Sunday, October 1, 2017
Eagle Crest, a 126-bed skilled nursing facility in California, once known as Carmichael Care & Rehabilitation Center, is "voluntarily" closing its doors. A major reason for parent corporation Genesis HealthCare's decision appears to be an incident of sexual contact between two aged residents at the facility in February, 2017. Not a violent contact and apparently not one involving physical or mental injury. But clothing was removed and fluids were later documented. Now residents are being transferred and more than 70 employees will reportedly be laid off.
As one of the two residents had Alzheimer's disease, and thereby was deemed unable to consent to sexual relations, the facility "self-reported" the contact as possible abuse to appropriate state authorities. A criminal investigation found no grounds for prosecution. A California Department of Public Health report, however, made the recommendation to federal authorities last summer to "drop the facility from its medicare provider rolls, a drastic action that strips a nursing home of its critical government funding," according to news reports. The actual closure action was made voluntarily by Genesis.
Those are some of the black and white facts reported by the Sacramento Bee, which has published a series of news articles tracking this facility for many months. The "gray" facts are more complicated, and raise questions at the heart of any LTC operation:
- Is it possible the state overreacted and misconstrued a "quasi-consensual" contact between a "lonely man and a confused woman"?
- How far must a LTC provider go to prevent intimate contact between residents?
- After one report of sexual contact between residents, does that mean one or both residents must be treated as a risk that requires special procedures to prevent -- or at least reduce the likelihood -- of them being involved in future sexual contact?
- How does a long-term care facility achieve a restraint-free environment -- a federally sanctioned goal -- while also charged with protecting ambulatory residents from intimate contact?
- Is it possible for residents (and their family members or other health care agents?) to release a facility from liability arising from "un-consented" sexual relations among residents?
October 1, 2017 in Cognitive Impairment, Consumer Information, Crimes, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, State Cases, State Statutes/Regulations | Permalink | Comments (0)
Thursday, September 28, 2017
On Tuesday, September 26, 2017, at the same time that there was much sound and fury, but no vote, on the Graham-Cassidy Senate effort to repeal Obamacare, the U.S. Senate quietly approved on a voice vote Senate Bill 870, titled "Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017"or "CHRONIC Care" for short.
The vote sends the bill on to the House for any next step of action. In press releases after the vote, sponsors welcomed Senate passage as a sign of bipartisan support for "strengthening and improving health outcomes for Medicare beneficiaries living with chronic conditions," noting:
“This bill marks an important step towards updating and strengthening Medicare’s guarantee of comprehensive health benefits for seniors,” said [Oregon's Senator Ron Wyden,] the ranking Democrat on the Senate Finance Committee. “Medicare policy cannot stand idly by while the needs of people in the program shift to managing multiple costly chronic diseases,” Wyden said. “This bill provides new options and tools for seniors and their doctors to coordinate care and makes it less burdensome to stay healthy.”
The bill that passed the Senate on Tuesday was co-sponsored by Senate Finance Committee Chairman Orrin Hatch (R-Utah), as well as Sens. Johnny Isakson (R-Ga.) and Mark Warner (D-Va.)
Initial review of the modestly ambitious bill shows that if passed in full by the House, the legislation would extend by 2 years the "Independence at Home Demonstration program," now in its 5th year, with funding otherwise set to run out at the end of September. Additional provisions address "telehealth" services and direct studies or accounting reports on Medicare Advantage plans.
The Independence at Home Demonstration program seems worthy of additional operation and tracking, as at least on paper it trends towards what most people seem to want, i.e., better health care access while still at home, rather than waiting for facility-based services. For more on preliminary outcomes from the Demonstration program, see "Corrected Performance Results" from Year 2, released in January 2017.
On the other hand, it is difficult to resist the irony that a great deal of work seemed to go into crafting the acronym, "CHRONIC," which also happens to be the street name for "very high-quality marijuana."
My special thanks to my newest Dickinson Law colleague, Professor Matthew Lawrence, who comes to us with fabulous experience in health care law, for helping identify this active piece of legislation.
Tuesday, September 26, 2017
Check out this updated policy brief, Policy Brief: Requirements for Reporting to Law Enforcement When There is a Suspicion of a Crime Against a Nursing Home Resident. The Long Term Care Community Coalition (as an aside, take a look at their cool url) released this updated brief with information about changes and 2017 updates
1. The potential fines for violations of the law are subject to adjustment for inflation. The fines indicated below are current as of September 2017.
2. New CMS guidelines for these (and other) requirements are in effect as of November 28,
2017. A summary of the guidelines for reporting can be found at the end of this brief. The
full federal Guidance can be found on the CMS website:
The overview explains that
The law broadens and strengthens the requirements for crime reporting in all long term care
facilities (including Nursing Facilities, Skilled Nursing Facilities, LTC Hospices, and Intermediate Care Facilities ...) that receive $10,000 or more in federal funds per year. The facility must inform the individuals covered under the law - its employees, owners,
operators, managers, agents, and contractors - of their duty to report any "reasonable
suspicion" of a crime (as defined by local law) committed against a resident of the facility. After forming the suspicion, covered individuals have twenty-four hours to report the crime to both the State Survey Agency and to a local law enforcement agency. If the suspected crime resulted in physical harm to the resident, the report must be made within two hours.
The brief explains the policy requirements and offers recommendations for consumers, state agency folks and long term care facilities. There is also a summary of the regs as well as definitions of commonly used words.
The brief can be downloaded as a pdf here.
September 26, 2017 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare, State Cases | Permalink | Comments (0)
Monday, September 25, 2017
Video: Elder Law Attorney Uses Her Experiences to Explain Why Graham-Cassidy Repeal of ACA Isn't Right Answer
In a 3-minute YouTube video, Texas Elder Law Attorney Jennifer Coulter explains how the Affordable Care Act has affected her clients -- and herself -- in a positive way. She makes a principled, compelling case for why "getting it right" on health care is far more important than political sound bites and rushed repeal measures.
Sunday, September 24, 2017
Some time back we told you that the Medicare card would be redone so beneficiaries' Social Security numbers no longer appeared on the cards. CMS has released the design for the new Medicare cards. Still sporting the red, white and blue design, you will see that the Medicare number is different now-no more Social Security number!!!
Issuing new cards may sound like a simple thing, but it really is a big deal, when you stop and think about it, especially given the number of folks on Medicare.
Here is an excerpt from CMS to health care providers:
Medicare is taking steps to remove Social Security numbers from Medicare cards. Through this initiative the Centers for Medicare & Medicaid Services (CMS) will prevent fraud, fight identity theft and protect essential program funding and the private healthcare and financial information of our Medicare beneficiaries.
CMS will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN) both on the cards and in various CMS systems we use now. We’ll start mailing new cards to people with Medicare benefits in April 2018. All Medicare cards will be replaced by April 2019.
Wednesday, September 20, 2017
The Chicago Tribune ran a story on changes to Medigap policies, Why Seniors Should Choose Wisely When Selecting Medigap Supplement Insurance. The article explains that
In 2020, people who are on Medicare and don't already have what's known as Plan F or Plan C Medigap insurance won't be able to buy it because the federal government will close those plans to new participants. That means that when people go onto Medicare at 65, or if they switch Medicare-related insurance during the next couple of years, they are going to have to be diligent about scrutinizing insurance possibilities before some of those doors start to close.
If you are wondering why this is newsworthy, given that there are a number of other Medigap plans available, the story explains the popularity of Plan F.
In the past, people have tended to veer toward Plan F Medigap insurance when they wanted all retirement medical costs covered. Plan F is the most popular of the many Medigap insurance plans because it is the most comprehensive. It doesn't cover dental, vision, or medicine, but if retirees pay their monthly premiums they shouldn't have to pay anything else for doctors, tests or hospitals. Even medical care overseas is partially covered.
The article notes that over half of beneficiaries purchase Plans C or F. Then why would Congress do away with these popular plans? Well, according to the article, "the popularity of Plans F and C made them unpopular with federal lawmakers and brought about the change that will happen in 2020. In 2015, Congress decided to shut the doors on Plan F and C in 2020 to reduce government spending on Medicare. Although Medigap plans are purchased from private insurance companies, people use them along with Medicare provided by the government. Critics argue that Plan F makes it too easy for people to go to the doctor without thinking twice about the cost."
Even if a beneficiary has Plan F, after 2020, the beneficiary may see a rise in premiums "because the plan won't be taking in any more young, healthy people. As those in Plan F grow older and sicker, the insurance companies may go to government regulators and request the right to raise rates." The article notes that some advisers are suggesting beneficiaries take a hard look at Plan G. Of course, if Plan G becomes the new Plan F in terms of popularity, then it's likely that Plan G premiums will increase. One expert quoted in the article suggests that a Medigap policy be viewed as a lifetime choice and the beneficiaries need to be sure that the policy purchased is portable.
Friday, September 15, 2017
Hear the word hospice and what do you think? The patient is close to dying, right? Kaiser Health News did a story about hospice care that explains the patient doesn't have to be on the edge of dying. Shedding New Light On Hospice Care: No Need To Wait For The ‘Brink Of Death’ examines the misconception about hospice care.
Although hospices now serve more than 1.4 million people a year, this specialized type of care, meant for people with six months or less to live, continues to evoke resistance, fear and misunderstanding... “The biggest misperception about hospice is that it’s ‘brink-of-death care,’” said Patricia Mehnert, a longtime hospice nurse and interim chief executive officer of TRU Community Care, the first hospice in Colorado.
People who have some time left may find that using hospice gives them a better quality of life. "New research confirms that hospice patients report better pain control, more satisfaction with their care and fewer deaths in the hospital or intensive care units than other people with similarly short life expectancies." (The article referenced in the quote requires purchase or subscription). The KHN article explains the differences in the four levels of care offered by hospice, including respite care, routine care, general inpatient care and continuous care. Routine care is the most typical, with visits by aides and an RN, the frequency of which is dictated by the patient's condition. One of the biggest misconceptions, according to the article, the family thinks hospice folks will be in the home with the patient continuously. As a result, the family or patient may need to hire aides or companions to get the needed help. The article discusses provision of medications, choice of doctors, medication concerns, discharge and care of the patient in the last few days of life.
Thursday, September 7, 2017
CMS has released a new webpage as part of its settlement of the Jimmo case. The Center for Medicare Advocacy press release explains that "[t]he Jimmo webpage is the final step in a court-ordered Corrective Action Plan, designed to reinforce the fact that Medicare does cover skilled nursing and skilled therapy services needed to maintain a patient’s function or to prevent or slow decline. Improvement or progress is not necessary as long as skilled care is required. The Jimmo standards apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, for care in Inpatient Rehabilitation Facilities/Hospitals."
The CMS Jimmo website
reminds the Medicare community of the Jimmo Settlement Agreement (January 2013), which clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met). Specifically, the Jimmo Settlement Agreement required manual revisions to restate a “maintenance coverage standard” for both skilled nursing and therapy services under these benefits:
Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient's current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.
Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.
The Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve. The Jimmo Settlement Agreement is consistent with the Medicare program’s regulations governing maintenance nursing and therapy in skilled nursing facilities, home health services, and outpatient therapy (physical, occupational, and speech) and nursing and therapy in inpatient rehabilitation hospitals for beneficiaries who need the level of care that such hospitals provide.
The website provides links to added resources, FAQs and pdfs of resources.
Tuesday, September 5, 2017
The National Center of Law & Elder Rights has announced an upcoming free webinar on Managed Care for Dual Eligibles and Medicare Coordination Programs on September 20, 2017 at 2:00 p.m. edt. Here's a description of the webinar
Dual eligible individuals, those with both Medicare and Medicaid coverage, represent the most medically needy and costly population for both Medicare and Medicaid. In an effort to improve health outcomes and reduce healthcare spending, the Centers for Medicare and Medicaid Services (CMS) has been testing financial alignment demonstrations in thirteen states to better coordinate and integrate care for dual eligibles.
What has been learned from these demonstrations so far? What are the take-aways for states that did not participate? This webinar will provide an update on these dual eligible demonstrations and review early evaluations of the programs. The webinar will also cover other recent efforts by CMS to address issues unique to dual eligible including issues around access to durable medical equipment.
Following the training, the audience will have a better understanding of the two models being tested in the demonstration, the fully capitated model and the managed fee-for-service model. They will also know about challenges and innovations during the almost four years since the demonstrations were launched and what further evaluation is being planned.
This is an advanced webinar. Legal service attorneys and aging and disability network professionals who work with dual eligibles are encouraged to attend.
Click here to register.
Sunday, September 3, 2017
Here's something to give you pause. The HHS Office of Inspector General has released an early alert. The Centers for Medicare & Medicaid Services Has Inadequate Procedures To Ensure That Incidents of Potential Abuse or Neglect at Skilled Nursing Facilities Are Identified and Reported in Accordance With Applicable Requirements (A-01-17-00504) dated August 24, 2017,
alert[s] [the CMS administrator about] ... the preliminary results of our ongoing review of potential abuse or neglect of Medicare beneficiaries in skilled nursing facilities (SNFs). This audit is part of the ongoing efforts of the Office of Inspector General (OIG) to detect and combat elder abuse. The objectives of our audit are to (1) identify incidents of potential1 abuse or neglect of Medicare beneficiaries residing in SNFs and (2) determine whether these incidents were reported and investigated in accordance with applicable requirements.
The 14 page letter provides a lot of detail about the situation and offers a number of recommendations, including immediate action: "implement procedures to compare Medicare claims for [ER] treatment with claims for SNF services to identify incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs and periodically provide the details of this analysis to the Survey Agencies for further review and ... continue to work with ... HHS ... to receive the delegation of authority to impose the civil monetary penalties and exclusion provisions of section 1150B." Longer term the alert suggests new regulations among other ideas.
September 3, 2017 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)
Sunday, August 20, 2017
The Centers for Medicare & Medicaid Services (CMS) is working diligently to make healthcare quality information more transparent and understandable for consumers in all stages of life to empower them to take ownership of their healthcare choices. This includes decisions about end-of-life care, when consumers in a time of vulnerability need transparent, digestible information to make the best choice for their care or the care of their loved ones.
We at CMS understand that there are many difficult decisions that come with a terminal illness—including deciding if hospice is right for you and which hospice to choose—which is why we have launched Hospice Compare. This new website will help empower you by allowing you to easily and quickly compare hospice providers on various aspects of care and assess the quality of care that potential hospices provide.
Hospice Compare provides information on hospices across the nation and allows patients, family members, caregivers, and healthcare providers to compare hospice providers based on some key quality metrics, like what percentage of a hospice provider’s patients were screened for pain or difficult or uncomfortable breathing and if their patients’ preferences are being met. Specifically, the quality measures look at the percentages of patients who received recommended treatment, for example:
- Patients or caregivers who were invited to discuss treatment preferences, like hospitalization and resuscitation, at the beginning of hospice care;
- Patients or caregivers who were invited to discuss beliefs and values at the beginning of hospice care;
- Patients who were checked for pain at the beginning of hospice care;
- Patients who received a timely and thorough pain assessment when pain was identified as a problem;
- Patients who were checked for shortness of breath at the beginning of hospice care;
- Patients who got timely treatment for shortness of breath; and
- Patients taking opioid pain medication who were offered care for constipation.
The information on Hospice Compare can be used along with other information you gather about hospice providers in your area. In addition to reviewing the information on Hospice Compare, you’re encouraged to talk to your doctor, social worker, other healthcare providers, and other community resources when choosing the best hospice for care for you or your loved one.
In addition to Hospice Compare, Medicare also offers a number of other websites that can help you select providers and facilities to meet a wide range of care needs, including Inpatient Rehabilitation Facility Compare; Long-Term Care Hospital Compare; Hospital Compare; Physician Compare; Nursing Home Compare; Medicare Plan Finder; Dialysis Compare; and Home Health Compare.
Hospice Compare is available here
Monday, August 14, 2017
According to recent stories about Medicare observation status, poor elders may be harder hit by this than those with more affluence. Medicare’s Observation Care Policy More Likely To Affect Low-Income Seniors makes note of "[a] new study finds that low-income patients are more likely to be kept in the hospital under observation, and the higher out-of-pocket spending that accompanies not being officially admitted is a bigger burden for them." The study referenced is published in the American Journal of Medicine. The article's abstract explains:
Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Since low-income status is associated with increased hospital utilization, there is concern that such beneficiaries may be at increased risk for high utilization and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high utilization and high financial liability for observation care compared to higher-income beneficiaries.
A subscription is required to access the full article.
Kaiser Health News recently ran a story about the end of life consultations now covered by Medicare. End-Of-Life Advice: More Than 500,000 Chat On Medicare’s Dime offers some interesting statistics on the number of consults. "In 2016, the first year health care providers were allowed to bill for the service, nearly 575,000 Medicare beneficiaries took part in the conversations, new federal data obtained by Kaiser Health News show." In fact, that number is almost double of what the AMA projected for 2016. Although those numbers are good news for the proponents of the law, when compared to the numbers of Medicare beneficiaries overall, the percentage is quite low.
[O]nly a fraction of eligible Medicare providers — and patients — have used the benefit, which pays about $86 for the first 30-minute office visit and about $75 for additional sessions.... Nationwide, slightly more than 1 percent of the more than 56 million Medicare beneficiaries enrolled at the end of 2016 received advance-care planning talks, according to calculations by health policy analysts at Duke University....
The article explores some explanations for these numbers, including lack of knowledge of the benefit by doctors and lingering concerns over the "death panels" controversy.
Monday, July 24, 2017
Checking yourself out of the hospital, rather than being discharged, is known as DAMA (discharge against medical advice). The New York Times ran an article about the challenges in deciding to leave the hospital. The Patient Wants to Leave. The Hospital Says ‘No Way.’ references a recent study that illustrates the issues that may occur for elders who want to leave the hospital. "Though A.M.A. discharges occur far more frequently in younger patients, a recent study in The Journal of the American Geriatrics Society analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges." The article also discusses why folks choose to leave, for example, they feel better, they are worried about money, or they're afraid. The article also discusses the arguments against the DAMA and some confusion about the impact of DAMA on subsequent care. The abstract of the article, Discharge Against Medical Advice of Elderly Inpatients in the United States, elaborates "[d]ischarge against medical advice (DAMA) is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, there is a lack of national data on DAMA in this subgroup... Although DAMA rates in individuals aged 65 and older were one fourth of those found in individuals aged 18 to 64, an increasing trend was found in both groups..." To order the article, click here.
Wednesday, July 19, 2017
Governing ran a recent story about how states will pay for in-home care for their residents who are elders. As Demand for At-Home Care Grows, States Debate How to Pay for It considers that aging Boomers may not want to reside in nursing homes and if they stay at home, they will need care at home. With a likely greater demand for inhome care, how will it be delivered and who will pay?
[F]iguring out how to pay for more home-based care is mostly left up to the states. Medicaid is the primary payer for home- and community-based care, although states can decide whether or not they’ll offer the coverage. All 50 states and the District of Columbia do have home- and community-based programs of some type, but most states have waiting lists for their programs. Meanwhile, 59 percent of Medicaid funding goes to nursing homes, where about half of those in long-term care receive their services. “Nursing home institutions are a powerful player in the health-care setting, so there’s long been political pressure to not pay for more home health care,” says [Kevin] Prindiville [, executive director of Justice in Aging].
The article highlights California and Washington state, at opposite ends of the spectrum in handling this issue. Waivers may help, or shifting money through legislation that gives flexibility.
Tuesday, July 18, 2017
I read this article last week in the New York Times (also published by the Kaiser Health News), the topic of which is something we should consider seriously. Poor Patient Care at Many Nursing Homes Despite Stricter Oversight discusses Medicare's Special Focus status.
While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to an analysis of federal health inspection data. Of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.
The article highlights some individuals' experiences, with the basis of the article concerning the Special Focus program.
Special focus facility status is reserved for the poorest-performing facilities out of more than 15,000 skilled nursing homes. The Centers for Medicare and Medicaid Services, or C.M.S., assign each state a set number of slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.
More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts. This year, the $2.6 million budget allows only 88 nursing homes to receive the designation, though regulators identified 435 as warranting scrutiny.
The article also discusses lapses by those facilities once on the watch list, how a facility earns its way off the watch list and how long it typically takes to do so and the staffing ratios in such facilities.
Background information about the special focus initiative can be found on the CMS website. You can find the list of special focus facilities on CMS website. For example, here is the one published in June of 2017.
Monday, July 17, 2017
The Medicare Trustees have also released their annual report on the health of Medicare J Medicare offers some helpful information about how to read the report
The Trustees Report is a detailed, lengthy document, containing a substantial amount of information on the past and estimated future financial operations of the Hospital Insurance and Supplementary Medical Insurance Trust Funds (see the links in the Downloads section below). We recommend that readers begin with the "Overview" section of the report. This section is fairly short, is written in "plain English," and summarizes all the key information concerning the expected financial outlook for Medicare. Substantial additional material is available in the later sections for those wishing to delve more deeply into the actuarial projections.
The report is downloadable as a pdf here. This report runs 263 pages (just a tiny bit shorter than the one from the SSA Trustees). Again, what do we want to know? We want to know whether Medicare is on sound financial footing. So let's get right to the bottom line (or pages 40-42). Here are the relevant portions of the conclusion in Section II
Total Medicare expenditures were $679 billion in 2016, and the Board projects that they will increase in most future years at a somewhat faster pace than either aggregate workers’ earnings or the economy overall. The faster increase is primarily due to the number of beneficiaries increasing more rapidly than the number of workers, coupled with a continued increase in the volume and intensity of services delivered. Based on the intermediate set of assumptions under current law, expenditures as a percentage of GDP would increase from the current 3.6 percent to a projected 5.9 percent by 2091.
The HI trust fund fails to meet the Board of Trustees’ short-range test of financial adequacy. In addition, as in past reports, the HI trust fund fails to meet the Trustees’ long-range test of close actuarial balance.
HI experienced deficits from 2008 through 2015, but annual surpluses are expected from 2016 through 2022 before deficits return for the remainder of the 75-year projection period. The projected trust fund depletion date is 2029, one year later than estimated in last year’s report. Actual HI expenditures in 2016 were slightly lower than the previous estimate. The projections are lower throughout the short-range period due to lower utilization and provider update assumptions. HI taxable payroll in 2016 was slightly higher than previously projected, and projections for HI tax income are lower after 2017 due to slower real-wage growth assumptions.
The HI actuarial deficit in this year’s report is 0.64 percent of taxable payroll, down from 0.73 percent in last year’s report. This result is due primarily to lower-than-estimated spending in 2016 and lower projected inpatient hospital utilization.
The financial outlook for SMI is fundamentally different than for HI due to the statutory differences in the methods of financing for these two components of Medicare. The Trustees project that both the Part B and Part D accounts of the SMI trust fund will remain in financial balance for all future years because beneficiary premiums and general revenue transfers are assumed to be set at a level to meet expected costs each year. However, SMI costs are projected to increase significantly as a share of GDP over the next 75 years, from 2.1 percent to 3.7 percent under current law. The projected Part B costs in this report are slightly higher over the short-range and long-range periods than the comparable projections in the previous report due to higher-than-expected actual spending for outpatient hospital services and physician-administered drugs in 2016 and a methodological change resulting in higher drug spending for patients with end-stage renal disease. The Part D short-range and long-range projections are lower than in past years’ reports, largely due to the increase in drug manufacturer rebates and lower utilization of hepatitis C drugs.
The financial projections shown for the Medicare program in this report reflect substantial, but very uncertain, cost savings deriving from provisions of the ACA and MACRA that lower increases in Medicare payment rates to most categories of health care providers. Without fundamental change in the current delivery system, these adjustments would probably not be viable indefinitely.
* * *
Policy makers should determine effective solutions to the long-range HI financial imbalance. Even assuming that the provider payment rates will be adequate, the HI program does not meet either the Trustees’ short-range test of financial adequacy or long-range test of close actuarial balance. HI revenues would cover only 88 percent of estimated expenditures in 2029 and 81 percent in 2050. By the end of the 75-year projection period, HI revenues could pay 88 percent of HI costs. Policy makers should also consider the likelihood that the price adjustments in current law may prove difficult to adhere to fully and may require even more changes to address the financial imbalance.
The projections in this year’s report continue to demonstrate the need for timely and effective action to address Medicare’s remaining financial challenges—including the projected depletion of the HI trust fund, this fund’s long-range financial imbalance, and the rapid growth in Medicare expenditures. Furthermore, if the growth in Medicare costs is comparable to growth under the illustrative alternative projections, then these further policy reforms will have to address much larger financial challenges than those assumed under current law. The Board of Trustees believes that solutions can and must be found to ensure the financial integrity of HI in the short and long term and to reduce the rate of growth in Medicare costs through viable means. Consideration of such reforms should not be delayed. The sooner the solutions are enacted, the more flexible and gradual they can be. Moreover, the early introduction of reforms increases the time available for affected individuals and organizations—including health care providers, beneficiaries, and taxpayers—to adjust their expectations and behavior. The Board recommends that Congress and the executive branch work closely together with a sense of urgency to address these challenges.
Friday, July 14, 2017
Justice in Aging has released a new issue brief for July about Medicare Savings Programs (MSP). Proposed Cuts to Medicaid Put Medicare Savings Programs At Risk explains the importance of the MSP for many Medicare beneficiaries, including paying their premiums. If the MSP program were cut or eliminated, many beneficiaries may no longer be able to afford Medicare.
Many low-income older adults are only able to participate in Medicare because Medicare Savings Programs help with their Medicare premiums, deductibles and co-pays. These critically important programs reach over 7 million people with Medicare, including 1.7 million older adults who are too poor to be able to afford Medicare but do not qualify for other Medicaid programs.1 With $772 billion in Medicaid cuts, the Better Care Reconciliation Act now being considered in the Senate could knock many older adults and people with disabilities off these programs, making Medicare unaffordable. As a result, those with the greatest needs will lose access to Medicare benefits because they will be unable to shoulder Medicare costs.
The brief explains QMBs, SLMBs, and QIs. It also explains the relationship between MSP and "Extra Help". Regardless of the Senate vote (maybe this week) on repeal and replace, the information in the brief about MSP and the other programs is really helpful. Check it out!
Thursday, July 6, 2017
NPR recently ran a story about beneficiaries enrolled in Medicare Advantage plans. As Seniors Get Sicker, They're More Likely To Drop Medicare Advantage Plans discusses a recent "GAO report, released this spring, [that] reviewed 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to "preferred doctors and hospitals" or other medical care as the leading reasons for leaving." The article notes the positives to MA plans, but also some concerns: "some critics argue the plans can prove risky for seniors in poor or declining health, or those ... who need to see specialists, because they often face hurdles getting access." The GAO report referenced in the story is available here.
Tuesday, June 20, 2017
Consider those who need home health care but say no. Kaiser Health News recently ran a story on this very topic. Some Seniors Just Want To Be Left Alone, Which Can Lead To Problems explain that the percentage of those who want to be left alone is higher than you may think. "As many as 28 percent of patients offered home health care when they’re being discharged from a hospital — mostly older adults — say “no” to those services, according to a new report." The report is from a roundtable that was sponsored by the Alliance for Home Health Quality & Innovation and United Hospital Fund. The report, I Can Take Care of Myself: Patients' Refusals of Home Health Care Services runs 23 pages.
Here are highlights of the report (found on page 1):
Medical care is moving from hospitals and other institutions into the community, which for most people means care at home, where they want to be. With shorter hospital stays and more complex post-discharge needs, the importance of home health care services, including skilled care and personal care, in discharge planning and transitional care is increasing.
Some studies show that patients who receive home health care after hospital discharge are less likely to be readmitted. Other studies show that patients who receive home health care report better quality of life.
Although data are limited, approximately 6-28 percent of patients eligible for home health care refuse these services, for a variety of reasons.
Even less is known about the process by which hospital staff identify patients for referral to home health care, how they explain these services, and how well they address the full range of patients’ and family caregivers’ transitional care needs.
Patients and their family caregivers have similar goals but may have different needs and attitudes about home health care.
Policy and system barriers to accessing services include inflexible criteria for eligibility, inadequate payment for home health care agencies’ services for patients with complex conditions, and shortages of trained workforce.
Recommendations from Roundtable participants include interventions that improve communication about care challenges and home health care services, qualitative and quantitative research on all aspects of home health care refusals, policy changes to increase access and coordination, and continuity across providers and care settings.