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Vol. 17, No. 8
September 7, 2017
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Two Healthcare Deadlines Loom
With the Senate Health, Education, Labor and Pensions committee hearings, aimed at stabilizing the Obamacare marketplace, unfolding in the early weeks of September, two deadlines loom. September 27 is the deadline for insurers’ final decisions on whether to offer plans in 2018. The most important element remains the availability of low income premium subsidies that the Trump Administration has thus far approved on a tenuous month-to-month basis while threatening to stop them altogether. The Administration also
signaled its continued opposition to Obamacare implementation by announcing a major cut in funding for advertising and promotion for ACA enrollment. The move was met by strong criticism in a
letter from ranking Democratic members of the five House and Senate committees with health care reform jurisdiction.
Meanwhile a deadline of a different sort has been set by the Senate parliamentarian who has now
ruled that Congressional use of the reconciliation process to pass a repeal bill with just 51 votes will expire September 30, thereby significantly reducing the opportunity for Republicans alone to enact renewed ACA repeal legislation.
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Bi-Partisan Options from Senate and Governors
August saw no shortage of ideas for moving beyond the polar extremes of the “repeal and/or replace” debates of the first six months of this year. For their part the Senate HELP committee’s chairman, Lamar Alexander (R-TN) and ranking member Patty Murray (D-WA) have been
working towards a minimum one year subsidy stabilization bill that would include additional state plan waiver options. From a bipartisan group of
governors from eight states came a set of proposals in late August designed to provide “1) immediate federal action to stabilize markets, 2) responsible reforms that preserve recent coverage gains and control costs, and 3) an active federal state partnership that is based on innovation and a shared commitment to improve overall health system performance. Just as these proposals have brought together governors from across the political spectrum, we are confident they can attract support across party lines in both chambers of Congress.”
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Republican Senators Cassidy and Graham Offer Proposal Similar to Repeal Bills
A
conservative alternative being crafted by Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) most closely tracks the goals and approaches of the heretofore rejected repeal bills. As described by the critical Center on Budget and Policy Priorities, the plan “would eliminate the ACA’s marketplace subsidies and enhanced matching rate for Medicaid expansion, replacing them with an inadequate block grant whose funding would shrink further over time (compared to current spending levels) and then disappear altogether after 2026. The plan would also convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per beneficiary funding for seniors, people with disabilities, and families with children. Finally it would allow states to waive ACA provisions that prohibit health insurance plans from placing annual or lifetime limits on coverage and require them to cover key services.”
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Minnesota Stabilizes Health Insurance Market
In the midst of the churning activity in Washington, New York Times reporter Robert Pear
examined one state’s apparently successful effort to stabilize its health insurance market through the mechanism of a reinsurance system. In Minnesota, Pear writes, “rate increases requested for 2018 are relatively modest, thanks in part to a new program under which the state will help pay the largest claims. State officials and insurers say that, as a result of the program, premiums next year will be about 20% lower than they would otherwise have been. The program—for which Minnesota has budgeted about $270 million in each of the next two years—potentially benefits all of the 160,000 people buying insurance on their own, not just those with large claims.”
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New CMS Web Page Clarifies Standard for Medicare Skilled Level Coverage per Jimmo Settlement
A long-running struggle by long-term term care advocates has finally culminated in a CMS
announcement of a new web page implementing a court
decision (Jimmo v. Sebelius) that requires recognition of a “maintenance” standard for determining Medicare skilled level coverage. As described in a
press release from the Center for Medicare Advocacy, the web page makes clear to patients, families, and providers that “Medicare
does cover skilled nursing and skill 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.
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Hospital ‘Observation Status’ Decision Will Be Challenged as a Class Action
In another important legal development, the US District Court in Connecticut has permitted class action status in a case challenging the inability of patients to contest hospital “observation status” decisions that can substantially increase their charges and prevent any coverage of post-hospital skilled care. As
described by co-counsel for the plaintiffs, the Center for Medicare Advocacy, “84-year-old Nancy Niemi of North Carolina was hospitalized for 39 days earlier this year after her doctor sent her to the emergency room. It took weeks to stabilize her blood pressure and she experienced serious complications. But unbelievably, Ms. Niemi was characterized as an outpatient on ‘observation status’ for her entire hospitalization, and she therefore lacked the three-day inpatient stay Medicare requires for coverage of her subsequent, very expensive care in a nursing home. Ms. Niemi’s son tried to help her challenge her lengthy placement on observation status, but Medicare does not allow beneficiaries to appeal this issue. She still owes thousands of dollars to the nursing facility. However, due to the federal court decision, she is now a member of a nationwide class of hospital patients who may gain the right to appeal their placement on observation status.”
The “observation status” problem is underscored in a new
study that concludes that “poor or nearly poor Medicare beneficiaries may be at risk for high out-of-pocket expenses related to observation care. Current Medicare cost-sharing policies related to observation care place disproportionate financial burden on low income beneficiaries.”
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Preliminary ‘Alert’ Finds Problems in Reporting Abuse of Medicare Beneficiaries in SNFs
Skilled nursing facility quality of care came under very critical scrutiny in a
preliminary “alert” from HHS’s Office of Inspector General finding substantial deficiencies in the reporting of possible abuse and neglect of Medicare beneficiaries. “We identified 134 Medicare beneficiaries whose injuries may have been the result of potential abuse or neglect that occurred from January 1, 2015 through December 31, 2016. We also found that a significant percentage of these incidents may not have been reported to law enforcement. As a result, we determined that CMS has inadequate procedures to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are identified and reported.”
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‘Special Focus’ SNFs Fail to Correct Care Issues
Meanwhile, adding to the concerns expressed by the OIG, Kaiser Health News’ Jordan Rau
exposed the failure of “special focus” SNFs to correct serious quality problems. “While ‘special focus’ status is one of the federal government’s strictest forms of oversight,” Rau reports, “nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care. Kaiser Health News’ analysis of federal health inspection data indicates that of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half–52%–have since harmed patients or put patients in serious jeopardy within the past three years. These nursing homes were in 46 states. Some gave patients the wrong medications, failed to protect them from violent or bullying residents and staff members, or neglected to tell families or physicians about injuries, inspection records show. Years after regulators conferred clean bills of health, levels of registered nurses tend to remain lower than in other facilities. Yet despite recurrences of patient harm, nursing homes are rarely denied Medicare and Medicaid reimbursement.”
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Trump Administration Proposal to Curtail Mandatory Bundled Payments
Mandatory bundled payments for joint replacements and cardiac treatments, heralded by President Obama’s CMS officials as a Medicare cost saving measure, will be substantially curtailed by the Trump Administration according to an August
proposed regulation. The complex proposal invites comments through October 17.
One family’s very distressing experience with a partial hip replacement bundled payment episode is narrated in a blog post referenced in the Media Watch section (last entry).
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‘Iowa Stopgap Measure’ and Other Medicaid Waiver Proposals Raise Concerns
Medicaid state waiver applications are receiving much attention in the wake of HHS Secretary Tom Price’s expression of receptivity earlier this year. Iowa offers the latest example of such an application with, in the words of
Modern Healthcare’s Harris Meyer, its “sweeping new proposal to revamp its individual insurance market and abolish its federal exchange. The state’s plan—called the Iowa Stopgap Measure—was submitted to HHS and the US Treasury Department under section 1332 of the Affordable Care Act. Under Iowa’s state innovation waiver request, residents would receive premium subsidies based on broad age and income categories, without using ACA’s calculation to cap premium cost at a certain percentage of a person’s income. The state revenue department would determine a person’s eligibility and level of subsidy, rather than having that determination made by the federal exchange. But outside experts,” Meyer continues, “say eliminating cost-sharing reductions would make health care unaffordable for lower income people, who would face a $7,350 per-person deductible under the Iowa waiver proposal. The state’s proposed standard plan also would charge copayments for various services—such as $400 for advanced imaging and $10 to $300 for prescription drugs—though it would not charge any coinsurance percentage.”
ACA expert, Prof. Timothy S Jost, in an extensive
Health Affairs analysis of Iowa’s proposal, cautions that it “raises a number of concerns” and is “a watershed moment.” “The ACA specifically requires that a 1332 waiver ‘ensure cost-sharing protections against excessive out-of-pocket spending that are at least as affordable’ as under the ACA. Clearly, cost-sharing would dramatically increase for Iowans who now qualify for cost-sharing reductions. Individuals who now face deductibles of a few hundred dollars—or perhaps not at all—would face deductibles of thousands of dollars.”
Taking a broader look at proposed Medicaid waivers, the
Center on Budget and Policy Priorities argues that in the main they contain “damaging” elements that would undermine Medicaid’s mission and objectives. “These include requests to condition Medicaid eligibility at work and work-related activities or drug screening and testing, impose premiums on people with incomes below the poverty line, limit how long people can remain enrolled in Medicaid coverage, and lock people out of coverage if they don’t submit renewal paperwork on time or don’t report changes in employment or income within 10 days. If approved, these proposals would substantially reduce coverage and impose significant barriers to care. Approval would sharply depart from the historical role of waivers in promoting Medicaid’s objectives.”
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Hospitals Lack Quality of Care Data on Post-Acute Care
Patients and family caregivers face very stressful decisions as hospital stays near transition to post-acute care; but a new
study finds that quality of care data about skilled nursing facilities is almost never offered by the discharging hospital. “Despite the fact that hospitals are now held more accountable for the care that patients receive in the post-acute care setting, concerns about the (federally mandated) principle of patient choice paradoxically may undermine hospitals ability to respond to that accountability. A system based on quality reporting and competition for patients cannot succeed if patients do not have the data necessary to make an informed choice. Hospitals should provide the data and help patients and their families understand them.”
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ER Visits Shown Mostly to Be Unavoidable
Questioning conventional wisdom, emergency medicine researchers have
concluded that only 3.3% of all visits to emergency departments should be classified as “avoidable” — visits where patients do not require any diagnostic or screening services, procedures, or medications, and were discharged home. Study findings showed that among such purported visits; patients were most commonly discharged with alcohol- mood- or dental-related conditions. “Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” said physician Becky Parker, president of the American College of Emergency Physicians. “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that — myths.”
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Cost Burden of Dementia Diagnosis Substantially Higher Than Someone Without
The substantial cost burden of dementia compared to the cost of caring for someone without dementia is examined in a
study that evaluates the effect of reducing functional decline on behavioral and psychological symptoms by 10% for 12 months. “From time of diagnosis,” the authors report, “costs for a person with dementia over a lifetime were $184,500 greater than for someone without dementia.
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Guide to ACA-Related State Medicaid Expansion Waivers
The Kaiser Family Foundation has
published a comprehensive guide to ACA-related state Medicaid expansion waivers under section 1115 of the Social Security Act. Kaiser’s issue brief provides details of seven approved waivers – Arizona, Arkansas, Indiana, Iowa, Michigan, Montana, and New Hampshire – and three pending ones –Arkansas, Kentucky, and Indiana. “While each (approved) expansion waiver is unique, they include some common provisions, such as implementing the Medicaid expansion through a premium assistance model; charging premiums beyond is authorized in federal laws; eliminating non-emergency medical transportation, an otherwise required benefit; and using health and behavior incentives to reduce premiums and copayments.”
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State Variations in High Need Adult Populations
Another comprehensive
report — focusing on state variation in high need adult populations — emanates from the Commonwealth Fund. “The size of high need populations — those with multiple chronic conditions and functional limitations — differs across states,” accounting for 8% or less of adults in Alaska, Colorado, Hawaii, Minnesota, and Utah, but 20% of adults in West Virginia. In all states, high need adults are far more likely to have health insurance and a usual source of care than other adults. Nonetheless, high need adults face significant barriers accessing needed care in many states. In Alabama, Georgia, Idaho, North Carolina, and South Carolina, for example, 40% or more of high need adults reported not seeing a doctor when needed or not filling a prescription because of costs. Wide variation in states’ performance suggests there may be opportunities to learn from states that more comprehensively meet needs for sicker individuals.”
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National Institute of Nursing Research ‘The Science of Caregiving: Bringing Voices Together’ Summit
In early August the National Institute of Nursing Research convened a national conference, The Science of Caregiving: Bringing Voices Together Summit. The event gathered scientists, caregivers, providers,and healthcare professionals to learn about the issues and challenges facing caregivers and related science. Keynoting the “Summit” was PBS NewsHour’s Anchor and Managing Editor Judy Woodruff, who delivered a moving, personal account of her family’s difficult experiences caring for a disabled, albeit thriving, son. FCA Executive Director Kathleen Kelly moderated Plenary Session 2, Creating Change in Caregiving: Research to Policy. The entire program is available for
viewing online
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Aid-in-Dying (AID) Laws: An Overview and Analysis
Writing in the American Bar Association’s Health eResource, attorney Pamela S. Kaufmann offers a detailed overview and analysis of aid-in-dying (AID) laws now enacted in seven states. “The AID movement has gained enormous momentum, and it is reasonable to expect that AID laws will be enacted in several more states in the next decade. The state statutes are modeled after Oregon’s, the first such law. As a result, they are the same in all key respects. The California act, for example, allows terminally ill state residents who leap through various procedural hoops to take AID drugs to expedite their death. Commentators have observed that pursuing death under this law requires time and patience. The law’s emphasis on process reflects the delicate balancing of the rights of all affected parties. It is also designed to prevent impulsive action, duress, or abuse.”
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National Center on Law and Elder Rights
The National Center on Law and Elder Rights is a newly established
Internet resource providing free case consultation assistance for attorneys and other professionals seeking more information to help older adults. The Center also offers a national web-based legal training curriculum on topics ranging from health and long term services to advance planning, elder abuse, and consumer protection, with relevant materials available for download.
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Caregiving Is a Lonely Business
Caregiving is Hard Enough. Isolation Can Make It Unbearable is the title of a New York Times
article by aging issues contributor Paula Span. “Caregiving is done with a lot of love and affection, but there’s a lot of loss involved,” Span quotes gerontologist Carey Wexler Sherman. “People talk about friends disappearing, about even family members not wanting to be involved. It’s a lonely business.” Sometimes, Span continues, caregivers isolate themselves, citing geriatric social worker Barbara Moscowitz’s comment that clients lament that, with a loved one whose dementia related behavior can be startling, venturing out in public creates more apprehension than pleasure. In the words of Marcy Sherman-Lewis, wife of an Alzheimer’s patient, “don’t invite me for lunch—you know I can’t go, just bring pizza and a bottle of wine and come by.”
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Doctor-Patient Recordings and Audio Files
In a second August New York Times
article
, Span turns to a practice that may be coming to more and more physician offices: recording and securely posting audio files of a doctor-patient encounter. “It’s not a crazy idea, especially for older patients who typically contend with several health conditions, so they visit more doctors more often and take more drugs. They may also have hearing loss and research shows that they struggle more than younger patients to recall information from doctors’ visits. “Often when older patients want to tell a faraway relative what the doctor said, they struggle and fail because complex language was used and they don’t have a record,” according to Dartmouth researcher Dr. Glyn Elwyn. Span goes on to report that the University of Texas Medical Branch at Galveston has gone so far as to buy recorders and batteries in bulk, offering them to patients at cancer clinics. And at the Barrow Neurological Institute in Phoenix, neurosurgeon Dr. Randall Porter, prefers video. Without recordings, Porter states, “patients forget 80% of what we say by the time they hit the parking lot. He understands why that might be: He’s often talking about cutting open their skulls, an emotionally laden subject.”
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Increased Training and Improved Working Conditions for Home Health Aides Could Save Billions
Eduardo Porter, also taking to the pages of the New York Times, makes a strong
plea for improving the working conditions of the thousands of home health aides, personal care attendants and certified nursing assistants who provide long-term care for a fast aging population. “Home care is absolutely the bottom rung of the ladder, but home care workers are the people that spend the most time with the client,” according to Adria Powell, who runs Cooperative Home Care Associates in New York. Porter points to a new book by MIT professor Paul Osterman—Who Will Care For Us—that argues that despite a number of deep-rooted obstacles, shortchanging long-term care is shortsighted. Home health aides trained to do more—to spot patients’ health problems, to keep track of the pills and doctors’ appointments, and to offer advice on healthy living—could wring billions of dollars in savings from the healthcare system.
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Limited Information on Post-Acute Care Choices
In a Health Affairs
blog post
, Brian E. McGarry and David Grabowski address the shortcomings in available information to assist caregivers in making more informed post-acute care choices. “Anyone who has ever had to make such decisions or assisted a loved one in choosing a post-acute provider has likely asked the question: why is it so hard? Some of this difficulty reflects the fact that it is a challenging process. A lot is at stake at the time of hospital discharge, and there are typically numerous options, spanning a variety of care settings. The decision often needs to be made quickly with little time to collect quality information or visit potential providers.” The authors focus particular attention on CMS’s Nursing Home and Home Health Compare tools on Medicare.gov. “Although these online report cards were designed to facilitate easy comparisons across providers on meaningful characteristics, evidence suggests that they are coming up short. The shortcomings are likely exacerbated for post-acute patients due to several design and dissemination issues, particularly with the Nursing Home Compare tool.”
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Innovations in Care for ‘High-Need’ Patients
Peter Long,
expanding on recently published policy recommendations regarding care for “high need” patients—the small cohort of patients with complex needs who represent the greatest usage of the healthcare system—offers an approving look at a comprehensive undertaking in Denver, Colorado, that “relies on specialized intensive outpatient clinics to serve as adult patients’ medical homes or multidisciplinary special needs clinics for high risk pediatric patients. These innovations not only improved patient outcomes and patient and provider satisfaction, but also resulted in reductions in expected spending. Denver Health’s success demonstrates the real potential of strategic models to improve care for patients while curbing healthcare spending.”
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Medicare’s Joint Repair Bundled Payment Program Critique
“Bundling” can have several connotations, from getting warm in the winter to amassing political contributions. For
Timothy Hoff
, however, who experienced Medicare’s joint repair bundled payment program when his 90-year-old mother suffered a hip fracture, the term came to mean simply “encouraging hospitals to move joint replacement patients quickly to somewhere else. What my siblings and I saw it made me feel as if the ‘bundle’ in which she had been captured was working against and not for her. A 90-year-old with dementia is a unique patient with special circumstances. Yet my siblings and I were told initially that on average participation in the bundled program meant five days of Medicare-Part A covered rehabilitation for a partial hip replacement. ‘You know your mother is part of a care bundle,’ a nurse on my mother’s floor mentioned to me one day. These bundles may sound great on paper but not from my perspective. Instead of paying full attention to my mother and her feelings, my siblings and I had to be hypervigilant agitators within the health care system—a system that listened to us best when we took a adversarial posture. This is not the fulfillment of the patient-centered care goal that CMS so desires. It’s far from it.”
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FAMILY CAREGIVER ALLIANCE ANNOUNCEMENTS
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Apply Now for the 2017 Rosalinde Gilbert Caregiving Legacy Awards
Family Caregiver Alliance is seeking innovative Alzheimer’s/dementia programs that support caregiving for awards of $20,000 each. The Caregiving Legacy Awards are possible thanks to the generous and continuing support of The Rosalinde and Arthur Gilbert Foundation. The Caregiving Legacy Award categories include: Creative Expression, Diverse/Multicultural Communities, and Policy and Advocacy. This is an award (not a grant) for existing programs.
For more information and to view the online application, visit
caregiver.org/gilbert-awards. The application deadline is Monday September 11, 2017, 5 p.m. (Pacific Time).
*
Previous applicants are encouraged to apply again.
* Yes, there will be a deadline extension announced early next week.
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FCA/NCC RESEARCH REGISTRY
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CREDITS
Contributing to Caregiving Policy Digest are Alan K. Kaplan, attorney and health policy consultant, Kathleen Kelly, and Francesca Pera (editing and layout).
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