That may not sound like a lot of money in this day and age of Medicare and Medicaid fraud cases, right? After all, North American Health Care Inc. reportedly settled a false claims case with the Department of Justice earlier this month in a rehabilitation services investigation by agreeing to pay $28 million.
But, the Kindred Health Care sanction is actually a penalty for failing to comply with the terms of a previous multimillion dollar settlement by the feds with Gentiva. As part of that settlement, the company and its successors agreed to comply with a Corporate Integrity Agreement (CIA). From the Office of Inspector General, Department of Health and Human Services press release:
It is the largest penalty for violations of a CIA to date, the Office of Inspector General (OIG) said.
The record penalty resulted from Kindred's failure to correct improper billing practices in the fourth year of the five-year agreement. OIG made several unannounced site visits to Kindred facilities and found ongoing violations. "This penalty should send a signal to providers that failure to implement these requirements will have serious consequences," Mr. Levinson said. "We will continue to closely monitor Kindred's compliance with the CIA."
OIG negotiates CIAs with Medicare providers who have settled allegations of violating the False Claims Act. Providers agree to a number of corrective actions, including outside scrutiny of billing practices. In exchange, OIG agrees not to seek to exclude providers from participating in Medicare, Medicaid, or other Federal health care programs. CIAs typically last five years.
The post-acute care world -- which includes hospice, nursing homes, rehabilitation and home care -- is a tough marketplace. According to a McKnight News report, Kindred is also closing some 18 sites as "underperforming." For more on Kindred's operations, including its explanation of the penalty as tied to pre-acquisition practices of Gentiva, see this article in Modern Healthcare, "Kindred Pays Feds Largest Penalty Ever Recorded for Integrity Agreement Violations."
Wednesday, September 21, 2016
Stetson's 18th annual National Conference on Special Needs Trusts & Special Needs Planning takes place on October 19-21, 2016 at the Vinoy Hotel in St. Petersburg, Florida. Early Bird Registration rates end September 23, 2016. The national conference spans two days, with general sessions in the mornings and three tracks of breakout sessions in the afternoons (basics, advance and administration) Information about the conference, including the agenda, speakers, and links to register is available here. (Full disclosure, I'm the conference chair. Hope to see you at the conference!)
Tuesday, September 6, 2016
Kaiser Health News (KHN) ran the story, ‘America’s Other Drug Problem’: Copious Prescriptions For Hospitalized Elderly, focusing on the problems of polypharmacy in elders. Opening with examples of actual patients, one of whom was taking 36 prescriptions, the story focuses on the issue of elders taking multiple medications and the implications of doing so.
An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.
“This is America’s other drug problem — polypharmacy,” said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. “And the problem is huge.”
Among the problems with polypharmacy noted in the article is whether the patient actually needs the drug and the role of medication issues in the patient's hospitalization. The numbers are high:
Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.
Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable “adverse drug events” occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).
The article reviews the instances where patients are prescribed additional prescriptions during hospitalization and on discharge, are confused about what medications to take. Who becomes the "traffic cop" to keep the patients from undergoing drug-related complications? The pharmacist! Focusing on the inpatient geriatric unit in one hospital, the story explores the importance of the clinical pharmacist's inclusion in a patient's medical team. The featured hospital hired their clinical pharmacist about 3 years ago, according to the story, with "[t]he idea was to bring a pharmacist into the hospital’s geriatric unit to improve care and reduce readmissions among older patients." How successful has this been?
Having a pharmacist ... on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.
Over a six-month stretch after [the clinical pharmacist] started working in UCLA’s Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.
This seems like a really great idea and hopefully one that will be picked up by other geriatric units.
Thursday, September 1, 2016
Giving more evidence of the potential impact of aging boomers in America, officials in Humboldt County, a North Coast county in California, describe potential shutdowns of three area nursing homes as potentially "catastrophic." The reason for the closures? The problem isn't lack of residents. Operators find it difficult to attract adequate personnel, especially CNAs, needed to staff the care facilities. From the North Coast Journal article describing the latest problem:
Rockport Healthcare Services, the management company for five of Humboldt County's six skilled nursing facilities, announced today that they have filed relocation notices for three sites: Pacific, Seaview, and Eureka Rehabilitation and Wellness Centers. The relocation notices, filed with the California Department of Public Health, are the first step in closing these facilities, which collectively contain 258 beds, and relocating their patients.
Stefan Friedman, spokesperson for Rockport, said in a statement that the company is continuing to work with community partners to "find a solution to [a] severe staffing crisis," but it is possible that after public health approves their relocation notice they will shut down the facilities.
That, said Area 1 Agency on Aging ombudsman Suzi Fregeau, would be "catastrophic."
Although many patients stay only briefly in skilled nursing facilities, receiving rehabilitation after leaving the hospital, the facilities are often the last stop for patients who cannot afford in-home healthcare professionals and need 24-hour care. Their vital role in the continuum of care was felt last year, when the facilities — five of which are owned by the same company, Brius Healthcare — stopped accepting patients. Hospital administrators, hospice workers and families all felt the pinch, and many North Coast residents had to go to facilities far away from Humboldt County. Fregeau said the potential closure will be even worse.
"It means that residents are going to be placed in facilities a minimum of 150 miles away," she said. "People are going to be dying in communities they’ve never lived in."
Sad to think that some of the prettiest areas of California are struggling with attracting and keeping adequate numbers of trained people.
Monday, August 29, 2016
PACE programs can be a great thing for certain Medicare beneficiaries, but the popularity of PACE programs hasn't seemed to grow as much as one might think. The New York Times ran a story on August 20, 2016 about the for-profit model for PACE programs. Private Equity Pursues Profits in Keeping the Elderly at Home explains that "[u]ntil recently, only nonprofits were allowed to run programs like these. But a year ago, the government flipped the switch, opening the program to for-profit companies as well, ending one of the last remaining holdouts to commercialism in health care. The hope is that the profit motive will expand the services faster." Is there a significant demand for PACE programs with the Boomers doing their aging thing? Is a for-profit model the way to go to provide the type of services needed by PACE participants?
The article discusses these issues and presents both sides. Recall that "[t]he goal of the program, known as PACE, or the Program of All-Inclusive Care for the Elderly, is to help frail, older Americans live longer and more happily in their own homes, by providing comprehensive medical care and intensive social support. It also promises to save Medicare and Medicaid millions of dollars by keeping those people out of nursing homes."
The article also discusses the possible role of tech in providing care, but notes the importance of socialization. CMS had a pilot before approving the for-profit model and is going to keep an eye on things.
The for-profit centers were approved, to little fanfare, after the Department of Health and Human Services submitted the results of a pilot study to Congress in June 2015. The demonstration project, in Pennsylvania, showed no difference in quality of care and costs between nonprofit PACE providers and a for-profit allowed to operate there.
The Centers for Medicare and Medicaid Services has vowed to closely track the performance of all PACE operators by measuring emergency room use, falls and vaccination rates, among other metrics. The National PACE Association, a policy and lobbying group, is also considering peer-reviewed accreditation to help safeguard the program. Oversight is now largely left to state Medicaid agencies.
Monday, August 22, 2016
The New York Times on Sunday had an exceptionally well written and important article about the latest trend in senior care. For-profit companies are now allowed to participate in PACE, the Program of All-Inclusive Care for the Elderly, a Medicare- and Medicaid-approved program designed to permit innovation in care that doesn't require residence in high-priced settings such as traditional nursing homes. Sarah Varney writes:
Inside a senior center here [in Denver], nestled along a bustling commercial strip, Vivian Malveaux scans her bingo card for a wining number. Her 81-year-old eyes are warm, lively and occasionally set adrift by the dementia plundering her mind.
Dozens of elderly men and women -- some in wheelchairs, others whose hands tremble involuntarily -- gather excitedly around the game tables. After bingo, there is more entertainment and activities: Yahtzee, tile-painting, beading.
But this is no linoleum-floored community center reeking of bleach. Instead, it's one of eight vanguard centers owned by InnovAge, a company based in Denver with ambitious plans. With the support of private equity money, InnovAge aims to aggressively expand a little-known Medicare program that will pay to keep oldr and disabled Americans out of nursing homes.
The feature-length article details how "private equity firms, venture capitalizes and Silicon Valley entrepreneurs have jumped" onto the PACE niche. For more on this important development, read Private Equity's Stake in Keeping the Elderly at Home.
My thanks to Laurel Terry and Karen Miller for sharing this article with us.
Wednesday, August 3, 2016
Pennsylvania attorney Douglas Roeder, who often served as a visiting attorney for my former Elder Protection Clinic, shared with us a detailed Penn Live news article on what the investigative team of writers term "avoidable deaths" in nursing homes and similar care settings. The article begins vividly, with an example from Doylestown in southeastern Pennsylvania:
Claudia Whittaker arrived to find her 92-year-old father still at the bottom of the nursing home's front steps. He was covered by a tarp and surrounded by police tape, but the sight of one of his slim ankles erased any hope it wasn't him. DeWitt Whittaker, a former World War II flight engineer, had dementia and was known to wander. As a result, his care plan required him to be belted into his wheelchair and watched at all times. Early on Sept. 16, 2015, Whittaker somehow got outside the Golden Living home in Doylestown and rolled down the steps to his death.
"It wasn't the steps that killed him. But the inattention of staff and their failure to keep him safe," his daughter said.
The article is especially critical of recent data coming from for-profit nursing homes in Pennsylvania, pointing to inadequate staffing as a key factor:
In general, according to PennLive's analysis, Pennsylvania's lowest-rated nursing homes are for-profit facilities. Half of the state's 371 for-profit homes have a one-star or two-star rating – twice the rate of its 299 non-profit nursing homes. The reason for that discrepancy, experts say, isn't complicated: Studies have found that for-profit nursing homes are more likely to cut corners on staffing to maximize profit.
Spokespeople from both the for-profit and nonprofit segments of the industry are quoted in the article and they push back against the investigators' conclusions.
I have to say from my own family experience that while adequate staffing in care settings is extraordinarily important, older residents, even with advanced dementia, often have very strong opinions about what they prefer. My father is in a no restraint dementia-care setting, with a small cottage ("greenhouse") concept and lots of programming and behavioral interventions employed in order to avoid even the mildest of restraints. It was a deliberate choice by the family and my dad walks a lot around the campus and has his favorite benches in sunny spots.
The trade-off for "no restraints" can be higher risk. Residents, including my father, are sometimes stunningly adept at escape from carefully designed "safety"plans, such as those necessary in the summer heat of Arizona. Family members often remain essential members of the care team. For example, this summer I plan my daily visits at the very hottest part of the day, in order to help try to lure my father, a late-in-life sunshine worshiper, back into the cool. I watch the staff members exhaust themselves intervening with other ambulatory and wheelchair residents who are constantly on the move.
None of this "care stuff" is easy, but certainly the Penn Live article paints a strong picture for why better staffing, better financial resources, and more reality-based plans are necessary. For more, read "Failing the Frail." Our thanks to Doug for sharing this good article.
August 3, 2016 in Cognitive Impairment, Consumer Information, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Housing, Medicaid, Medicare, Property Management | Permalink | Comments (0)
Tuesday, August 2, 2016
Health and Human Services (HHS) Office for Civil Rights issued guidance in late May, 2016 for long term care facilities. The guidance, Guidance & Resources for Long Term Care Facilities: Using the Minimum Data Set to Facilitate Opportunities to Live in the Most Integrated Setting " is on using the minimum data set (MDS) so "residents receive services in the most integrated setting appropriate to their needs."
There are 3 recommendation sections of the guidance (actually there are 4, but the 4th deals with further resources). Why did OCR issue this guidance?
OCR has found that many long term care facilities are misinterpreting the requirements of Section Q of the MDS. This misinterpretation can prevent residents from learning about opportunities to transition from the facility into the most integrated setting. We are therefore providing a series of recommendations for steps that facilities can take to ensure Section Q of the MDS is properly used to facilitate the state’s compliance with Section 504 and to avoid discrimination.
The recommendations include a discussion of the importance of knowing about local resources and community based services, ensuring compliance with applicable civil rights laws ("[b]ecause Section Q is designed to assist residents in returning to the community or another more integrated setting appropriate to their needs, proper administration of Section Q of the MDS can further a state’s compliance with civil rights laws.") and the importance of maintaining up-to-date policies and procedures, and training employees.
McKnight's News is a publication for insiders in the long-term care industry, reaching professionals who operate nursing homes, extended care sites, CCRCs and more. John O'Connor, who has been with McKnight's for more than 20 years, recently published a candid editorial about factors affecting health care fraud in the industry. He writes:
[G]iven how easy it is to cheat these days, we probably shouldn't be terribly surprised that so many operators give in to temptation. That's especially the case when it comes to invoice preparations.
Let's be honest: How hard is it to put a resident in a higher RUGs category than is probably accurate? Or to bill for therapy services that were not actually delivered? Or to have therapists working overtime doing services that never should have occurred in the first place? And that, my friends, is just the tip of the proverbial iceberg.
Throw in stiff competition, incentives that reward upcoding, a dearth of interested investigators and good old-fashioned human greed, and what we have here is a breeding ground for creative accounting.
For more, read "It's Time for 'The Talk' About Healthcare Fraud."
Thursday, July 28, 2016
This week my in-basket sported the latest copy of the Family Law Quarterly and it is a strong lineup of symposium authors writing on a range of issues connected to late-in-life marital woes. The articles in the Spring 2016 issue include:
- The Challenging Phenomenon of Gray Divorces, by Paula G. Kirby & Laura S. Leopardi
- Representing the Elderly Client or the Client with Diminished Capacity, by Robert B. Fleming
- The Battle for the Biggest Assets: Dissolution of the Military Marriage and Postdivorce Considerations for Aging Clients, by Brentley Tanner
- Residence Roulette in the Jurisdictional Jungle: Where to Divide the Military Pension, by Mark E. Sullivan
- Family Support, Garnishment and Military Retired Pay, also by Mark E. Sullivan
- Premarital Agreements for Seniors, by Peter M. Walzer & Jennifer M. Riemer, and
- Financial Abuse of the Dependent Elder: A Lawyer's Ethical Obligations, by Jeanne M. Hannah
In my review of the articles, I would have liked to see more discussion of the potential expectations of the couple about payment of their respective long-term care costs, especially as a party's carefully signed premarital agreement may prove to be irrelevant to the state's analysis of eligibility for Medicaid to cover long-term care. In most states, authorities insist on counting assets of both halves of the couple, without regard to any premarital agreement. This is where "elder law" attorneys can be of help to traditional "family law" attorneys in planning. Compare this Elder Law Answers' discussion of "Five Myths About Medicaid's Long-Term Care Coverage."
Sunday, July 10, 2016
In early June, the Urban Institute released a brief that examines whether Catastrophic Insurance Improve Financing for Long-Term Services and Supports. The abstract explains
A catastrophic insurance program could improve the way long-term services and supports are financed. The program would require enrollees who need care to wait a few years before they could collect benefits, but then it would provide those benefits as long as necessary. Our modeling results show that such a program could reduce Medicaid spending and provide financial relief to hard-pressed states. It could also reduce out-of-pocket spending for families facing catastrophic costs and fund new services and supports. By setting aside funds to cover future spending, a catastrophic insurance program could also raise national saving.
As we well know, paying for long-term care is a challenge for many. As the authors note, "[c]urrently, most people with LTSS needs rely mostly on unpaid family caregivers for assistance. If they need more help, they generally pay out of pocket until they exhaust their financial resources and then turn to Medicaid. New financing approaches could combine public insurance for catastrophic LTSS costs with initiatives to promote private long-term care coverage for other expenses. Our projections suggest that these options could significantly reduce Medicaid spending and provide better financial protection for older people who develop LTSS needs."
Looking at the ways long-term care is financed by many, the authors consider whether an insurance model might be the answer
New LTSS insurance programs could provide better financial protection to people with disabilities; improve the care they receive; and reduce Medicaid costs, which are creating financial problems for many state governments. By setting aside funds today to cover future LTSS spending, new insurance programs could raise national saving. And they could provide families with stronger incentives to save by reducing reliance on Medicaid, which discourages saving because it only pays benefits to people with virtually no wealth outside of their home. The effectiveness of any new insurance program, of course, depends on its particular features, such as eligibility requirements, the size of the daily benefit, and the financing mechanism.
The authors examine a few models to gauge their workability and conclude
An LTSS catastrophic insurance program that requires enrollees with LTSS needs to wait a few years before collecting benefits but then extends those benefits as long as necessary could substantially improve the way LTSS needs are financed in the United States. Such a program could reduce Medicaid spending, providing financial relief to hard-pressed states. It would also reduce out-of-pocket spending for families facing catastrophic costs and fund new services for older adults with LTSS needs, although these impacts would be somewhat smaller than those from a similar-sized program that provided front-end, but time-limited, benefits. By setting aside funds today to cover future LTSS spending, a new catastrophic insurance program could raise national saving. And it could provide families with stronger incentives to save by reducing reliance on Medicaid, which discourages saving because it only pays benefits to people with virtually no wealth outside of their home.
Program details need further analysis. We modeled only a few options, and alternative designs could have different effects. For example, a new insurance program could provide larger daily benefits, which would reduce Medicaid and out-of-pocket spending more than the plan we modeled but would also require more funding. Or new programs could require enrollees to wait even longer to receive benefits than the program we modeled, which would offset less Medicaid and out-of-pocket spending but cost less. Our research is only the first step in the analysis required to design new LTSS financing programs, but it illustrates the potential power of our simulation tool in demonstrating how new options can interact with existing programs.