Tuesday, September 17, 2019
Although it's been a bit of time since Colorado 's medical aid-in-dying (MAD) law went into effect, but recent events suggest the topic has not been settled. According to Kaiser Health News, Firing Doctor, Christian Hospital Sets Off National Challenge To Aid-In-Dying Laws
A Christian-run health system in Colorado has fired a veteran doctor who went to court to fight for the right of her patient to use the state’s medical aid-in-dying law, citing religious doctrine that describes “assisted suicide” as “intrinsically evil... [the doctor] had planned to help her patient... end his life at his home [the patient] is eligible to use the state’s law, overwhelmingly approved by Colorado voters in 2016."
This illustrates the clash between faith-based hospitals and state laws. "As hospitals across the country have consolidated, five of the top 10 hospital systems by net patient revenue are associated with the Roman Catholic Church ... [t]hat includes hospitals that did not previously have any religious affiliation. Meanwhile, there are 10 U.S. jurisdictions where aid-in-dying has been approved and public support for the option is increasing."
Stay tuned-this is going to take a while to be resolved through the courts.
Monday, September 16, 2019
A recent story from the New York Times highlights the role of long-term care hospitals in carrying for elders. For Older Patients, an ‘Afterworld’ of Hospital Care explains that for these long-term care hospitals, sometimes referred to as " a long-term acute care hospital"... is where patients often land when an ordinary hospital is ready to discharge them, often after a stay in intensive care.But these patients are still too sick to go home, too sick even for most nursing homes."
Never heard of these LTCH? There are a fair number of them, and they treat quite a large number of individuals."Close to 400 such hospitals operate around the country, some free-standing, others located within other hospitals, most for-profit. They provide daily physician visits, high nurse-to-patient ratios and intensive therapy...In 2017, they accounted for about 174,000 hospital stays. Medicare covered about two-thirds of them, at a staggering cost of $4.5 billion, the Medicare Payment Advisory Commission has reported."
A recent study published in the Journal of American Geriatrics Society notes poorer outcomes for these individuals. The article notes that there is a decline in the use of these hospitals, with tighter regulations and more stringent patient requirements. Oftentimes the LTCH is a stop between the hosptial and nursing home. This "should prompt frank discussions among families, doctors and patients about whether a frail older person leaving an intensive care unit or standard hospital truly wants to spend another month or more in an L.T.C.H. and then move to a nursing home, which is the likely scenario." There are other options and the article notes the importance of having a conversation with the patient and family about them.
Wednesday, September 11, 2019
There are two upcoming webinars that I wanted to alert you about so you can register. The National Center on Elder Abuse is hosting a webinar on September 18, 2019 from 3-4 edt, on Recognizing and Addressing Abuse in Long-Term Care Facilities. According to the email announcement
People living in long-term care (LTC) facilities can be vulnerable to abuse and neglect. Recognizing and addressing abuse and neglect in LTC facilities as well as knowing their rights is crucial for both residents and their family members.
This webinar presented by the Paralysis Resource Center will help to understand the rights of residents of LTC facilities, identify the signs of abuse and neglect, and learn how to report concerns and complaints to the appropriate agencies. Attendees will learn about the important role of the Long-Term Care Ombudsman Program in addressing complaints and how to contact the program. The webinar will also seek to empower people with paralysis and their family members by providing information on choosing a long-term care facility and tips for advocating for quality care.
The webinar will be presented by Amity Overall-Laib, Director of the National Long-Term Care Ombudsman Resource Center (NORC). Amity served as a local long-term care ombudsman in Texas for six years advocating for residents in 65 nursing homes and 130 assisted living facilities in a 12-county region. During her tenure in Texas, she led the formation of the Gulf Coast Culture Change Coalition, resulting in two free conferences for long-term care consumers, providers, advocates and regulators promoting culture change practices and has presented at local, state, and national conferences. She also had the pleasure of representing fellow local ombudsmen on the Board of Directors for NALLTCO (National Association of Local Long-Term Care Ombudsmen). Amity was previously a consultant to NORC then served as Manager for Program and Policy.
To register, click here.
Next, the National Center on Law & Elder Rights is hosting a webinar on Issues at the Intersection of Social Security and Medicare on October 8 at 2 eastern time. According to the email announcement,
Social Security benefits and Medicare benefits are closely intertwined, and most people who receive one also receive the other. The close connection means that a problem with one benefit will sometimes cause problems with the other benefit. It can be difficult to figure out which agency is responsible and where to go for relief. This webcast will focus on why cross-program issues occur and what advocates can do to resolve them.
Presenters will share:
- Agencies and key players: Who is in charge of what?
- Situations when Medicare and Social Security benefits are linked and when they are not.
- Issues that arise and strategies for resolving them, including state buy-in issues for Medicare Part B premiums, and challenges keeping Medicare active during an appeal of the termination of Social Security disability benefits.
To register, click here.
September 11, 2019 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Programs/CLEs, Social Security, Webinars | Permalink | Comments (0)
Tuesday, August 27, 2019
Since 2011 the Center for Medicare Advocacy has been pursuing a nationwide class action lawsuit seeking an appeal for Medicare beneficiaries who are classified as hospital outpatients in observation status. (Alexander v. Azar, 3:11-cv-1703, U.S. District Court, Connecticut.) Co-counsels in the case are Wilson, Sonsini, Goodrich & Rosati and Justice in Aging.
The Alexander trial was held before US District Court Judge Michael Shea from August 12 – 20, 2019. The Judge ordered post-trial briefing, which is expected to take approximately 75 days. Then the parties will await Judge Shea’s decision.
Medicare beneficiaries who received “observation services” in a hospital on or after January 1, 2009 and either did not have Medicare Part B, or, were hospitalized for at least three consecutive days but not three days as an inpatient, may be a member of the Alexander class. No action is required to “join” the class. Individuals who meet the class definition, are in the class (note that the class definition is subject to change). We recommend saving paperwork related to the hospital observation status and to costs that may have resulted from it.
Friday, August 23, 2019
The New York Times was considering that question in a recent article,Older People Need Rides. Why Aren’t They Using Uber and Lyft?
More than half of adults over 65 own smartphones, the Pew Research Center has reported. Yet among adults 50 and older, only about a quarter used ride-hailing services in 2018 (a leap, however, from 7 percent in 2015). By comparison, half of those aged 18 to 29 had used them.
In a survey by AARP last year, only 29 percent of those over 50 had used ride-hailing apps. Two-thirds said they weren’t likely to do so in the coming year, citing in part concerns about safety and privacy. (Given data breaches at Uber, that’s no baseless fear.)
So wouldn't these options help people remain more independent, especially while we wait for self-driving cars to become widely available for all of us? One expert quoted in the article said absolutely! "One reason for such optimism: evidence that with personalized instruction, older adults can master the mobile apps and take “networked transportation” to medical appointments, entertainment and leisure activities, social visits and fitness classes."
A recent study from U.S.C. covered in the article noted when the researchers "offered three free months of unlimited Lyft rides to 150 older people in and around Los Angeles (average age: 72) who had chronic diseases and reported transportation problems... [w]ith training, nearly all used Lyft, most through the mobile app (a few used a call-in service), for an average of 69 trips. On follow-up questionnaires, almost all riders reported improved quality of life."
That's great news but the companies are seeing an opportunity here.
Lyft and Uber and others are contracting with third parties, bypassing the need for older riders to use apps or to have smartphones at all.
They’re joining forces with health care systems, for instance. In the past 18 months, more than 1,000 — including MedStar, in the Washington area, and the Boston Medical Center — have signed on with Uber Health for “nonemergency medical transportation,” the company said.
Case managers and social workers can use Uber or Lyft to ferry patients to or from clinics and offices, reducing missed appointments.
In addition, they are working with various senior communities and exploring other programs for those who have mobility issues, including the ability to order accessible transportation and training drivers of how to assist riders with mobility issues! There are other smaller companies carving out a part of the market, whether portal-to-portal service or the ability to call for a ride by phone. The article also explores the potential costs in using ride-hailing services.
In the U.S.C. study, the typical trip cost $22; the cost per month, had users actually paid it, averaged $500. After the study, about a fifth of riders said they wouldn’t continue using ride-hailing, mostly because of cost.
Some Medicare Advantage programs now cover rides to medical appointments and pharmacies; Lyft expects to partner with most Advantage plans by next year....But most older Americans still use traditional Medicare, which doesn’t cover such transportation.
Wednesday, August 21, 2019
Kaiser Health News ran an article about the issues Medicare presents for beneficiaries who want to retiree to other countries. Dream Of Retiring Abroad? The Reality: Medicare Doesn’t Travel Well explains the issues:
As the number of American retirees living overseas grows, more of them are confronting choices ... about medical care. If they were living in the United States, Medicare would generally be their coverage option. But Medicare doesn’t pay for care outside the U.S., except in limited circumstances.
Expatriate retirees might find private insurance policies and national health plans in other countries. But these may not provide the high-quality, comprehensive care at an affordable price that retirees expect through Medicare. Faced with imperfect choices, some retirees cobble together different types of insurance, a mix that includes Medicare.
The article notes that the quality of the health care may be dependent on the country, and as the number of U.S. retirees move to other countries, they need to think hard about how they will pay for health care. The article discusses issues with private health insurance policies, the costs and rates, which may be different depending on the country. Even with private health insurance, expats need to look at Medicare as the article explains:
Even when retirees buy a private policy, Medicare is another piece of the puzzle that they have to consider. Once people become eligible for Medicare coverage, usually at age 65, they face a 10% premium penalty for every 12 months they are not enrolled in Part B, which covers outpatient services. (People who are 65 but still covered by an employer plan generally do not face that penalty.)
After paying into the Medicare system for decades, it’s no wonder some expats are frustrated that they can’t generally use the program outside the United States.
That’s just the way the law is written, an official at the federal Centers for Medicare & Medicaid Services said.
And retirees should honestly consider whether they will spend the rest of their lives overseas.
Sunday, August 18, 2019
Last week, the class action suit against CMS on observation status finally went to trial. According to the story from the Medicare Rights Center, Lawsuit Seeks to Improve Medicare Beneficiary Access to Nursing Facilities explains the importance of the case, as the trial started last week:
Because an observation stay is not officially considered an inpatient stay, it does not count as a qualifying hospital stay for purposes of Medicare SNF coverage—which means Medicare will not pay for any subsequent SNF care. This leaves patients on the hook for the entire cost of a needed SNF stay—potentially thousands of dollars. Beneficiaries unable to afford this care may self-discharge against medical advice and return home before they are physically or mentally ready, and potentially suffer further devastating and expensive acute health effects.
Currently, people with Medicare cannot appeal the decision to classify a hospital stay as an outpatient stay, but a court case—Alexander v. Azar—may change that. In 2011, seven plaintiffs filed a class action lawsuit to try to gain the right to appeal the decision to classify them as outpatients in observation stay instead of as inpatients who would potentially be eligible for SNF coverage. After many twists and turns, the case has finally made it to trial.
More information about the trial that got underway last week was provided in a Kaiser Health News article, Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage which contains lots of interesting info about the issue and the litigation. For example, "'HHS’ Office of Inspector General urged CMS to count observation care days toward the three-day minimum needed for nursing home coverage. It’s No. 1 on a list issued last month of the 25 most important inspector general’s recommendations the agency has failed to implement." The importance of this case can't be emphasized enough. I'll update you when I know more.
Friday, August 2, 2019
I debated a bit about the title to this post, thinking I should call it-outliving your ability to pay for long-term care. But I think the interesting point to this post is not that potential but what one state has done to fund public long-term care. Pew Stateline ran this story, Getting Older, Going Broke: Who’s Going to Pay for Long-Term Care? Here's what is going on.
Washington state created the first public long-term care insurance plan, which will be funded through payroll taxes.
In 2017, Hawaii began providing up to $70 a day to residents who work while also taking care of elderly family members at home. Hawaii pays for the program, Kupuna Caregivers, out of its general budget.
The state estimates 154,000 residents are the unpaid caregivers of elderly family members. Kupuna Caregivers currently helps 134 Hawaiians pay for transportation, adult day care, personal care services and home-delivered meals.
Another Hawaii program, Kupuna Care, provides services to seniors in need of help with daily activities. This year, lawmakers passed a series of elder care bills, adding $11.2 million to the $9.7 million appropriated in the state’s budget.
A handful of other states, including Arizona, California, Michigan and Minnesota, also are exploring public long-term care options for people who otherwise might have to spend down their assets to qualify for Medicaid.
The article also notes that one member of the U.S. Congress has proposed a Medicare long term care benefit (would this be Part F?)
Here's a little more about the various states' actions
Minnesota is considering two private-sector options to address the problem. One would be to require insurers’ supplemental Medicare policies to include limited home chore benefits. That approach would cost beneficiaries about $8 a month... [and the] other would be to allow the sale of term life insurance policies that convert to a long-term care product once the beneficiary reaches retirement age....
In October, Michigan officials will begin studying what the state can do to help residents pay for long-term care. Illinois lawmakers this year also ordered a study to calculate how many seniors are likely to need long-term care; the possible financial impact on their families; the availability of caregivers and the tax implications of a state-run long-term care program.
The Arizona Senate passed a bill in April that would create a pilot program providing grants of up to $1,000 a year to reimburse caregivers taking care of disabled family members at home. The program would be paid for out of a $1.5 million a year fund included in the state budget....
And in California, where the population over 65 is projected to nearly double to 8.6 million in the next decade, lawmakers recently approved a $1 million study to weigh the costs of different long-term care plans.
. . .
Washington’s new state-operated plan will pay lifetime benefits of up to $36,500 to help people pay for in-home care (provided by a professional or a family member), assisted living, or a nursing home. It will be funded through a payroll tax of 0.58% for all workers. (Self-employed people can opt in.) But the state won’t begin making payroll deductions until 2022, and benefits won’t kick in until 2025.
Not every state is on this bandwagon, however. "Last year, Maine voters overwhelmingly rejected a ballot initiative that would have raised income taxes by 3.8% to pay for a long-term care plan." Interesting stuff.
Tuesday, July 30, 2019
Have you ever used the Medicare Plan Finder? The GAO released a report a few days ago about it. Medicare Plan Finder: Usability Problems and Incomplete Information Create Challenges for Beneficiaries Comparing Coverage Options explains that the website isn't too user-friendly, with a redesign coming soon.
Medicare beneficiaries have many decisions to make when selecting their health and prescription drug coverage. Their choices affect their out-of-pocket costs and which providers they can see. The Medicare Plan Finder website is a primary source for comparing options.
Many officials who assist beneficiaries in selecting coverage—about three-quarters of those we surveyed—told us beneficiaries struggle with the website. They and others said it is difficult to navigate, contains complex terms, and lacks information needed to compare coverage options.
Medicare’s administrator plans to launch a redesigned website in August.
Here are the highlights from the GAO report:
The Medicare Plan Finder (MPF) website—a primary resource for comparing Medicare coverage options—is difficult for beneficiaries to use and provides incomplete information, according to stakeholders and research studies. These sources and directors of State Health Insurance Assistance Programs (SHIP) GAO surveyed—who assist beneficiaries with their Medicare coverage choices—reported that beneficiaries struggle with using MPF because it can be difficult to find information on the website and the information can be hard to understand. For example, MPF
requires navigation through multiple pages before displaying plan details,
lacks prominent instructions to help beneficiaries find information, and
contains complex terms that make it difficult for beneficiaries to understand information.
In response to GAO's survey, 73 percent of SHIP directors reported that beneficiaries experience difficulty finding information in MPF, while 18 percent reported that SHIP counselors experience difficulty.
Further, the results include "incomplete estimates of costs under original Medicare, making it difficult to compare original Medicare and Medicare Advantage (MA), the program's private heath plan alternative." Further, Medigap plan info isn't included in the results, with 75% "of the SHIP directors surveyed [reporting] that the lack of Medigap information in MPF limits the ability of beneficiaries to compare original Medicare to MA."
This is worrisome, given the emphasis on using the Medicare website for beneficiaries. So it will be important to examine the redesigned website to make sure it is more user-friendly, and contains complete and accurate info.
The full report is available here. Stay tuned.
Monday, July 15, 2019
According to a recent story published in Modern Healthcare, Nursing home staffing levels often fall below CMS expectationsfocuses on a new study that "[n]ursing home staffing levels are often lower than what facilities report, which could compromise care quality, new research shows....Self-reported direct staffing time per resident was higher than the CMS' payroll-based metrics 70% of the time, according to a new study published in Health Affairs. Staffing levels were significantly lower during the weekends, particularly for registered nurses."
We know the importance of staffing as a quality measure and ensuring quality of care, so this study is very important. "Researchers compared facility-reported staffing and resident census data and annual inspection survey dates from the Certification and Survey Provider Enhanced Reports to the CMS' long-term care facility Staffing Payroll-Based Journal from 2017 to 2018. The payroll-based data offered a more granular look, showing how staffing evolves over time rather than relying on static point-in-time estimates that were subject to reporting bias and rarely audited...."
When comparing for-profit SNFs with NFP SNFS, the researchers found the for-profits "more likely to report higher staffing numbers ... and [s]taffing levels increased before and during the times of the annual surveys and dropped off after."
The use of payroll data to determine staffing levels has only been in effect a little over a year. The story focuses specifically just on staffing levels. A log-in is required to access the study.
Wednesday, July 10, 2019
Ugh, this article in the Washington Post covers a serious and worrisome topic. Hospices go unpunished for reported maggots and uncontrolled pain, watchdog finds reports on a recently released HHS Office of Inspector General report, 2019: Vulnerabilities in Hospice Care.
The OIG report is actually two reports "which found that from 2012 through 2016, the majority of U.S. hospices that participated in Medicare had one or more deficiencies in the quality of care they provided to their patients. Some Medicare beneficiaries were seriously harmed when hospices provided poor care or failed to take action in cases of abuse. OIG made several recommendations in both reports to strengthen safeguards to protect Medicare hospice beneficiaries from harm and to ensure hospices are held accountable for deficiencies in their programs."
The first report, Hospice Deficiencies Pose Risks to Medicare Beneficiaries, 07-03-2019 | Report (OEI-02-17-00020), found that
[t]he most common types of deficiencies involve poor care planning, mismanagement of aide services, and inadequate assessments of beneficiaries. In addition to these, hospices had other deficiencies that also posed risks to beneficiaries. These failings-such as improperly vetting staff and inadequate quality control-can jeopardize beneficiaries' safety and lead to poor care. In addition, one-third of all hospices that provided care to Medicare beneficiaries had complaints filed against them. Over 300 hospices had at least one serious deficiency or at least one substantiated severe complaint in 2016, which we considered to be poor performers. These hospices represent 18 percent of all hospices surveyed nation-wide in 2016. Most poor performers had other deficiencies or substantiated complaints in the 5-year period. Some poor performers had a history of serious deficiencies.
The full report is available here.
[s]ome instances of harm resulted from hospices providing poor care to beneficiaries and some resulted from abuse by caregivers or others and the hospice failing to take action. These cases reveal vulnerabilities in CMS's efforts to prevent and address harm. These vulnerabilities include insufficient reporting requirements for hospices, limited reporting requirements for surveyors, and barriers that beneficiaries and caregivers face in making complaints. Also, these hospices did not face serious consequences for the harm described in this report. Specifically, surveyors did not always cite immediate jeopardy in cases of significant beneficiary harm and hospices' plans of correction are not designed to address underlying issues. In addition, CMS cannot impose penalties, other than termination, to hold hospices accountable for harming beneficiaries.
The second full report is available here. In addition there is a slide show available on YouTube, a one page flyer available here, a one-page graphic of the top issues available here, a flyer on beneficiary rights available here and more.
Tuesday, July 2, 2019
Last week Bloomberg Law ran a story about a new scam. Scammers Target Seniors With DNA Tests, Health Agency Says explains that the "free DNA test" is being sent to elders. "Companies offering the tests use the information gathered to steal identities or bill Medicare for unnecessary tests, the U.S. Department of Health and Human Services Office of Inspector General said in an agency fraud alert. The fraudsters are targeting victims through telemarketing, booths at public events and door-to-door visits." The fraud alert from HHS'Inspector General, Fraud Alert: Genetic Testing Scam offers these suggestions for elders:
If a genetic testing kit is mailed to you, don't accept it unless it was ordered by your physician. Refuse the delivery or return it to the sender. Keep a record of the sender's name and the date you returned the items.
Be suspicious of anyone who offers you free genetic testing and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.
A physician that you know and trust should approve any requests for genetic testing.
Medicare beneficiaries should be cautious of unsolicited requests for their Medicare numbers. If anyone other than your physician's office requests your Medicare information, do not provide it.
If you suspect Medicare fraud, contact the HHS OIG Hotline.Always remember that very little in life is free and if an offer sounds to good to be true, it isn't true.
Thursday, June 13, 2019
The Center for Medicare Advocacy (CMA-full disclosure, I'm on their board) has been litigating with CMS on the observation status issue. The latest litigation on the observation status, Alexander v. Azar, has a new opinion decided on June 4, 2019. On a motion for clarification and reconsideration filed by CMS, as well as a motion to seal, the Court in the June 4 order grants in part and denies in part the motion to seal and denies the motion for reconsideration and clarification.
Stay tuned. This case is going to trial in the fall!
Thursday, May 16, 2019
The New York Times ran an article recently that doesn't bode well for many elder Americans. Many Americans Will Need Long-Term Care. Most Won't be Able to Afford It reviews what is referred to as
the middle-class bind ... [where the elder has t]oo much money to qualify for Medicaid or subsidized housing, but not enough to pay for long-term care, an industry that has primarily pursued the well-off. ...
A recent analysis in Health Affairs, pointedly titled “The Forgotten Middle,” investigated how many middle-income seniors will be caught in that bind. The numbers were grim.
Using data from the national Health and Retirement Study, including personal income and assets and health status, the researchers defined the middle-income cohort as Americans from the 41st to the 80th percentile in terms of financial resources....
In 2029, for people 75 to 84 (ages when they’re likely to need long-term care), that would mean access to about $25,000 to $74,000 a year in current dollars. Over age 85, the middle-income category extends to $95,000.
The projection is that two-thirds are going to need some type of long-term care, yet "more than half will be unable to pay assisted living fees and medical costs in 2029, the study found." Even those owning a home aren't as house-rich as they may think. Plus this group has a lot of debt, and not that much in savings.
The United States, unlike many Western democracies, has never created a broad public program covering long-term care. Medicare pays for doctors, hospitals, drugs and short-term rehab after hospitalization — not for independent or assisted living.
That could change one day — imagine a new Medicare Part LTC — but “that will be incredibly difficult to achieve politically,” [said one expert].
Policy types instead suggest more incremental changes by both government and industry. Perhaps Medicaid could cover seniors with slightly higher incomes, or modify its regulations to include housing costs along with health care.
Monday, May 6, 2019
Kaiser Health News ran a story, Short-Staffed Nursing Homes See Drop In Medicare Ratings. "In its update in April to Nursing Home Compare, the Centers for Medicare & Medicaid Services gave its lowest star rating for staffing — one star on its five-star scale — to 1,638 homes. Most were downgraded because their payroll records reported no registered-nurse hours at all for four days or more, while the remainder failed to submit their payroll records or sent data that couldn’t be verified through an audit." The payroll records analyzed provide a good picture of various nursing homes and how they comply with the regulations. "CMS has been alarmed at the frequency of understaffing of registered nurses — the most highly trained category of nurses in a home — since the government last year began requiring homes to submit payroll records to verify staffing levels." In addition KHN has an interactive tool, Look-Up: How Nursing Home Staffing Fluctuates Nationwide.
Thursday, April 25, 2019
I hope you know by now that the SSA and Medicare Trustees have released their annual reports. The news is about what you would expect, if you follow the news on their annual reports. One might say that the SSA Trustees gave us good news this year. Social Security Combined Trust Funds Gain One Year Says Board of Trustees. Disability Fund Shows Strong Improvement—Twenty Years projects that the fund will "run out of money" after 2034, meaning we have gained a year. "Running out of money" means that starting in 2035, SSA will pay 80% of benefits, rather than 100%. For years, I've explained to students about the SSA Trust Fund and the Trustees Report. This year it dawned on me, when talking about the folks affected by the short fall, I'm part of those who will be affected. I'm no longer teaching something abstract. I know people, including myself and my colleagues, who will be in that group absent action by Congress. The SSA Trustees report is available here. With Medicare, the trustees really didn't have good news for us. Medicare Trustees Report shows Hospital Insurance Trust Fund will deplete in 7 years tells us "that the HI Trust Fund will be able to pay full benefits until 2026, the same as last year’s report." The Medicare Trustees report is available here.
Sunday, March 31, 2019
The Medicare Part D donut hole closed this year (yay) and although it may be gone, it's not forgotten.
Due to federal legislation, the donut hole is closed for brand-name drugs in 2019. This closure means that [that a beneficiary] will be responsible for 25% of the cost of ... brand-name drugs in this coverage period. Although the donut hole for brand-name drugs has closed, [the beneficiary] may still see a difference in cost between the initial coverage period and the donut hole. For example, if a drug’s total cost is $100 and [the beneficiary] pay[s] [the] plan’s $20 copay during the initial coverage period, [the beneficiary] will be responsible for paying $25 (25% of $100) during the coverage gap. The donut hole will close for generic drugs in 2020, at which point [a beneficiary] will be responsible for 25% of the cost of ... generic drugs.
Kaiser Health News last week ran a story about the demise of the donut hole and the out of pocket costs beneficiaries still face. Doughnut Hole Is Gone, But Medicare’s Uncapped Drug Costs Still Bite Into Budgets focuses on the need for an annual cap on out of pocket drug spending by telling the stories of some of those who have significant out of pocket costs even with the elimination of the donut hole. "Legislative changes have gradually closed the doughnut hole so that, this year, beneficiaries no longer face a coverage gap. In a standard Medicare drug plan, beneficiaries pay 25 percent of the price of their brand-name drugs until they reach $5,100 in out-of-pocket costs. Once patients reach that threshold, the catastrophic portion of their coverage kicks in and their obligation drops to 5 percent. But it never disappears."
Although none of the Medicare programs have caps on spending, the article illustrates that those enrolled in original Medicare can purchase Medigap policies, which do not extend to Part D prescription drug plans. There's a great chart in the article that compares the existing Part D program with proposed legislation which illustrates the effect of the recent proposal to cap the annual amount.
Stay tuned and stay healthy.
For those who read this Blog regularly, thank you. Especially as I have been leaving the bulk of recent postings to my wonderful blogging colleague and all-round elder law guru, Rebecca Morgan. Thank you most of all, Becky!
It is early morning on a Sunday as I type this. The Arizona sun is not quite above the eastern horizon. A calm morning after several days ... okay, I confess, weeks ... of small troubles. I had time to read The New York Times, and there it is once again, an article with a title and content that seem right on point for what I am pondering:
For the last several weeks, my sister and I have been struggling to understand how best to help our mother in the latest part of her journey with dementia. Recently she fell twice in single week, when rising before dawn and struggling to get dressed by herself. She did not need to be up so early, but in a lifetime of early rising, it is hard to change. Learning new routines, such as calling for help, is never easy, but especially so when memory and awareness are impaired by dementia. Her second fall resulted in what Mom had long feared most, a fear that will resonate for many people. She fractured her hip, as well as a few annoying ribs.
This put the three of us, my sister, my mother and me, squarely in the middle of doctor consultations, hospitals, rehabilitation centers, home care agencies and a search for alternatives for care. Do you have a mental image of Queen Elizabeth in London? Perhaps you have seen photos or news footage of her in recent weeks, walking with determination and carrying her purse, as she attends to her royal duties? Well, Queen Elizabeth and our mother are the same age and seem to have very similar abilities to persevere. We think of our mother as a slightly smaller version of the Queen, perhaps walking a bit slower although with equal commitment to the task, complete with her own favorite handbag. Or she was until the recent set of events.
At age 93, Mom sailed through surgery to stabilize her fractured hip, and even did pretty well during the first phase of recovery in the hospital. One small blessing for Mom is that she has no memory of the falls, no recollection of the surgery, and no memory of pain. Thus she's surprised when it "hurts" to try to stand, much less walk. Of course, both pain and understanding of what pain signifies, are important reminders of the need to take things slow.
We've done the hospital surgery stay "thing" before with Mom, and we've learned to treat such events as a marathon, rather than a sprint. We've learned, for example, that our mother's agitation after surgery makes IVs difficult and that any form of narcotic pain medication is likely to trigger days of vivid and disturbing hallucinations. For pain, fortunately tylenol is enough with Mom. We work hard to come up with a way for someone (usually my sister, until I can fly in) to be there each night, when we know hospital staffing levels can be low and call buttons may not be answered quickly. We know that without being there, when Mom does sometimes complain of pain, we will to need to remind the staff that tylenol is usually sufficient.
We try to rotate nights. My sister is a pro, and after weeks of my somewhat frantic naps on airplanes, I've become pretty good at falling into a wakeful sleep mode in an upright position. Staying overnight in a hospital is disorienting for the healthiest person and much more so for someone like my mother who cannot understand why this "hotel" has staff members that keep waking her up at night to take her temperature and hand her medication to swallow. I will be forever grateful to the nurse who, after my mother spit a full mouthful of water and the medicine back in her face, nonetheless returned promptly to help throughout the third shift, still offering smiles and kind words. The nurses who advocate for change in The New York Times article have it right -- "safe staffing levels" are one key to sound hospital care; only with adequate staffing can nurses be expected to keep working in such taxing circumstances.
The next decision was about where to go after the hospital. One option presented by the discharge planner was to go to a skilled nursing facility, a/k/a nursing home. We had previewed a wide range of places and we already had a list of possibilities. But we were pretty confident Mom could tolerate physical therapy, and therefore, after consultation, we opted for a facility that specialized in rehabilitation.
One complication: The rehab facility's admissions director said that they were not willing to take someone with dementia unless the family made sure there was 24/7 assistance during periods of confusion and, they emphasized, to keep her from wandering. With gratitude, we accepted a brochure offered by the admissions director for a local home care agency that they had worked with before. My sister, a true angel, and I, very much a mortal, knew we couldn't do this alone.
And thus began a strange variation on the "Bell Rings; Nobody Comes" theme of The New York Times article about hospital care.
The first yellow flag was when one of the line staff, a certified nursing assistant (CNA) at the rehab facility, who heard we were hiring companions from an agency, commented, "Well, okay, if you want to do that, but just so you know, these people don't do a darn thing. They won't lift a finger to help." I didn't know what to say; I think I said something like, "Well, let us know if there is a problem."
The "problem" emerged quickly. Companions from the home care agency said the rehab staff were not responding to call buttons when help was needed for our mother. The rehab staff were complaining that the companions didn't provide any help. I talked to an administrator at the rehab center. He assured me that their policy was for staff to respond promptly to call buttons and that he would remind the staff that a family member or hired companion was doing "the right thing" by using the call buttons to seek help.
But the reports continued, even as Mom began to recover more function, and thus actually needed more help in key tasks because she was more mobile. Different companions and even friends reported that the CNAs at the rehab center would, for example, help our mother to the bathroom toilet, but then would refuse to stay until she finished. Some reported the CNA turning to the agency's companion and saying with disdain, "You should handle it from here."
I tried talking again with Rehab's administrators, this time the director of nursing. She was also quick to reassure me that we were not wrong to ask the rehab staff to assist our mother in the bathroom and to remain with her till she finished, as our mother was still unable to rise on her own and also could not or would not use the pull cord. She thought the most recent report was about one new rehab employee, who may not yet understand his or her role.
But the reports continued. One report came from a friend visiting Mom. She noticed buzzers ringing endlessly on Mom's floor, even when available staff were chatting nearby. I tried talking with the management staff again. At one point, the home care agency actually swooped in and removed a companion we hired to help our mother, after the rehab center complained to them that the companion was complaining "too loudly" about the rehab staffing and lack of coordination with staff. In response to the turmoil my sister ended up taking another night shift in rehab (after a long-day as an administrator for a charter school). I started planning another flight to Arizona.
I slowly began to realize that this was not a problem that could be "fixed" with polite requests or even more directly-worded complaints about staffing roles. I learned:
- The direct care workers at the rehab center felt seriously over-worked and under-appreciated;
- The rehab center was often short-staffed, especially when employees called off on short notice;
- The direct care workers resented the agency's companions "doing nothing" when an extra pair of hands, any hands, would have made their work easier;
- There was tension between the direct care workers, most of them CNAs, and the cehab Center's other "higher" staff, including nurses and shift supervisors;
- Family members of other patients were also concerned and confused about what to do about unevenness of care. They weren't required to have a companion as their loved one did not have the dreaded "dementia." But their need for prompt assistance for loved ones recovering from car accidents, strokes, or major surgery was just as great.
A family member of another patient in rehab commented to me, "This is a broken system." At first I thought she meant the Rehab Center. But she clarified. "This is just one part of a broken care system." She meant that all of care is a broken system.
March 31, 2019 in Cognitive Impairment, Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Games, Health Care/Long Term Care, Medicare, State Statutes/Regulations | Permalink | Comments (1)
Thursday, March 7, 2019
The New York Times ran a story that notes that nursing homes are closing in rural America, leaving residents with few options. Nursing Homes are Closing Across Rural American, Scattering Residents highlights the dilemma for many in rural areas when the local nursing home closes. "More than 440 rural nursing homes have closed or merged over the last decade ... and each closure scattered patients like seeds in the wind. Instead of finding new care in their homes and communities, many end up at different nursing homes far from their families. ... In remote communities ... there are few choices for an aging population. Home health aides can be scarce and unaffordable to hire around the clock. The few senior-citizen apartments have waiting lists. Adult children have long since moved away to bigger cities." Think about the implications when the facility closes and there isn't another one near by. Not only might the resident suffer from transfer trauma, there are other implications. As the article notes, with distance comes the lack of ability for frequent visits, the time spent traveling to the new SNF, the inability to get to the new SNF quickly if a need arises and the vagaries of Mother Nature who may heap bad weather on the area, making it unsafe to travel. There are various reasons why nursing homes in rural communities are closing, including financial instability, Medicaid reimbursement rates, failure to meet the minimum health and safety standards and even the inability to hire staff.
Tuesday, February 19, 2019
Kaiser Health News ran a story recently, Seniors Aging In Place Turn To Devices And Helpers, But Unmet Needs Are Common details the use of caregivers and assistive devices to help them age in place. Reporting on a new study, the article notes that there are a substantial majority of elders with insufficient help and adapt their living in order to get by. The study, published in the Commonwealth Fund, Are Older Americans Getting the Long-Term Services and Supports They Need? explains this issue "[o]lder adults’ needs have evolved and are no longer met by the Medicare program. With the recent passage of the Bipartisan Budget Act of 2018 (BBA), Medicare Advantage (MA) plans can now provide beneficiaries with nonmedical benefits, such as long-term services and supports (LTSS), which Medicare does not cover."
The key findings and the conclusion from the study abstract show:
Two-thirds of older adults living in the community use some degree of LTSS. Reliance on assistive devices and environmental modifications is high; however many adults, particularly dual-eligible beneficiaries, experience adverse consequences of not receiving care. Although the recent policy change allowing MA plans to offer LTSS benefits is an important step toward meeting the medical and nonmedical needs of Medicare beneficiaries, only the one-third of Medicare beneficiaries enrolled in MA plans stand to benefit. Accountable care organizations operating in traditional Medicare also should have the increased flexibility to provide nonmedical services. from the study.