Monday, May 15, 2017
The Commonwealth Fund has released a new issue brief regarding Medicare out of pocket costs. Medicare Beneficiaries’ High Out-of-Pocket Costs: Cost Burdens by Income and Health Status examines the out of pocket costs faced by Medicare beneficiaries" "Fifty-six million people—17 percent of the U.S. population—rely on Medicare. Yet, its benefits exclude dental, vision, hearing, and long-term services, and it contains no ceiling on out-of-pocket costs for covered services, exposing beneficiaries to high costs." The issue brief concludes that
More than one-fourth of all Medicare beneficiaries—15 million people—spend 20 percent or more of their incomes on premiums plus medical care, including cost-sharing and uncovered services. Beneficiaries with incomes below 200 percent of the poverty level (just under $24,000 for a single person) and those with multiple chronic conditions or functional limitations are at significant financial risk. Overall, beneficiaries spent an average of $3,024 per year on out-of-pocket costs. Financial burdens and access gaps highlight the need to approach reform with caution. Already-high burdens suggest restructuring cost-sharing to ensure affordability and to provide relief for low-income beneficiaries.
The Commonwealth Fund used 2 "indicators" in doing the research, the "High total cost burden" and "underinsurance". The issue brief notes that lower-income beneficiaries may have significant out of pocket costs. "When premiums, cost-sharing, and spending on uncovered services are included, more than one-fourth of all beneficiaries (27%)—an estimated 15 million people—and two of five beneficiaries with incomes below 200 percent of the federal poverty level spent 20 percent or more of their income on health care and premium costs in 2016." As far as the other indicator, the Commonwealth Fund found "that one-fourth of beneficiaries are underinsured—that is, they spend at least 10 percent of their total annual incomes on medical care services, excluding premiums. Of beneficiaries with incomes below the poverty level, one-third spent 10 percent or more... Despite having Medicare or supplemental coverage, these people are effectively underinsured." (citations omitted).
The brief concludes with these observations:
Despite the substantial set of benefits that Medicare provides, many beneficiaries are left vulnerable because of financial burdens and unmet needs. As Medicare enters its sixth decade and the baby boom population becomes eligible, the costs of the program will increase, likely placing it on the policy agenda. Despite Medicare’s notable recent success in controlling costs per beneficiary, total spending will increase as the program covers more people.
The high financial burdens documented in this brief illustrate the need for caution. Half of Medicare beneficiaries have low incomes; one-third have modest incomes (200% to 399% of poverty). Any potential policy should first consider the impact on beneficiaries.
Access and affordability remain key concerns. In any discussions of potential Medicare reform, it will be important to pay particular attention to consequences for those vulnerable because of poor health or low income. Indeed, the findings point to the need to limit out-of-pocket costs and enhance protection for low-income or sicker beneficiaries.
As the single largest purchaser of health care in the country, Medicare policies directly influence insurance and care systems across the country. With a projected one-fifth of the population on Medicare by 2024, keeping beneficiaries healthy and financially independent is important to beneficiaries, their families, and the nation. (citations omitted).
Monday, May 8, 2017
Justice in Aging, the Center for Medicare Advocacy and the National Consumer Voice for Quality Long-Term Care have issued another in the series of issue briefs about the revised nursing home regulations. Return to Facility After Hospitalization covers several important topics including notice, bed holds, right to return and appeal rights. Here is the executive summary:
Bed hold rights are set by state law. Federal law complements state law by requiring facilities to notify residents of those rights. Notice of bed hold rights must be provided at two separate times: in advance of a hospitalization, and at the time of transfer to a hospital. The advance notification must include the resident’s right to a bed hold, whether the state’s Medicaid program pays for a bed hold, and the facility’s bed hold policies (which must be consistent with state and federal law). The time-of-transfer notification must describe the resident’s bed hold rights under the facility’s policy.
Federal law also establishes a resident’s right to return to the facility even if a bed hold period has been exceeded, or if the resident did not have a bed hold. The resident can return to her previous room if available, or to the next available room if the previous room is not available. The regulations specify that the resident can request a transfer/discharge hearing if the facility refuses to accept her back.
Wednesday, May 3, 2017
Justice in Aging announced the release of two additional issue briefs concerning the revised nursing home regs. One brief concerns quality of care and the other, grievances and resident/family councils.
The executive summary for the quality of care issue brief explains
The substantive requirements for quality of care are retained in the revised regulations, and the Centers for Medicare & Medicaid Services (CMS) affirms the regulations’ overriding goals: supporting person-centered care and enabling each resident to attain or maintain his or her highest level of well-being. Finding all of the requirements presents a challenge, however. CMS has significantly reorganized the quality of care provisions, moving some provisions to other regulatory sections, expanding the standards of the prior regulations, and adding several entirely new requirements.
The executive summary for the grievances and resident/family councils issue brief explains:
Residents have the right to file grievances and the facility must work to resolve those concerns promptly. A grievance official at the facility is responsible for complaint handling. Each facility must have a grievance policy and provide residents with information about how to file a grievance, how to contact the grievance official, a time frame for complaint review, a written decision, and information about other entities with which grievances can be filed. Written decisions must include, but are not limited to, the steps the facility took to investigate the complaint, the findings, whether the complaint was confirmed or not, and the action the facility has taken or will take to correct the problem.
The resident has a right to: form and participate in a resident council; have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents; and participate in the family council. There must be a staff person assigned to assist both resident and family councils and the council, along with the facility, must approve this person. The councils must be given a private space in which to meet and no one outside of a resident or family member can attend without invitation. The facility must act upon council concerns and recommendations and provide a reason for its decision, although it does not have to implement all that the councils request.
All of the issue briefs are available here.
Monday, May 1, 2017
Late last week I learned that CMS may be reversing course on prohibiting pre-dispute arbitration clauses in nursing home admission contracts. I couldn't decide if my response should be "say it isn't so" or "you have got to be kidding me". Nevertheless, Justice in Aging reported in their weekly newsletter, This Week in Health Care Defense that:
CMS Backtracks on Nursing Home Arbitration Prohibition
As part of last year’s revision of nursing facility regulations, CMS prohibited federally-certified nursing facilities from obtaining arbitration agreements at the time of admission. CMS concluded that it was unfair to have residents and families waive legal rights during such a difficult and chaotic time. Now, however, CMS has reversed course and has filed language that would revise the regulation to allow facilities to obtain arbitration agreements at admission. For more on the revised regulations, see the series of issue briefs developed by Justice in Aging in partnership with the Center for Medicare Advocacy and the National Consumer Voice for Quality Long Term Care.
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).