Recently in nursing homes Category

Money Follows the Person is a cornerstone of the federal government's effort to move Medicaid beneficiaries from nursing homes into the community. But a new study commissioned by Medicaid itself shows how difficult those transitions can be. In the 30 states that have been testing the program over the past three years, only 8,500 people have used MFP to return to their communities.

That's just a tiny fraction of the nearly 1 million people who are eligible, and only about one-quarter of the 35,000 the participating states initially hoped to move. And of the 8,500 who have enrolled in the program, one-third lived in just one state--Texas. By contrast, California has signed up only 186 people since MFP began, and New York only 165, according to the study done by Mathematica Policy Research Inc.  

The concept makes great sense. Move people out of nursing homes, where most don't want to live and where the costs to Medicaid are extremely high, and help them get back to their homes or other community residences. Unfortunately, states have struggled to turn this concept into reality.     

Most troubling for the frail elderly, it turns out that while three out of every four people eligible for the program are age 65 or older, only one-quarter of participants are seniors. Money Follows the Person has been far more successful for younger adults with physical and developmental disabilities than for the frail elderly. 

Mathematica identified several reasons why so few frail elders participate. The biggest may be that they have no home to return to. In the original design, MFP participants had to have been nursing home residents for at least six months. Because many elderly people sold their homes or given up their apartments when they moved into a nursing facility, it was not possible for them to return to their communities. In addition, in many states participants were not allowed to move into assisted living facilities.

Just as troubling, many states don't have enough subsidized rental housing or funding for necessary home and community based services, such as personal aides or transportation. Unfortunately, the growing wave of state budget cuts is likely to make that problem even worse.  

Still, there is some good news. The 2010 health reform law (the Affordable Care Act) allows people to use the program after only 90 days in a nursing facility, instead of six months. That will make another 112,000 people eligible to participate. The health law also promised an additional $1.75 billion in funding, gives states new flexibility in providing community-based services, and continued MFP experiment until 2014.

Long-term care experts and top government officials have had high hopes for Money Follows the Person. They see it as key to helping both the frail elderly and younger people with disabilities receive the supports and services they need at home and not in nursing facilities. But as the Mathematica study suggests, MFP has so far fallen far short of those expectations.   

Powerful Republicans are pushing the twin ideas of capping the federal contribution to Medicaid and eliminating federal regulation of the program. These changes would do profound damage to the Medicaid benefit for long-term care, whether it is provided at home or in nursing facilites.

This plan would turn Medicaid from a federal entitlement into a block grant. Over time, states would be responsible for paying a growing share of the program costs but in exchange would have broad flexibility over who to cover and what benefits they'd receive. In such an environment, chances are good that fewer aged and disabled would be eligible for benefits and they'd receive less assistance than they do today. At the same time, providers such as nursing homes and home health agencies would likely get lower Medicaid payments even though the program reimbursements are already at dangerously low levels.  

Today, the federal government pays about 57 percent of Medicaid costs (the actual amount varies from state to state and ranges from 50 percent to about 80 percent). While the elderly and disabled account for only 25 percent of the 50 million Medicaid enrollees, the program spends two out of every three of its dollars on this population. More than one-third of the total Medicaid budget, or $125 billion, went to long-term care supports and services alone in 2009, according to a new study by the Kaiser Family Foundation.

Under the current arrangement, the federal government pays its share no matter how quickly Medicaid costs rise. Thus, because Medicaid rose by 7.7 percent in 2009 (mostly because the recession drove many newly-unemployed into the program), the federal contribution increased to keep up. In fact, Washington's share actually grew even more thanks to the much-reviled 2009 stimulus law.

By contrast, under a block grant the federal share would increase only up to a cap, say equal to the growth rate of the economy plus one percent. In 2009, this would have resulted in no increase in federal payments for the program. As a result, states would have had to scale back their Medicaid programs, including their long-term care services.

Over time, the federal contribution would fall significantly, leaving the states with more and more responsibility for the program and less and less assistance to pay the bills. Governors who support a block grant insist it would drive greater efficiencies.And it might, for instance, make it easier for states to expand their home and community based long-term care programs. 

But it is also likely to generate major cuts in both benefits and reimbursements. In addition, without minimum federal standards, the differences among state long-term care benefits, already dramatic, would only grow.As a result, residents of one state may receive much better long-term care than residents of a neighboring jurisdiction.  

Despite these risks, GOP governors came to Cngress today to demand the changes. Mississippi Governor Haley Barbour, who is mulling a presidential bid--told a congressional committee that states should not have to "kow-tow" to the federal government and insisted the program be turned into a block grant. Mississippi, as it happens, recieves a greater federal Medicaid payment than any other state.

Even more troubling, these Medicaid cuts would come on top of what are likely to be freezes or cuts in non-Medicaid benefits for the frail elderly, such as nutrition, energy assistance,and housing.  

My guess is that much of this call for a Medicaid block grant is political posturing. It is hard to believe that many governors would turn their backs on hundreds of billions of dollars in federal aid at a time when they are struggling to balance thier budgets. I suspect what Barbour and his colleagues really want is the money with less regulation. But given federal budget pressures, their GOP friends on Capitol Hill may give them both.        

As Medicaid budget pressures grow, more states are turning long-term care over to private managed care companies. USA Today reports that six states now require both frail elderly and younger adults with disabilities to enroll in insurance-run Medicaid managed care plans. Another 10 states are planning to either create or expand these programs, according to the story.

The reason, of course: money. States pay the insurance plans a fixed amount to care for these patients. And the private insurers say they can provide quality care for less cost through their use of care coordinators and by keeping many people at home. 

Tennessee, for instance, pays private insurers an average of $4,400 per patient per month to provide Medicaid long-term care services. Under this system, if the insurer can provide care for less, it makes a profit. If its costs are higher, the insurer is at risk for the difference. This is a big incentive to create a care plan built around home care, which for many beneficiaries can be far less costly than a skilled nursing facility.

USA Today reported that one Tennessee insurer, Amerigroup, spent about $3,000 per month to care for one patient at home. The cost for this patient in a nursing facility would have been almost $4,600 per month and a money-loser for the insurer.     

Medicaid managed care isn't new. States have been using it for acute care beneficiaires (mostly low income mothers and kids) for years. But long-term care patients are a very different challenge.

One one hand, more than any other population, the frail elderly need to have their care coordinated. They have complex medical needs, often suffer from multiple chronic diseases, and frequently take many medications. If a mix of care managers, personal assistance, nursing, and other services and supports can help them get the care they need at home for less money, that is great.

This flat fee, or capitated, payment model works well with programs such as hospice and PACE, for instance.   

On the other hand, many insurance companies badly damaged their reputations in the 1980s and '90s with managed care plans that seemed more intent on maximizing profits than care. It will be important to put protections in place to be sure that the frail elderly, who are often unable to advocate for themselves, are getting the care they require.

The other problem with Medicaid managed care is that these beneficiaries often receive their physician and hospital care through Medicare, not Medicaid. Because these two programs are so poorly coordinated, seniors who transition from, say, home to hospital to rehab and back to home may not get proper care as they cross settings.

This lack of coordination between Medicare and Medicaid also creates some perverse and dangerous incentives. If, for instance, a Mediciad managed care patient winds up in the hospital as a result of poor care, neither Medicaid nor the managed care firm is on the hook. The bill, instead, is paid by Medicare.

If managed care is going to work well, there will have to be much closer delivery and financial relationships between these two payers, as there is with successful programs such as PACE or through provider-based managed care mechanisms such as Accountable Care Organizations.           

The news for critical long-term care services and supports provided by the states--either through Medicaid or other funding--keeps getting worse. The toxic combination of a still-slow economy, huge structural budget pressures on all levels of government, and growing demands for aging and disability services is leading to ongoing cuts in both critical benefits to individuals and payments to providers.

The latest evidence comes from two new reports. Following an extensive survey of state officials, AARP reports that 31 states cut their non-Medicaid long-term care services programs in Fiscal Year 2010 and at least 28 expect to slash them in the coming budget year. These essential programs include home-delivered meals, transportation, adult day care, housing, and foster care.

At the same time, a report by the American Health Care Association--which represents mostly for-profit nursing homes-- concludes that skilled nursing facilites are losing increasing amounts of money on their Medicaid long-term care beds. It concludes that nursing facilities are paid $17 per day less for long-term care than it costs them to provide these services. It is easy to criticize these results as self-serving, but the general trend is hard to dispute. And it could result in dramatic cuts in these long-term care resources. While this may not be a short-term problem in communities with an oversupply of nursing homes, this trend may already be curbing services in low-income areas. 

The AARP study reported that only a handful of states cut Medicaid benefits last year, but that was because the federal government, as part of its stimulus effort, increased its share of program payments. In addition, states that took the extra federal money were barred from cutting Medicaid benefits--although they could trim or freeze provider payments. Normally, the federal government pays about 60 percent of the cost of Medicaid while the states pay the rest (the amount varies from state to state).

However, this additional federal Medicaid funding is already winding down, and will disappear completely on July 1. Even more troubling, AARP found many states built the higher federal payments into this year's budgets, a decison that will force even deeper cuts in state programs as those dollars dry up. Just this week, lawmakers in Texas and Ohio proposed major cuts in Medicaid.  

AARP also asked state officials whether they intended to pursue additional federal funding for home and community based services that's been promised under the 2010 health reform law. Despite their serious financial shortfalls and the growing interest among policy analysts and advocates in expanding community services, state officials were remarkably cautious about whether they'd embrace these initiatives.

I'll have more to say about these studies soon, but they are both worth reading.       

In the decade between 1999 and 2008, almost 3,000 nursing homes closed while the number of skilled nursing facility beds shrunk by nearly 100,000, or about 5 percent, according to a new study in the Archives of Internal Medicine. In a nation with more nursing homes than McDonald's, and at a time when long-term care can be provided in other settings, that may not be a bad thing. These days, many frail elderly receive care at home or in assisted living facilities, settings they often prefer to skilled nursing facilities.

But the Archives study by Zhanlian Feng and coauthors also raised some serious concerns. The report concluded that many of these closures occured in minority and low-income communities, the same areas where other care alternatives may be unavailable.

Other studies have shown that relatively few assisted living facilities--which are overwhelmingly private pay--are located in these neighborhoods. In addition, while data are scarce, it appears that many low-income and minority serniors may have limited access to high-quality home care. In other words, for one segment of the population, good care may increasingly be unavailable. 

A study published last year in Health Affairs, David Stevenson and David Grabowski of the Harvard Medical School found that larger assisted living facilities (those with 25 beds or more) were far more likely to be located in higher income counties than in poor jurisdictions. 

As a result, low-income seniors who are unable to live at home--perhaps because there may be no one to care for them or because their home may not be suitable for someone with disabilities--have very few options. Many may move to small board-and-care homes--often a room they rent in a local home where assistance is provided by an unlicensed caregiver. Others may get no care at all.  

From the perspctive of the long-term care industry, the Archives paper reflects another troubling trend. Most long-term care in SNFs is paid by Medicaid, and reimbursements for these patients are often lower than the cost of providing care. By contrast, Medicare, which pays for post-acute and rehabilitation services, is far more generous. Medicare typically pays $500 or more per day for these services while Medicaid may pay just $125 for a long-term care bed (these payments vary by state and Medicare payments are adjusted to reflect patient needs).

The result: Growing industry consolidation and an increasing shift away from long-term care and towards more lucrative post-acute services. These choices make perfect economic sense. And they are often praised by advocates for the elderly, who argue that aging services should be provided in the community. However, for some seniors, including some with dementia or those with no family members to help provide care, nursing homes or assisted living facilities may be their only alternatives. Sadly, for many, those options are increasingly unavailable.           

More than half of long-term care residents in skilled nursing facilities made at least one emergency room visit in 2006. A quarter had two or more. Even more troubling, 38 percent were admitted to the hospital at least once that year, and nearly half were admitted twice or more. In all, one-quarter of all hospitalizations for nursing home residents were potentially preventable.

These very troubling statstics are included in a new study released today by the Kaiser Family Foundation. Even more worrisome were the reasons why: Kaiser does not have good statistics on this, but it hired Lake Research Partners, a survey research firm, to ask physicians, nurses, social workers, and family members about these hospital visits. The responses are hair-raising--not because they show uncaring or greedy docs, or sleazy nursing homes, but because they expose the routine systemic problems that drive hospitalizations.

Among the reasons so many nursing home residents land in the hospital:

The Friday effect: Nursing homes don't have the staff to deal with medical issues, especially on weekends. So they send them to the ER.

Nursing facilities and family members prefer that residents die in the hospital.  

Docs would rather care for patients in the hospital, in part because it is more convenient  or because they get test results quicker.

Financial incentives: Physicians think they get paid more for caring for a patient in the hospital, and nursing homes may get paid more after a long-term care resident has been hospitalized for at least three days and returns to their facility.

Lack of a relationship between nursing homes staff and residents: It turns out that residents are more likely to get sent to the hospital in the first months of their nursing home stay.

Families consent.They don't object, perhaps because they believe their loved one will get better care in the hospital. This is especially true if the resident has no advance directive.

Malpractice fears. Docs were afraid they'll be sued if they don't hospitalize a sick resident. 

Dr, Cheryl Phillips, the immediate past president of the American Geriatrics Society and a member of the panel that discussed the studies at Kaiser today, described a typical situation. Imagine, she says, you are a doctor who has several patients in your waiting room. You see patients at multiple nursing homes and you get a call from a nurse at one. One of your patients--a resident in the facility--"is not doing well," the nurse says.She doesn't know quite what's wrong, but things are not right. You could leave your patients in the waiting room and drive to the nursing home. Or you could say, "Send her to the hospitall." It isn't hard to guess what happens.

Thse potentially needless trips to the hospital cost Medicare a bundle, and, most important, hospital stays can be bad for chronically-ill elders. The new health reform law will drive many patients out of the hospital sooner, and many are likely to be cared for in nursing homes. These important studies raise some important questions about whether those facilities are prepared to take on those sub-acute patients.   

The other day, Josh Wiener, who is one of the nation's experts on long-term care, presented three papers on certified nursing assistants (CNAs) in nursing homes. Josh and his colleagues at the consulting firm RTI International looked at quality of care, immigration, and injuries. And some of what they found may surprise you. The papers are available here (some may require subscriptions)

The first question they asked was what workforce issues determined quality of care in nursing facilities. Lots of research has identified the problems: worker shortages and high turnover, low wages and few benefits, poor training, and a sometimes-hostile relationship between aides and managers. But which of these problems could be linked to low quality?

Surprsingly, Josh and his colleagues did not find much difference in some of these characteristics between high- and low-quality facilities. For instance, wages didn't seem to matter much. Neither did staffing levels. But access to health insurance and paid days off did matter and so did a more collegial organizational culture. This last finding suggests that the culture change movement in nursing homes, which attempts to create an environment where aides are given both more authority and responsibility, may be on to something.  

Their second paper looked at immigration, an important issue since about 20 percent of CNAs are foreign-born. Some results were not surprising. For instance, Wiener found only about half of immigrant CNAs reported English as their primary language. And half reported problems communicating with residents. But it turns out that nearly as many (41 percent) native born workers also reported these problems.

Other results were just as interesting. Foriegn-born workers were older, more likely to be married, and better educated than their U.S-born colleagues. Their average wages were about 10 percent higher and while fewer reported getting bonuses or reimbursement for training, more said they got paid holidays and subsidized child care. And immigrants were more likely to work for the highest quality facilities (based on the government's five-star rating system)

Finally, Josh and his colleagues looked at injuries. Aides have among the highest injury rates of any occupation in the country--the Labor Department reports that almost nine percent were hrt on the job in 2006, the third highest among any occupation in the U.S.

But Josh found many more injuries than were officially reported. He found that nearly 60 percent of nursing home aides reported suffering some injury during the course of the year. While most were back injuries caused by lifting, many others were inflicted by residents (12 percent were a result of bites).

One way to reduce back injuries is through the use of mechanical lifts. Josh found that 88 percent of facilities had these devices available, but only 61 percent of aides said they always used them. The research also found that madatory overtime, inexperience, lack of training, and lack of time to spend with residents all contributed to injury.  

These results are contrversial, espcially some of the conclusions about the relatonship between pay and staffing and quality. But, as with all of Josh's research, it is worth looking at.

Instead of admitting patients, hospitals are increasingly keeping them under "observation status." This decision results in lower Medicare payments to the hospitals and more out-of- pocket costs for patients. But it also means that Medicare is no longer paying for some admissions to nursing homes, and is instead shifting those expenses to residents and their families. 

What's going on? It is complicated. But here is the story: In the past, if a physician felt it was appropriate, a patient was admitted to a hospital for care. However, hospitals, which are under increasing pressure from Medicare to reduce costs, are becoming more cautious about formally admitting people who may not meet government criteria for in-patient care but are too sick to go home. 

These days, this decision is often not made by a doctor, but by a computer program called InterQual.Why InterQual? Because it is the software used by the Medicare inspectors, hospitals rely on it as well. Hospitals do this because if they do admit a patient and Medicare determines later that she should have been kept under observation, the hospital must return part of its Medicare payment to the government.  

The consequences of this situation reach far beyond hospitals, however. Medicare provides limited payments for nursing home care, and in fact is the biggest payer of post-hospitalization skilled nursing care. But it will pay only after a person has been in the hospital for at least three days. And time under observation does not count towards those three days. As a result, nursing homes are not being reimbursed by Medicare for these stays, and patients are being billed for their care, sometimes without advance notice.

A few weeks ago, Medicare held a meeting about all of this and got an earful--from hospitals, physicians, nursing homes, patients, and advocacy groups. Most agreed that time spent in a hospital under observation status should count against the three day rule.

This issue begs for clarification from Medicare. The agency needs to better explain the rules for admission and observation. It should rethink a system that relies on commerical software to make these determinations. And it should require nursing homes and hospitals to explain to patients in plain language who is paying for their stay, and why.