Sunday, January 24, 2021
Despite the existence of the COVID vaccine, it will be some time before life returns to the 2021 version of "normal." Loneliness is still a factor for many. I blogged a little over a week ago about my sister's cat and mentioned how pets can help combat loneliness. The New York Times ran a story about loneliness (not about my sister's cat) a couple of weeks ago. Combating an Epidemic of Loneliness opens with some interesting statistics. "Humans can survive three minutes without air, three days without water, three weeks without food and — according to survival lore — three months without companionship. Whether true or not, what’s clear is that people need people. And pandemics, many of us are learning, can be lonely times." The article explains what loneliness means-it's more than being by oneself. "A useful way to think about loneliness, she said, is as the difference between how much social connection people want and how much they are getting" one expert noted in the article. The article even mentions the brain science and studies undertaken on the topic. The article offers several suggestions to combat loneliness:
(1) Friend-but not just anyone you call "friend." "
When seeking out connections, focus on your most unconditionally supportive friends and family. Some research shows that people feel more stressed and disconnected when their friendship networks include people who have betrayed them, weren’t there for them during tough times, frequently argue with them or otherwise cause negative feelings. A call with a close friend, in other words, will probably help more than a college reunion over Zoom.
(2) Be helpful to others. Remember random acts of kindness? Those can be done even if you are staying home. (3) Start a hobby. (4)Reach out to others-lots of folks are lonely, and the article suggests younger people may need this connection.
And I'll add this to the list. If you have a pet, give it a hug.
Thursday, January 21, 2021
A few days ago, CNN ran this story: Coronavirus will knock more than a year off average US life expectancy, study finds.
A new study published in the Proceedings of the National Academy of Sciences projects that Covid-19 will reduce US life expectancy in 2020 by 1.13 years, with a disproportionate number of deaths occurring among Black and Latino populations. When combined with provisional estimates of US death rates for the first half of the year, the data show a clear rise in the mortality rate as the pandemic took hold of the nation.
Tuesday, January 19, 2021
PHI has released a new report, Caring for the Future: The Power and Potential of America’s Direct Care Workforce. Here are the key takeaways from the report
- Caring for the Future' describes the many profound challenges that have long faced this country’s direct care workforce.
- To our collective detriment, direct care workers remain undervalued and underutilized in the long-term care sector.
- Improving direct care jobs requires a comprehensive, national strategy that guides leaders across the public and private sectors.
The executive summary, available for download here, explains
Every day around the country, direct care workers leave their homes to ensure that older adults and people with disabilities have the care and support they need. These 4.6 million workers are the paid frontline of support for consumers and their families, growing as a workforce annually as people live longer and demand surges. They work in private homes, nursing homes, and residential care settings. They are unquestionably essential, as the COVID-19 pandemic has tragically underscored. They are predominantly women, people of color, and immigrants—diverse workers disproportionately impacted by structural racism and gender inequality. These workers are not valued, compensated, or supported at the level they deserve. Caring for the Future: The Power and Potential of America’s Direct Care Workforce explains these and other challenges and offers a clear and achievable path toward achieving quality jobs for this critical workforce.
The executive summary covers f0ur sections and lists eight recommendations. The entire 126 page report is available here.
Monday, January 18, 2021
There are so many stories being published about COVID and the impact on elders, I'm just going to include a few in this post.
I had mentioned a few weeks back that some states were circumventing the CDC recommendation on the second priority tier for vaccination. Florida is among those states, choosing to vaccinate those 65 and older. In case you weren't aware, Florida has a lot of folks 65 and older. And not enough vaccine doses for everyone. When the second batch of vaccines arrived, stories appeared regarding confusion and inefficiencies regarding signing up to receive the vaccine. (I and several of my friends can tell you first-hand accounts of this). As the New York Times described it, ‘It Became Sort of Lawless’: Florida Vaccine Rollout Turns Into a Free-for-All. It's not just Florida having this problem, as noted in Online Sign-Ups Complicate COVID-19 Vaccine Rollout For Older People.
We need to remember that not everyone has access to a computer or reliable internet-so are we leaving out an entire group in that 65 and over category eligible for the vaccine? With states left to administer the programs, Vaccination Disarray Leaves Seniors Confused About When They Can Get a Shot.
It seems to me that COVID news has been pushed off the news as the #1 story, replaced by the insurgency (rightfully so) but we shouldn't lose focus on the increasing spread of the pandemic. So we know things are going to get worse, before they get better---we haven't seen the surge from the Christmas holidays, but it's coming and very soon. Just look at what happened at Thanksgiving: COVID Kills Over 12,000 Nursing Home Residents in Weeks Surrounding Thanksgiving.
Finally, if you don't read any of these articles, read this one. COVID-19 And Congress Have Left The Senior Citizen Safety Net In Tatters explains the impact the pandemic and the economy is having on senior centers.
Wednesday, January 13, 2021
Kaiser Health News ran an article (before Congress recessed), Seniors Face Crushing Drug Costs as Congress Stalls on Capping Medicare Out-Of-Pockets.
Many Americans with cancer or other serious medical conditions face ... prescription drug ordeals. It’s often worse, however, for Medicare patients. Unlike private health insurance, Part D drug plans have no cap on patients’ 5% coinsurance costs once they hit $6,550 in drug spending this year (rising from $6,350 in 2020), except for very low-income beneficiaries.
President-elect Joe Biden favors a cap, and Democrats and Republicans in Congress have proposed annual limits ranging from $2,000 to $3,100. But there’s disagreement about how to pay for that cost cap. Drug companies and insurers, which support the concept, want someone else to bear the financial burden.
That forces patients to rely on the financial assistance programs. These arrangements, however, do nothing to reduce prices. In fact, they help drive up America’s uniquely high drug spending by encouraging doctors and patients to use the priciest medications when cheaper alternatives may be available.
The article examines the cost of specialty drugs and reviews the results of a 2019 Kaiser survey on the issue. The high cost of such drugs may impede a person's ability to retire, the article noted. The article reviews the situation of some folks who have had to make treatment decisions based on costs and some choose to not have a prescription filled due to the costs.
There is help from some non-profits, but beneficiaries may not know about them. "The high drug prices and coverage gaps have forced many patients to rely on complicated financial assistance programs offered by drug companies and foundations. Under federal rules, the foundations can help Medicare patients as long as they pay for drugs made by all manufacturers, not just by the company funding the foundation."
Stay tuned to see if Congress takes up the issue when it reconvenes.
Sunday, January 10, 2021
Mark your calendars for a free briefing on January 14 at noon eastern for a free webinar from the Kaiser Family Foundation. A Shot in the Arm For Long-Term Care Facilities? Early Lessons from the COVID-19 Vaccine Rollout to High Priority Populations:
KFF will hold an interactive web event at Noon Eastern time on Thursday, January 14 that will provide the latest data on COVID-19 cases and deaths in long-term care facilities and examine how the effort to vaccinate residents and staff in long-term care settings is going, challenges experienced so far, and opportunities for improvement.
The event will be co-moderated by Tricia Neuman, a Senior Vice President of KFF and Executive Director of the Program on Medicare Policy, and Rachel Garfield, a Vice President at KFF and Co-Director of the Program on Medicaid and the Uninsured. Priya Chidambaram, a Senior Policy Analyst at KFF, will provide the latest data on cases and deaths in long-term care facilities. A panel discussion on COVID-19 vaccination efforts will follow featuring a range of perspectives, including those of patients, nursing home officials, and pharmacy providers who are performing the vaccinations.
Click here to register for the webinar.
Friday, January 8, 2021
Earlier this week the Washington Post published this article, Wealthy donors received vaccines through Florida nursing home. According to the article, the "chief executive of MorseLife Health System, a high-end nursing home and assisted-living facility in West Palm Beach, Fla., [contacted] members of the board and major donors" and offered them the opportunity to get the COVID vaccine. This also "includ[ed] members of the Palm Beach Country Club, according to multiple people who were offered access, some of whom accepted it. The precise number of invitations, and how many may have also gone to non-donors, could not be learned." The article notes the confusion in Florida regarding the vaccination protocols that basically "highlights how the country’s patchwork approach to immunization against the coronavirus — leaving decisions about eligibility to state and local authorities as well as to individual providers —[and] is creating opportunities for facilities to provide access to well-connected people while thousands of others wait in line." The article also notes that those in charge took the position that they stayed within the protocols. The article mentions that a number of those offered the opportunity fell within the age group, but did not reside at the facility and concludes with information about the two views of what happened.
Wednesday, January 6, 2021
The New York Times recently ran an article that focused on how elders are persevering during the pandemic. How the Oldest Old Can Endure Even This introduces us to the concept of crisis competence. That is, "[n]o visitors. No friends at the dining table. Neighbors dying without notice. But many older adults have proved resilient during the pandemic, a phenomenon known as 'crisis competence.'" For those older adults who live in long term care facilities, they have had to give up more autonomy in return for being kept safe.
Maybe it's their perspective, having a history of years on which to face their present and their future.
A surprise of the pandemic has been how well many older adults have adapted to the restrictions. “There’s crisis competence,” said Mark Brennan-Ing, a senior research scientist at Hunter College’s Brookdale Center for Healthy Aging. “As we get older, we get the sense that we’re going to be able to handle it, because we’ve been able to handle challenges in the past. You know you get past it. These things happen, but there’s an end to it, and there’s a life after that.”
While people of all ages have struggled this year, those 65 and up are still more likely to rate their mental health as excellent compared with people under 50.
The article focuses on several residents of a ltc facility, which provides us with important insights. The article wraps up and offers this advice "A motto to take into the new year: Horrible stuff happens, and people rebound from it."
Tuesday, January 5, 2021
The Wall Street Journal published this piece back in December. Covid Spurs Families to Shun Nursing Homes, a Shift That Appears Long Lasting explains the trend
The pandemic is reshaping the way Americans care for their elderly, prompting family decisions to avoid nursing homes and keep loved ones in their own homes for rehabilitation and other care.
. . .
The drop-off has persisted since spring, including at times when the virus’s spread was subdued. In the summer, when many hospitals were performing near-normal levels of the kinds of procedures that often result in nursing-home stays, referrals to nursing homes remained down.
Occupancy in U.S. nursing homes is down by 15%, or more than 195,000 residents, since the end of 2019, driven both by deaths and by the fall in admissions, a Wall Street Journal analysis of federal data shows.
The decline in nursing-home patients covered by Medicare, which provides payments vital to the homes’ business model, is even steeper. That has left the industry in precarious financial shape. The biggest U.S. nursing-home company said in August it might not have enough money to pay its obligations.
I always ask my students two questions when we cover the topic of nursing homes: 1. do they believe nursing homes are important to our society for the provision of long term care? (they answer yes). 2. How many of them want to reside in a SNF at some point in their lives? (they answer no).
Surveys have long shown many patients don’t want to go to nursing homes. The pandemic has made them even less popular, according to a September survey of adults 40 and older by AARP. Just 7% said they would prefer a nursing home for family members needing long-term care, and 6% said they would choose one for themselves. Nearly three in 10 respondents said the pandemic had made them less likely to choose institutional care.
The article notes that the SNF industry has already begun to pivot, and home health care agencies are expanding their services. Medicare's changes to allow for more services in homes also help as some of the Advantage plans have already moved in that direction. The article provides some interesting anecdotes about some of the services available. It's past time for us to rethink how we provide long term care in this country. Long past time....
A subscription is needed to access the full article.
Thanks to Professor Dick Kaplan for sending me this article.
Monday, January 4, 2021
Happy 2021. Several articles have been published examining the pandemic's longer-term impact on SNFs. I wanted to point out two. First, consider the Washington Post article about how SNFs are structured, Profit and pain: How California’s largest nursing home chain amassed millions as scrutiny mounted.
More than 70 percent of the country’s nursing home providers use operating funds to pay themselves through so-called related parties — companies they or their family members partially or wholly own. In 2018, Brius nursing homes paid related parties $13 million for supplies, $10 million for administrative services and financial consulting, and $16 million for workers’ compensation insurance, state records show. The homes also sent a total of $64 million in rent to dozens of related land companies.
The practice is legal and widely supported by the industry, which argues that related parties help control costs and limit financial liability. Watchdog groups counter that nursing home owners can reap excessive profits from public funds by overpaying their own companies. Related parties generally do not have to disclose profits, leaving regulators with little way to assess the financial gains of owners.
Covid has changed the "business as usual" model, it would seem, as the article notes that "scrutiny has mounted in recent months as the federal government delivered about $54 million to Brius homes in coronavirus relief aid, meant as a lifeline for providers struggling to protect residents amid an unprecedented health crisis that has killed more than 92,000 nursing home residents nationwide." The Washington Post did an in-depth look at this SNF chain. The article details what the reporters discovered regarding finances and taxes. There are California groups that have called for the California legislature to revise the oversight of SNFs. The article indicates that efforts may also be made at a federal level. This detailed article is well worth reading and I plan to assign it to my students, so they can have a better understanding of the structure of SNFs.
The first coronavirus outbreak in the United States occurred in a nursing home near Seattle, in late February. Since then, the country has endlessly revised its hot spot map. Yet the situation in nursing homes and assisted-living facilities has only gotten worse: More than 120,000 workers and residents have died, and residents are now dying at three times the rate they did in July.
Long-term care continues to be understaffed, poorly regulated and vulnerable to predation by for-profit conglomerates and private-equity firms. The nursing aides who provide the bulk of bedside assistance still earn poverty wages, and lockdown policies have forced patients into dangerous solitude.
Fortunately... and maybe hopefully...., with the COVID vaccine and priority given to those who work and reside in SNFs, this won't be a story that continues in the same vein. But the author of this piece aren't telling us we will return to the prior way of things. "When the pandemic is finally history, we’ll need to deal with all of this: the staffing shortages, low pay and lack of accountability — the many ways we have failed residents, family members and staffers. The awful truth is that long-term care was designed to fail years before Covid-19." Why is this? Various stressors combined push the need for change in how long term care is provided. "Over the past few decades, the popularity of “aging in place,” combined with new medical technologies and longer life spans, has changed the nature of care for seniors and people with disabilities. Residents of the nation’s 15,400 C.M.S.-certified nursing homes are much older, sicker and poorer than they used to be." The article mentions the health of the residents, low pay for employees, employees working jobs at different facilities as contributing to the crisis.
The author makes a number of suggestions for changing long-term care in the U.S. and concludes with a call for action from the incoming administration
Most important, we must transform the way we think about long-term care — treating it not as human warehousing or the duty of underpaid women, but as an integral part of our medical system.
All of these changes are possible — and modest, really, given the magnitude of the emergency. By 2050, 19 million people will be 85 or older, and many will require help to live with comfort and a modicum of dignity. What we really need, for all Americans, is single-payer health insurance that covers quality long-term care. But short of that, Mr. Biden and Kamala Harris have a chance to make amends for the deadly failures of the current administration.
Wednesday, December 30, 2020
It's the end of 2020---finally---so here are a few recent items about Elders and COVID to close out 2020.
There is a lot to unpack in these articles. COVID has had a significant impact on elders, and it will be some time before we learn the full impact on elders, their families and the professionals who serve them. I expect several of my students in my spring seminar will write papers on these various issues.
Sorry to not end 2020 on a happy note. Here's to 2021 and rapid availability of the vaccine to all. Stay smart, stay masked and stay home. Thanks to our health care providers, first responders and those who keep us going.
Monday, December 28, 2020
The Tampa Bay Times reported recently on an uptick in the numbers of COVID deaths in Florida . Why are coronavirus deaths doubling in Florida’s nursing homes? references a recent report from AARP "that the COVID-19 death rate among Florida nursing home residents doubled in the three weeks around the Thanksgiving holiday, and infections continue to climb among the state’s most vulnerable residents. The death toll spike was so alarming that AARP decided to report on the data rather than wait for its scheduled monthly release on Jan. 10." One expert quoted for the article pointed to the state's failure to "to provide accurate, rapid-result testing of everyone entering elder-care facilities — staff, visitors, family caregivers and vendors." The AARP report with the Florida data is available here.
We all need good news these days. So here's one story for the holidays that should make you smile. Santa’s ‘Grandchildren’ Spread Joy In Italian Nursing Homes explains the Santa's grandkids project:
Despite a grim year marked by death and loneliness, the holiday spirit is descending on the Zanchi nursing home, one of the first in Italy to shut its doors to visitors after a COVID-19 case was confirmed in the nearby hospital on Feb. 23.
The bearers of glad tidings were the so-called “grandchildren of Santa Claus,” people who answered a charity’s call to spread cheer to elderly nursing home residents, many of whom live far from their families or don’t have any family members left.
The program, in its third year, continues to grow in popularity, with almost 6000 gits distributed to 228 SNFs. The featured nursing home had 43 residents participating which included virtual visits with Santa's grandkids, during which the SNF residents opened presents. It is worth noting that the volunteer grandkids also benefited from participating in the project.
Well done everyone!
Thursday, December 24, 2020
A couple of days ago, the Washington Post ran an uplifting article about a hug room in a SNF. After months of isolation, a ‘hug room’ lets Italian nursing home residents touch family for the first time tells us about "a 7-foot-tall piece of plexiglass, molded into a three-sided booth. It had four cutout holes, where protective sleeves would be added for arms. It was known, in the strange language of the pandemic, as a “hug room,” but it was less a room than a barrier: residents on one side, relatives on the other." Although not as ideal as living in a COVID free world (or at least a vaccinated one), this "plexiglass represented the sort of modest step some nursing homes are now taking in a year when they have faced excruciating decisions about how protective to be and how best to reduce their risks." The article references similar efforts taken by other SNFs.
A little bit of good news, then, for Christmas.
PPS-remember to thank first responders, health care professionals and all who keep us safe and going through this trying time. Stay safe and stay healthy.
Tuesday, December 22, 2020
It's going to be some time before we see good news stories about residents of SNFs---although the vaccination of SNF residents is good news. So here are several recent articles regarding SNFS and COVID-but be forewarned, these first two are not easy to read.
There are just no words....
(Thanks to Morris Klein and Professor Bauer for sending me the link to this article).
This last article brings up some interesting issues for class discussion-such as consent, refusal of consent, and inability to consent.
Please everyone-stay safe and remember to thank our first responders, health care professionals and essential workers. And let us never forget those we have lost to this pandemic.
December 22, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink | Comments (1)
Monday, December 21, 2020
JAMA network published this article, What Caring for My Aging Parents Taught Me That Medical Education Did Not is a first person account by the author of what he went through with his parents, and what he learned from the experience.
Slowly, however, things started to change. My parents seemed to have increasing difficulty staying organized. Instead of me calling them, they began calling me—at first weekly, then daily, and then multiple times per day. My father’s blood pressure was out of control, and he could not tell me what medications he was taking. My mother’s scoliosis, a problem since adolescence, now caused her to have significant difficulty walking. She looked thinner each time I saw her. Their physicians seemed not to be communicating well with each other. Finding their cell phones became a daily project.
Then came the identity theft: strange addresses on their credit card statements, charges to their accounts from Florida businesses when they were not living there, and even their telephone being answered by the identity thief himself. Managing these problems became my part-time job. Since credit card fraud departments are typically open only during business hours, I would sometimes spend afternoon hours on hold from my hospital office, waiting for someone to pick up, rather than charting, talking to a consultant, or doing research.
The move from their home of 30 years was the next step. They simply could not manage the house. Once spotlessly clean, it was now increasingly cluttered with tchotchkes from circa 1993. The garden was overgrown, the dishes dirty. After work, I typically spent an hour every day helping organize, donate, and throw away their belongings, so that we could put the house up for sale. Thankfully, the renovations went smoothly and the house sold quickly. Although not without drama, my parents moved to a retirement facility nearby.
The author created a list of what he wished he had known as he cared for his parents:
If you have the feeling that something may be an issue for your aging parents, it is almost definitely an issue.
- Make sure you know about all your parents’ financial accounts.
- You (and they) may need emotional support from people you would not expect.
- Advocate for your parents in the best way you can, but do not expect everything to be cut and dried.
- Use technology to help you (and them).
- Do not expect too much from the medical system.
- You must have the difficult conversations if the physicians will not.
- You may need to get them daily help.
- Do not forget to keep some perspective and occasionally laugh.
Great article! Thanks to Amos Goodall, Esq. for sending me the link.
Sunday, December 20, 2020
GeriPal, a geriatrics and palliative care blog, has released a podcast, Guardianship and End-of-Life Decision Making: A Podcast with Andy Cohen and Liz Dzeng, discussing a recent study led by Dr. Cohen.
The big surprise finding of this study was veterans who were nursing home residents aged 65 and older with moderate to severe dementia and who had a professional guardian were no more likely to receive high‐intensity treatments than the same population who died with decision makers who were not professional guardians. We talk to Andy about his study, potential reasons behind the study, and what, if anything, we should do differently knowing these results. We also talk to Liz about whether substituted judgement is really all that it’s cracked up to be.
The article, Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes and editorial, We Need a Paradigm Shift Around End‐of‐Life Decision Making, are available here and here.
December 20, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Health Care/Long Term Care | Permalink | Comments (0)
Friday, December 18, 2020
According to a story yesterday in the AP news, Spain’s parliament vote[d] to legalize euthanasia. The bill provides for medical aid-in-dying or euthanasia "for long-suffering patients of incurable diseases or unbearable permanent conditions." The bill next goes to their Senate. The article notes that "[e]uthanasia — when a doctor directly administers fatal drugs to a patient — is legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands and Switzerland. In some U.S. states, medically-assisted suicide — where patients administer the lethal drug themselves, under medical supervision — is permitted." The bill requires multiple requests by the patient, the first 2 of which must be written and made with two weeks between the requests. Medical professionals must be involved and requests are reviewed and granted by a regional oversight board. Only adult Spanish residents or citizens who can make rational decisions would be able to make such requests.
Friday, December 4, 2020
The Tampa Bay Times ran a profile of a local long term care facility that experienced a significant COVID outbreak last spring. Death at Freedom Square is an in-depth story about the people who live and work at Freedom Square and the spread of COVID within that facility. The article provides detailed reporting (In fact the TBT refers to this story as a "project"). The article is written in a way that tells the story of the people impacted, which makes it a compelling--- and sad---- read.
Nine months into the pandemic, the virus has killed more than 19,000 Floridians. About 40 percent of the deaths have been among senior care residents. In Pinellas County alone, more than 2 out of 3 coronavirus deaths are connected to nursing homes and assisted living centers.
Freedom Square, a 15-acre retirement complex built around a town square and a gazebo, was the early epicenter in Tampa Bay.
Of course, we all know that this is not the only facility that experienced a COVID outbreak, whether inside Florida or in other states. The human interest angle makes this a compelling read, but it also includes important information about the Florida responses and about the corporate structure for this facility.
The article is as gripping as it is saddening; the reporters use of the human interest angle helps remind us that we aren't talking about numbers---we are talking about people.
December 4, 2020 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations, Statistics | Permalink | Comments (0)
Thursday, December 3, 2020
Maryland elder law attorney Morris Klein sent me a link to an article recently published in the Washington Post. How government incentives shaped the nursing home business — and left it vulnerable to a pandemic explains
Federal money, through the Medicare and Medicaid systems, has long shaped the nursing home business — and in ways that left it completely vulnerable when the viral pandemic arrived in March.
For years, extra money has gone to pay for extra services, encouraging some nursing home owners to game the system and tempting unscrupulous operators to file false claims for reimbursement. In the recent past, the gold standard was physical and occupational therapy; now it’s respiratory care.
But stringent infection control, which might have kept the coronavirus at bay, has never been a revenue producer, even now during the pandemic. Similarly, there is no monetary incentive to hire more registered nurses, although studies suggest they have been crucial in minimizing covid-19 casualties in nursing homes.
According to the article, the fee for service model is centered on additional care that will bring in additional funds to the provider, "and one consequence is that employees who handle general care of residents — nursing assistants, primarily — rather than the specialty services are a low priority for operators. They are underpaid and in chronically short supply at nursing homes across the country."
The article includes specific resident stories during the time of COVID and compares the financials for SNFs from resident stays covered by Medicare and Medicaid. When COVID rampaged, folks put off surgeries, which affected the bottom line of many SNFs, per the article.
The temptation of the funding system leads some facilities to cross the line. "Working in a system that requires nursing homes to decide what extra services a resident needs, then provide those services, then bill the government, tempts some operators to game the rules and a few to commit outright fraud. Patients can be pushed into higher-paying categories of need. Services can be billed that were never rendered."
The lengthy article gives a really good picture of the funding system, how it works, the oversight and the remedies available to redress wrongdoing. I'm recommending this article to my students.