Wednesday, March 22, 2017
Justice in Aging has released a new brief on the revised nursing home regulations this one focusing on admissions, A Closer Look at the Revised Nursing Facility Regulations Admission. Here's the executive summary:
The revised regulations broadly prohibit facilities from using admission agreements or other documents that waive a resident’s rights. A resident cannot waive the protections of federal nursing facility law, or protections derived from any state or local nursing facility law. A resident also cannot waive his or her right to Medicare or Medicaid coverage, or any responsibility that the facility may have for the resident’s personal property. A facility cannot obligate a family member or friend to become liable for the nursing facility bill, although the facility can require the resident’s agent to agree to pay the resident’s money for the nursing facility expenses. The revised regulations prohibit pre-dispute arbitration agreements, but this consumer protection currently is blocked by a court order. Prior to admission, a facility must give notice of any special characteristics or service limitations.
The brief concludes with 4 suggestions for advocates and residents: careful review of the contract, sign the contract after residency in the SNF has begun, contest contract paragraphs that are improper and get a lawyer.
Tuesday, March 21, 2017
It's not final, it's not been passed, and changes are likely, but the current health care bill, known as the American Health Care Act, has a significant impact on elders. Last week's CBO report engendered a lot of discussion about the impact of this new health care proposal. The New York Times ran an article last week discussing it, No Magic in How G.O.P. Plan Lowers Premiums: It Pushes Out Older People. The article explains that lower premiums are on the way for some under this proposal. But, the way the lower premiums are achieved? "[T]he way the bill achieves those lower average premiums has little to do with increased choice and competition. It depends, rather, on penalizing older patients and rewarding younger ones. According to the C.B.O. report, the bill would make health insurance so unaffordable for many older Americans that they would simply leave the market and join the ranks of the uninsured."
We know that insurers want to have a broad pool to spread the risk. Typically, "older customers cost substantially more to cover than younger ones because they have more health needs and use their insurance more. By discouraging older people from buying insurance, the plan will lower the average sticker price of care." Ready for some sticker shock? Under the proposal, according to the story, the plan "increases the amount that insurers can charge older customers, and it awards flat subsidies by age, up to an income of $75,000. ... On premiums alone, prices would rise by more than 20 percent for the oldest group of customers. By 2026, the budget office projected, 'premiums in the nongroup market would be 20 percent to 25 percent lower for a 21-year-old and 8 percent to 10 percent lower for a 40-year-old — but 20 percent to 25 percent higher for a 64-year-old.'"
The story explains that it's not just the premiums that give the whole picture. Tax credits factor into this as well. Here is where the real sticker shock comes in. "[T]he change in tax credits matters more. The combined difference in how much extra the older customer would have to pay for health insurance is enormous. The C.B.O. estimates that the price an average 64-year-old earning $26,500 would need to pay after using a subsidy would increase from $1,700 under Obamacare to $14,600 under the Republican plan." Did you see that-an increase from $1,700 to $14,600...
The semester is quickly drawing to a close, but the bill could be a basis for an interesting class discussion on social policy, if you have time.
Monday, March 20, 2017
Wonder what is in the new health care bill? New Health Plan Broken Down appears in the Centre Daily Times on March 12, 2017. The article is written by Amos Goodall, a prominent elder law attorney (and graduate of Stetson's LL.M. in Elder Law). The article explains changes to the individual mandate (penalty repealed and replaced), preexisting conditions protection (none), age-based premiums (5:1 ratio & will be up to states which ration), cost-sharing subsidies (will be eliminated), over the counter drugs (adding reimbursement from HSA, FSA or Archer MSA), Medicaid expansion (changes financing) and per capita caps.
To read more about these and other proposed changes, click here.
Thanks to Amos for sending me the link to the story.
Thursday, March 16, 2017
Today is Call Congress About Medicaid day. Here is the information from the Medicare Rights Center:
Tell Congress to protect our care by joining today’s national call-in day. Urge your representative to vote “no” on the American Health Care Act... Call 866-426-2631 to contact your member of Congress.
The message is to vote no for changes to Medicaid and Medicare. The Medicare Rights Center also offers a one page issue brief on the proposed changes to Medicare, available here.
Regardless of your views, it is always important to make your voice heard.
Thanks to Kim Dayton, the elderlawprof blog founder, for sending me a note on this.
Friday, March 10, 2017
NBC Nightly News ran a story on March 8 about Medicare Observation Status and the Notice Act. Law Aims to Protect Medicare Patients from Surprise Hospital Bill explains the hospital's disclosure requirement for patients and notes that a bill has been introduced to once and for all solve the problems caused when patients are on observation status. "A bill reintroduced Wednesday by Congressman Joe Courtney, D-Connecticut, would make days spent "under observation" count towards qualification for Medicare coverage." The story featured comments from Judy Stein, executive director of the Center for Medicare Advocacy and former NAELA President (full disclosure, I serve of the Center's board).
Monday, March 6, 2017
The New York Times recently reported the death of Dorothy Rice whose work affected so many elder Americans. Dorothy Rice, Pioneering Economist Who Made Case for Medicare, Dies at 94 explains "Mrs. Rice was an analyst at the Social Security Administration when its study on aging highlighted how about half the population 65 and over had no health insurance — and that those who needed it most were the least likely to be able to afford it."
She wrote a Social Security bulletin in 1964 that described the need for Medicare, how the number of older Americans who were not covered by health insurance "'include disproportionate numbers of the very old — particularly women — those in poor health, and those no longer engaged in full-time employment.... The high cost of hospital and nursing home care, she added, 'presents special problems for the aged because of their large and often unexpected bills.'"
She was instrumental in estimating costs and learning about the requirements of elder Americans for health care.. Thank you Mrs. Rice.
Thursday, March 2, 2017
Kaiser Health News ran a story about specialized 911 responders for those under hospice care. For Some Hospice Patients, A 911 Call Saves A Trip To The ER explains a project in Fort Worth where
Fort Worth paramedics [are] trained for this type of hospice support — part of a local partnership with VITAS Healthcare, the country’s largest hospice organization — is to spend a longer stretch of time on the scene to determine if the symptoms that triggered the 911 call can be addressed without a trip to the emergency room. MedStar Mobile Healthcare, a governmental agency created to provide ambulance services for Fort Worth and 14 nearby cities, is one of several ambulance providers nationwide that have teamed up with local hospice agencies. The paramedic backup, enthusiasts argue, not only helps more hospice patients remain at home, but also reduces the potential for costlier and likely unnecessary care.
The article reports that almost 20% of hospice patients make a trip to the ER and this specialized paramedic may help the patient to avoid that trip. The article explains that these specialized paramedics are known as "community paramedics [and] they can offer a range of in-home care and support for home health patients, frequent 911 callers and others to reduce unnecessary ambulance trips."
The article explains how this works, noting that the community paramedic is dispatched along with other paramedics. The community paramedic provides many patients with an alternative to a trip to the ER.
Patients or their family members can still insist on going to the emergency room, and sometimes they do. Of the 287 patients enrolled in Fort Worth’s program for the first five years — all of whom had been prescreened as highly likely to go to the hospital — just 20 percent, or about 58 patients, were transported, according to MedStar data. In Ventura, ambulance transports for hospice patients calling 911 also have declined — from 80 percent shortly before the program’s start to 37 percent from August 2015 through December 2016 .....
Wednesday, February 8, 2017
Justice in Aging has released two new issue briefs concerning the new nursing home regs. One is on involuntary transfers and discharges and is available here. The other is on unnecessary medications and antipsychotic meds, and is available here. The briefs were done with the Center for Medicare Advocacy and the National Consumer Voice for Quality Long-Term Care.
Here's the executives summary for the transfer/discharge brief
The involuntary transfer/discharge regulations have changed, but not dramatically. Facilities still can force a transfer/discharge only under one of six specified circumstances, and a resident continues to have the right to contest a proposed transfer/discharge in an administrative hearing. The revised regulations narrow the facility’s ability to base a transfer/discharge on a supposed inability to meet the resident’s needs, by requiring increased documentation by the resident’s physician. The regulations also limit transfer/discharge for nonpayment, by stating that nonpayment has not occurred as long as Medicaid or another third-party payor is considering a claim for the time period in question. All transfer/discharge notices must be sent to the resident, resident representative(s), and (in a new requirement) the Long-Term Care Ombudsman program. The revised regulations now explicitly state that a facility cannot discharge a resident while an appeal is pending.
Here's the executive summary for the medications brief:
Regulations about unnecessary drugs and antipsychotic drugs have been moved from the quality of care section to the pharmacy services section. Some provisions have been moved but not otherwise changed: these include protection from unnecessary medications, requirements for gradual dose reductions, and the use of behavioral interventions in order to discontinue drugs, "unless clinically contraindicated." In addition, the pharmacy services regulation includes a new discussion of a broader category of psychotropic drugs, along with new controls over "as needed" (PRN) psychotropic drugs. The revised regulations also expand requirements for drug regimen reviews.
These and the first brief in the series are available here.
Sunday, February 5, 2017
As mentioned in a recent post, the observation status case was headed back to court. The February 2, 2017 opinion resulted in a favorable decision requiring corrective action. The Center for Medicare Advocacy released the following Court Orders Corrective Action Plan for Government's Noncompliance with Settlement in Jimmo v. Burwell explaining that the judge has "ordered the Secretary of Health & Human Services to carry out a Corrective Action Plan to remedy the Department’s noncompliance with the Settlement." What's included in this corrective action plan?
The judge ruled that the Corrective Action Plan will include a new CMS webpage dedicated to Jimmo, a published Corrective Statement disavowing the improvement standard, a posting of Frequently Asked Questions (FAQs), and new training for contractors making coverage decisions. In addition, and significantly, the Court largely adopted the Corrective Statement drafted by plaintiffs, and ordered the Secretary to conduct a new National Call to explain the correct policy.
The opinion is available here. Great job CMA! (in the interest of full disclosure, I'm on the CMA board)
Thursday, February 2, 2017
We've heard that Speaker Ryan has a plan to change Medicare, but that the President had made campaign promises about preserving it. So, have an opinion? Should it remain unchanged? Should it be changed? Here's your chance to make your voice heard. AARP is organizing a "thunderclap" campaign, asking those with an opinion share it with the President by Twitter, Tumblr or Facebook and they will all be posted on the same day, February 21, 2017. The website has more information about the specifics on how this works. Don't want to wait until then to make your opinion known? AARP also has a site for folks to contact Congress that makes it about as simple as can be with a prepared message for those who want Congress to support Medicare . (If you think Medicare should be changed, you may not be able to change the AARP standard message and you will need to email your elected representatives)
Wednesday, February 1, 2017
Several years ago CMS entered into a settlement in litigation that has become known as the Jimmo case. CMS agreed that the improvement standard wasn't in fact a standard for determining further Medicare therapy coverage and all was good, or so it seemed. Yet, now we learn it's not, according to a recent story in Kaiser Health News. Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute explains
Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.
So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.
The settlement was supposed to be the end of the matter, and instead of the improvement standard, Medicare was to make the decision as follows, "not ... on the 'potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.'” So in August of last year, the judge ordered the parties to get together to "improve" Medicare's educational initiative for those who deal with the claims and staff hotlines, as well as the ALJs. The parties reached an impasse, so it's back to court.
Sunday, January 29, 2017
There is a lot of buzz about changes to programs that impact elders and none of us knows what the end results will be. The Leadership Council on Aging Organizations has designated Tuesday (January 31) and Wednesday (February 1) as call your Senators and Representatives days. Here is the information from the American Society on Aging:
The Leadership Council of Aging Organizations (LCAO), of which ASA is a member, is organizing call-in days next Tuesday and Wednesday, January 31 and February 1. This is an opportunity for you to contact your Senators and Representatives to let them know of your concerns about preserving these major programs. To participate, dial 866-426-2631. You’ll hear a brief overview of the issues, and then be asked to enter your zip code to be connected with your legislators.
ASA offers some tips on talking points, available here.
Tuesday, January 24, 2017
A new one hour documentary, Alzheimer's: Every Minute Counts, is scheduled to begin airing nationally on PBS stations on Wednesday, January 25.
In part, the documentary will focus on research funding issues. Dr. Ruby Tanzi, a Harvard Medical School researcher who appears on the film, explained for NextAvenue's website:
We should be absolutely panicked at the government level. When the Medicare and Medicaid [treatment and care] bill for Alzheimer’s goes from one in five dollars to one in three dollars — that could happen over the next decade with baby boomers getting older — we could single-handedly collapse Medicare and Medicaid with Alzheimer’s disease.
Now, the government [research funding for Alzheimer's] has gone up to about a billion dollars. Which is great, it’s more money. It’s still not the billions of dollars that go to other age-related diseases. I’m glad that cancer and heart disease and AIDS get many billions of dollars, but Alzheimer’s has to get as much or more now given the epidemic and the urgency here with how many cases we’re going to have.
It’s going to crush us. Never mind the social burden on the families. I might add that two-thirds of patients are women. And most caregivers are women. What’s going to happen when so much of our female population is (struck) with this disease? So it’s a huge problem and if we don’t throw a ton of money at it now, it’ll be a disaster.
For more information on the documentary, including links to watch it on-line (free!), see PBS "Alzheimer's: Every Minute Counts." There is an important opportunity here for schools, including law schools, to host an airing of the documentary to promote discussion about strategies.
Tuesday, January 10, 2017
Kaiser Health News ran a story last week on the failure of CMS to recover significant overpayments from some Medicare Advantage plans. Medicare Failed To Recover Up To $125 Million In Overpayments, Records Show explains
An initial round of audits found that Medicare had potentially overpaid five of the health plans $128 million in 2007 alone, according to confidential government documents released recently in response to a public records request and lawsuit.
But officials never recovered most of that money. Under intense pressure from the health insurance industry, the Centers for Medicare and Medicaid Services quietly backed off their repayment demands and settled the audits in 2012 for just under $3.4 million — shortchanging taxpayers by up to $125 million in possible overcharges just for 2007.
The story reports the overpayments occur for various reasons, including billing errors and from "overcharge[ing] Medicare, often by overstating the severity of medical conditions...." The story reports on CMS audits of some health plans, events that led up to the settlement of the overpayment claims and a May, 2016 GAO report.
Tuesday, December 13, 2016
Here are the highlights:
GAO found that the Centers for Medicare & Medicaid Services (CMS) collects information on the use of the Nursing Home Compare website, which was developed with the goal of assisting consumers in finding and comparing nursing home quality information. CMS uses three standard mechanisms for collecting website information—website analytics, website user surveys, and website usability tests. These mechanisms have helped identify potential improvements to the website, such as adding information explaining how to use the website. However, GAO found that CMS does not have a systematic process for prioritizing and implementing these potential improvements. Rather, CMS officials described a fragmented approach to reviewing and implementing recommended website changes. Federal internal control standards require management to evaluate appropriate actions for improvement. Without having an established process to evaluate and prioritize implementation of improvements, CMS cannot ensure that it is fully meeting its goals for the website.
GAO also found that several factors inhibit the ability of CMS’s Five-Star Quality Rating System (Five-Star System) to help consumers understand nursing home quality and choose between high- and low- performing homes, which is CMS’s primary goal for the system. For example, the ratings were not designed to compare nursing homes nationally, limiting the ability of the rating system to help consumers who live near state borders or have multistate options. In addition, the Five-Star System does not include consumer satisfaction survey information, leaving consumers to make nursing home decisions without this important information. As a result, CMS cannot ensure that the Five-Star System fully meets its primary goal.
The full report is available here.
Monday, December 12, 2016
You will recall the issues with Medicare patients on observation status, rather than having been admitted into the hospital. The NOTICE Act was intended to ensure patients knew whether they had been admitted or were on observation status. CMS has released the observation status notice, known as MOON. The fact sheet explains
Enacted August 6, 2015, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and Critical Access Hospitals (CAH) to provide notification to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of such status.
The notice, CMS-10611, is available here. (click on the link to open the zip file).
Thursday, December 8, 2016
The National Consumer Voice for Quality Long-Term Care, the Center for Medicare Advocacy and Justice in Aging have released the first in a series of briefs regarding the changes to the Nursing Facility regulations. This first brief focuses on Assessment, Care Planning & Discharge Planning.
Here is the executive summary:
Revised nursing facility regulations broadly affect facility practices, including assessment care planning and discharge planning. The revised assessment process places greater emphasis on a resident’s preferences, goals, and life history. Regarding care planning, a facility must develop and implement a baseline care plan within 48 hours of a resident’s admission, with the comprehensive care plan to be developed subsequently. The care planning team has been expanded to require (among other things) participation by a nurse aide with responsibility for the resident, and the facility must facilitate resident participation. Care planning should include planning for discharge, and the facility must document any determination that discharge to the community is not feasible.
A facility now will have to complete an assessment as well as a baseline care plan that has to be done within 48 hours from admission, as well as a "'comprehensive, person-centered care plan; for each resident within seven days of the initial assessment."
As far as effective dates, the brief explains that "[t]he revised regulations’ assessment provisions are effective on November 28, 2016. Most care planning and discharge planning provisions will be effective on the same date, except for provisions relating to baseline care plans (11/28/2017) and trauma informed care (11/28/2019)."
Be sure to bookmark this brief (or save it to your important documents folder) and keep an eye out for the subsequent briefs. Kudos to these 3 amazing organizations!
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.
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.