Kaiser Health News had an article about the high cost of Medicare for nursing home residents.  Medicare beneficiaries who reside in long-term care facilities account for an excessive and preventable portion of Medicare spending because of high rates of hospitalization, emergency room visits and skilled nursing care, according to reports released by the Kaiser Family Foundation (KFF).   See reports here, here, and here.

“When we step back…delivery systems reforms may not only improve quality of care…but may also reduce spending,” said Gretchen Jacobson, a KFF principal policy analyst and co-author of the reports. (KHN is a program of the foundation.)

The three reports include quantitative data and information from interviews with doctors, nursing home officials and other health care providers and families of long-term care residents, many of whom acknowledged an inflated emphasis on hospitalizations and testing for that patient population.

While Medicare doesn’t pay for residence in nursing homes, assisted living facilities or other long-term care programs, Medicare does cover emergency room visits, hospitalizations and other medical treatments.

According to the reports, the 1.7 million Medicare beneficiaries who were in long-term care for all of 2006, or who died in care before the year’s end, cost the program an average of $14,538 per person — more than twice the average expenditure for all Medicare beneficiaries that year. Individuals in that category comprised just 5 percent of Medicare’s 47 million beneficiaries but accounted for 9 percent of all Medicare spending, or $25 billion.

Hospital expenses accounted for nearly 40 percent of Medicare spending on patients who lived in long-term care facilities. If the number of hospital stays could be cut by 25 percent, the researchers estimated, Medicare could save at least $2.1 billion in 2010, and would likely result in additional savings to Medicaid, which pays for more than 60 percent of nursing home residents. Medicaid is the state/federal health program for the poor.

Previous studies have estimated that 30 to 67 percent of these hospitalizations could be prevented with "well-targeted interventions," according to one of the Kaiser reports. Before those savings can take place, the current system of care must overcome what one of the reports called a “culture of hospitalization” that pervades the perceptions and behaviors of physicians, caretakers , and family members alike, experts said.

Physicians often prefer inpatient treatment due to convenience: hospitals have all the diagnostic tools they need in one place, and doctors can easily divide their time between multiple patients. Nurses interviewed for the qualitative report also said they felt unprepared or unqualified to deal with patients’ health problems in a residential facility or didn’t want to risk liability by ignoring potentially life-threatening ailments.

“The perception of best care is ‘Let’s send Mrs. M to the emergency room and see what the ER finds,’” said Dr. Cheryl Phillips, who is chief medical officer of the health-focused Bay Area nonprofit On Lok Lifeways and past president of the American Geriatrics Society.

A lack of qualified staff, combined with protocols and license restrictions, have further exacerbated the trend of defaulting to hospitalization. Proper coordination of care among nurses, physicians, and family members is essential in preventing unnecessary hospitalizations in the future, researchers concluded.

The reports showed that many of the hospitalizations of residents of long-term care facilities occurred within the first few months of their stay, when patients are often transitioning from a hospital setting into residential care. Providers often fail to ensure that medical records move with the patient from one facility to the next, and emergency room physicians may alter prescribed dosages without knowing a patient’s history or notifying anyone of the change.

Financial incentives for team-based, patient-centered care are needed to hold providers responsible for their patients’ health outcomes, researchers concluded. Which incentives—or disincentives—will work best is an open question. Under the current system, physicians profit from longer, more frequent hospitalizations, regardless of their necessity.

Phillips believes that a section of the reform bill that prioritizes coordination of care for individuals with multiple life-threatening ailments will by definition include most Medicare beneficiaries who are in long-term care.

An additional clause in the new health law, denying payment to hospitals that readmit certain patients within 30 days of the initial visit, is expected to further discourage unnecessary hospitalizations. That provision takes effect in October 2012.



Jails and Nursing Homes

Here’s the way it should be:

Let’s put the seniors in jail and the criminals in nursing homes.

This would correct two things in one motion:

Seniors would have access to showers, hobbies and walks.

They would receive unlimited free prescriptions, dental and medical treatment, wheel chairs, etc.

They would receive money instead of having to pay it out.

They would have constant video monitoring, so they would be helped instantly if they fell or needed assistance.

Bedding would be washed twice a week and all clothing would be ironed and returned to them..

A guard would check on them every 20 minutes.

All meals and snacks would be brought to them.

They would have family visits in a suite built for that purpose.

They would have access to a library, weight/fitness room, spiritual counselling, a pool and education…and free admission to in-house concerts by nationally recognized entertainment artists.

Simple clothing – i.e., shoes, slippers, pj’s – and legal aid would be free, upon request.

There would be private, secure rooms provided for all with an outdoor exercise yard complete with gardens.

Each senior would have a P.C., T.V., phone and radio in their room at no cost.

They would receive daily phone calls.

There would be a board of directors to hear any complaints and the ACLU would fight for their rights and protection.

The guards would have a code of conduct to be strictly adhered to, with attorneys available, at no charge to protect the seniors and their families from abuse or neglect.

As for the criminals:


They would receive cold food.

They would be left alone and unsupervised.

They would receive showers once a week.

They would live in tiny rooms, for which they would have to pay $5,000 per month.

They would have no hope of ever getting out.

"Sounds like justice to me!"




Jessica Zigmond wrote an interesting article published on Oct. 18, 2010 in Modern Healthcare about how to save Medicare funding by making small fixes in reimbursement.  "The CMS could save billions of dollars in the Medicare program by making substantive changes to the way care is managed, delivered and paid for at skilled nursing and other long-term-care facilities."

The program could save $2.1 billion if hospitalization rates among long-term-care residents were reduced by 25% based on a new study by Kaiser Family Foundation.  CMS will have to address issues that are driving Medicare expenditures for post-acute care, such as inadequate staffing, which includes the level of skill and training among skilled-nursing caregivers; low Medicaid costs for skilled-nursing stays that can lead facilities to seek more profitable services from Medicare to make up the difference; and the idea that long-term care has long been viewed as separate from healthcare rather than as an essential and costly component of the nation’s healthcare system.

"Federal statistics show that post-acute care in America is contributing to a surge in federal healthcare expenditures. In June, the Medicare Payment Advisory Commission reported that Medicare spent $54.4 billion in 2009 on all post-acute care—which includes skilled nursing facilities, home health agencies, inpatient rehabilitation hospitals and long-term-care hospitals—about a 29% increase over the $42.2 billion spent in 2005, and more than double the $26.6 billion the program paid in 2001. Skilled nursing accounted for the greatest amount—$25.5 billion in 2009—while long-term-care hospitals had the smallest share at $4.9 billion."

State Medicaid programs cover facility stays, while Medicare covers medical costs. Often, underfunding of Medicaid can lead to an increase in Medicare.  According to Kaiser’s report, Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Homes and Other Long-term-care Facilities, about 2.2 million Medicare beneficiaries lived in a long-term-care facility for some or all of 2006. These beneficiaries accounted for about 6% of the Medicare population but 17% of total Medicare spending.

Still, among Medicare beneficiaries who survived in long-term-care settings for all of 2006, 41% were in the top quartile of Medicare spending, with average Medicare expenditures of $26,732. And, the study showed, average Medicare spending is about two times greater for beneficiaries living in long-term-care facilities than for all others.

We spend a lot of money trying to fix things that went wrong that, with proper care, probably would not have gone wrong,” said Toby Edelman, a senior policy attorney with the Center for Medicare Advocacy in Washington. During the panel discussion, Edelman focused on what she sees as a significant problem in the long-term-care industry today: a lack of adequate staffing. In an interview, Edelman said there is a great need for clinical providers in this segment, including registered nurses, licensed practical nurses, licensed vocational nurses and certified nursing aides.

“Physicians and nurses say that long-term care facility staff often lack the skill and training needed to deal with medical issues, particularly those that are unanticipated and more acute in nature,” the report said, adding that this results from a host of factors, including inexperienced and unseasoned staff—partly as a result of high staff turnover rates—a lack of training and no clear policy on how to deal with certain medical situations, including when to hospitalize a resident; insufficient nurse-to-resident ratios that result in over-extended nurses; and licensing limitations that do not allow certain medical procedures and tests to be done on-site.

“We need to start with what is a fundamental level of staffing needed to take care of certain types of patient,” said Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging. “We need to pay for training, livable wage and benefits, supervisors,” he added. “We do know part of it is we need to manage better and part of it is we need to get paid for what we’re doing. But the direct caregiver is as important to a nursing home resident as a heart surgeon is to someone who needs multiple bypasses.”



Congratulations to Tom Rhodes and Beth Janicek, who received a $592,439 jury verdict after a 6 day trial against SavaSeniorCare and related entities represented by Lori Proctor (national trial counsel for SSC/SAVA).   Unfortunately, because of arbitrary limits imposed in Texas, the family will not be adequately compensated and will recieve a fraction of the amount the jury awarded.   The case involved a 76 year old nursing home resident who was neglected and developed avoidable bilateral decubitus ulcers on his hips which became infected.


The following article appeared in the San Antonio Express-News today regarding the verdict:


After more than a day of deliberation, a civil jury found a San Antonio nursing home negligent Wednesday in its care of a now-deceased resident who developed severe, infected bedsores.

Jurors ordered Retama Manor Nursing Center to pay the estate of Emilio Gonzalez $250,000 for his physical pain and suffering, $150,000 for mental pain and anguish and $192,439.88 in medical bills. But the nearly $600,000 verdict is expected to be reduced substantially after state District Judge Victor Negrón applies Texas tort reform caps that have been in place since 2003. Under Texas law, Gonzalez’s family is likely to receive $250,000 in damages and $75,000 in medical expenses to be paid to Medicare.

Mary Koenig, who filed the suit on behalf of her father, said she hopes the judgment sends nursing homes a message. “We wanted to make some changes in my dad’s name,” she said. “We just didn’t want him to be another statistic. We needed to bring attention to the problems that are out there.”

Gonzalez was a resident at Retama Manor from 2001 until months before his death in 2007 at the age of 76.

In closing arguments Tuesday, plaintiffs attorneys Tom Rhodes and Beth Janicek said the nursing home was intentionally understaffed in order to make more money, often leaving nurses with up to 60 residents to oversee at a time.

By the time Gonzalez was taken to Southwest General Hospital in August 2007, two bedsores had rotted to the bone, requiring an extended stay at a hospital specializing in wound treatment, they said.

Attorney Lori Proctor, who represented the nursing home, pointed out that Gonzalez’s bedsores had always healed before in the six years he spent at the nursing home. The difference this time, she said, was that he had recently been diagnosed with terminal lung cancer that was making it impossible for him to heal.



Ken Connor of Center for a Just Society wrote the below article titled Elder Abuse: America’s Dirty Secret

The plight of elderly Americans has been a top concern of the Center for a Just Society since our inception in 2005, and as senior citizens comprise an ever increasing percentage of our nation’s population, the need is greater than ever to draw attention to a little discussed, little known epidemic in American health care. According to a new study released this month by the American Association for Justice (AAJ), eldercare abuse in America has escalated from a shameful problem to a full-blown humanitarian crisis. As the report illustrates, our nation’s looming demographic boom will pose more than a financial challenge for our society – it will pose a moral challenge that is just as important: What kind of care and treatment does our society consider appropriate for its most vulnerable members?

As an attorney I have spent decades representing elderly men and women who have endured unspeakable abuse and neglect in nursing homes. Often, these conditions were so reprehensible and so degrading that – were they unearthed at daycare centers or even federal penitentiaries – members of Congress and the media would be crusading for reform. The AAJ’s report is rife with illustrations: A nursing home resident whose leg was amputated after becoming infested with maggots; an Alzheimer’s patient who died trapped in a freezer; a Florida nursing home resident who suffered from multiple falls, severe weight loss, multiple pressure sores, infections, dehydration, and eventually death by starvation; patients at a home in Illinois who were given antipsychotic drug injections "assembly-line style" as a means of "chemical restraint;" and an elderly nursing home resident who was sexually assaulted in the middle of the night at the hands of an orderly who was an ex-con.

If something major doesn’t change, and change soon, this is the kind of fate that awaits multitudes of Americans expected to join the ranks of the institutionalized elderly in the coming decades.

One of the major reasons why these reprehensible acts occur is because a culture of ruthless profiteering pervades much of the eldercare industry. Many nursing home operators are little more than real estate developers posing as health care providers. Large publicly owned companies and a consortium of private equity groups are finding the industry increasingly attractive. Their "rental units" are beds rather than apartments or condominiums or offices, and their "rental stream" is guaranteed by the federal government through the Medicare and Medicaid programs. Patients with many needs (typically Medicare patients who have been just discharged from the hospital) are their target "market" because Medicare provides a higher reimbursement than other government entitlement programs. A filled bed represents a guaranteed income stream. An empty bed generates no revenue. Hence, the facilities engage in aggressive marketing campaigns to ensure high "occupancy levels." And since labor accounts for the largest expense in the nursing home budget, operators often understaff their facilities in order to maximize profits. While these practices may be good for the bottom line, they are devastating for the patients. From the AAJ report:

For-profit nursing homes have on average 32 percent fewer nurses and 47 percent higher deficiencies than their non-profit counterparts. . . . This increased emphasis on profits has led to a distressing rise in neglected and abused seniors. Between 2000 and 2008, instances of "immediate jeopardy" – violations likely to result in serious harm or even death – rose 22 percent. More than 90 percent of all nursing homes were guilty of at least one violation.

How have we allowed this to happen? In addition to the demographic and economic factors at play – the ranks of the elderly are swelling, the birthrate is declining, and our entitlement programs are on the brink of collapse – there is an underlying cultural component to the elder abuse crisis in America. Over the last several decades American society has gradually shifted from a "sanctity of life" to a "quality of life" ethic. Increasingly obsessed with youth and utility, we have come to evaluate the net worth of human beings based on cost-benefit ratios and quality of life calculus. And not surprisingly, the elderly (who cost more to maintain than they produce, whose functional capacities have deteriorated because of old age or illness, and who serve as unwelcome reminders of our own mortality) do not score well using these standards. In the next 20 or 30 years, when our expanding elder cohort is consuming valuable resources and is no longer deemed "useful," one shudders to imagine what "solutions" might be devised to deal with the growing problem of eldercare.

The crisis of eldercare abuse, then, is one that begs for our attention and demands a solution. First and foremost, it is critical that the American people begin to view eldercare as one of the great moral problems of our generation. For too long we have viewed the coming Senior Tsunami solely in abstract economic terms while ignoring the "human factors" at stake. For the younger generations in particular – those expected to bear the fiscal brunt of replenishing our anemic entitlement infrastructure – it is easy for a sentiment of bitterness to prevail. However, we must remember that the elderly – no matter how disabled or helpless – are human beings who deserve to be treated with the full measure of dignity and respect. America’s senior citizens should not become victims of a sliding scale that erodes their humanity as their faculties decline. Those of us who care about the creation of a just society must be willing to defend the rights of the elderly no less vigorously than the rights of the unborn.

For Christians, the Bible is quite clear on this point. Most folks know that the Ten Commandments call upon us to honor our parents, but the Scriptures also tell us that we have a responsibility to care for our elders with willing hearts, in gratitude for the care they showed to us. St. Paul’s first letter to Timothy tells us that children and grandchildren "should learn first of all to put their religion into practice by caring for their own family and so repaying their parents and grandparents, for this is pleasing to God." (1 Tim. 5:4) Paul is adamant on this point: "If anyone does not provide for his relatives, and especially for his immediate family, he has denied the faith and is worse than an unbeliever." (1 Tim. 5:8)

The Apostle Paul’s message runs against the grain of modern American culture, which places a significant value on the immediate family but focuses little on the moral and civic obligations we have to our extended family and community elders (so few of us, after all, even identify with a discrete community anymore!). All the more reason, then, why a targeted campaign to ensure justice for the infirm and the elderly is critical. Next to the battle to secure the rights of the unborn, protecting the rights of the elderly in America may well turn out to be the most important civil rights movement of the 21st century.

To see how attitudes towards the infirm elderly devalue their lives in the minds of some, click on:  http://www.youtube.com/watch?v=RiTp1w48P3E

To read more of our research and writing on the topic of eldercare abuse in America, visit the Issues Page of our website here.

Forum: Brad Bradley examines the differences between our traditional constitutional liberties and the progressive ideal of equal outcomes: Fairness or Liberty?

CJS Blog: Zachary Gappa writes on school choice, elder abuse, Tea Party authenticity and more: Check out the CJS Blog.


Christine Vestal of Stateline wrote a great article on Tennessee’s new plan to change its health care system aimed at elderly and disabled residents. More of them are getting the assistance they need in their homes — at a much lower cost than at a nursing home.  
Just a few years ago, only a few hundred Tennesseans were able to get Medicaid funding for anything but a nursing home. Now, it is one of a handful of bellwether states that offer a broad range of alternatives to nursing home care.
“It’s a good thing to do and it probably can save some costs, but more importantly it really is an easy way to keep an awful lot of people in their homes, which is what I would want. I know it’s what my mother wants,” Governor Bredesen said in an interview with Stateline.
Like every other state, Tennessee is bracing for an avalanche in demand for long-term care as the biggest generation in American history — 77 million so-called Baby Boomers born between 1946 and 1964 — begins to hit retirement age next year.
Occupying more than 30 percent of states’ Medicaid bills, which in turn occupy more than 20 percent of overall state budgets, long-term care costs are growing faster than any other state expense.
That’s partly because Americans are living longer. By 2020, the number of people aged 85 years and older — those most likely to need long-term care — will increase by more than 40 percent, according to U.S. Census Bureau estimates. Even without those demographic pressures, states’ long-term care costs are daunting. The elderly and disabled represent about 25 percent of the total Medicaid population, but they account for more than 65 percent of the spending, according to the most recent federal data available.
It is well known that the vast majority of people with long-term care needs want to remain in their homes. And research shows that the cost of providing care in the community can be as little as one-third the amount of a comparable nursing home stay.
But the road to reforming state Medicaid plans is long and arduous because Medicaid — which pays nearly 50 percent of all nursing home bills in the country and 45 percent of all long-term care — is biased in favor of institutional care.

In 2008, the Legislature unanimously approved a bill that would make Tennessee one of just a few states to contract out its long-term care program to managed health care organizations. 
Like laws in Arizona and New Mexico, Tennessee’s new law counts on private companies to ensure that a broad array of services — from so-called personal services such as meal preparation, bathing and dressing to home improvements, including wheel chair ramps and even pest control — are provided without additional cost.
Two months ago, TennCare CHOICES, opened its doors statewide with the goal of helping 11,000 people remain at home or return to their homes in the first year — all for the same amount the state paid in 2009. “The change is like night and day,” says Wilo Clarke, a caseworker for a managed care company in central Tennessee where the program started as a pilot earlier this year. “More and more, people in the nursing facilities are hearing about this program. They want to do whatever it takes to go home.”
Under the plan, low-income frail elders and adults with disabilities who are medically eligible for nursing home care may opt to receive the services they need in their homes, as long as the total cost is equal to or lower than the cost of a nursing home stay.
It’s too early to tell whether CHOICES will accomplish its goals. But so far, more than 40 percent of some 3,300 new enrollees are opting either to move out of a nursing home or avoid going to one in the first place. In addition to allowing Medicaid to pay for alternative services, Tennessee’s CHOICES makes it easier for people to sign up for the program by providing a single point of entry — a caseworker with a local managed care organization.
For the managed care organizations, the financing structure is straightforward. The state gives them a flat monthly fee for each eligible long-term care recipient — whether in a nursing facility or living at home. Some patients will cost more and others will cost less. It’s the company’s job to ensure that the average cost for all enrollees does not exceed a specified level. 

The AARP, which advocates for the elderly, says that three people can receive long-term care services in the community for the cost of serving just one person in a nursing facility. Still, the big fear in offering more home-based services is that people who never would consider entering a nursing home “will come out of the woodwork” and apply for Medicaid. Surveys have shown that for each patient in a nursing facility, two more with the same level of disability are making do at home.
Bredesen acknowledges the state’s new program will result in Medicaid serving more people. But he says it’s a good thing, as long as overall costs do not climb.
Although the social and fiscal benefits of public funding for home- and community-based services are clear, states have been slow to take the steps required to bring about change. In the mid-1990s, a few states began recognizing the value of serving more long-term care patients in their homes. Alaska, California, Minnesota, New Mexico, Oregon and Washington State now spend more than half of their long-term care dollars on alternatives to nursing facilities. Colorado, Idaho, North Carolina, Texas and Vermont are moving in the same direction. But Tennessee and 23 other states have made less progress, spending less than one-quarter of their long-term care budget on non-institutional care.
The new federal health care law — the Patient Protection and Affordable Care Act — has a chance of changing that. It includes financial incentives for states to spend at least 50 percent of their long-term care dollars on non-institutional services and offers a grant for every person who leaves a nursing home to receive services in the community.