The Show Me State is closing its eyes when it comes to the use of medical marijuana in some local nursing homes.

This past November, Missouri voters gave their approval to legalize medical marijuana, the 33rd state to do so. But the executive director of the state veterans commission said that cannabis will remain prohibited in Missouri veterans homes.

Grace Link said at a meeting that the prohibition is necessary for the homes to remain in compliance with the U.S. Department of Veterans Affairs, which still considers marijuana illegal, the St. Louis Post-Dispatch reported.

“We have to meet VA standards,” Link said Monday “We have to comply with federal guidelines.”

Seven veterans’ nursing homes across Missouri serve 1,350 residents. Running afoul of federal drug laws could jeopardize $80 million in funds from the federal government, officials said.

The Washngton Post had an interesting article about the growing popularity of ObamaCare.  Trump has declared his intent to come up with a new health-care plan and backing a state-led lawsuit to eliminate the Affordable Care Act.  The problem is that Republicans know how popular the program is to many of their constituents.  The 2010 law known as Obamacare has become more popular and enmeshed in the country’s health-care system over time. Thirty-six states and the District of Columbia have expanded Medicaid — including more than a dozen run by Republicans — and 25 million more Americans are insured, with millions more enjoying coverage that is more comprehensive because of the law.

Even Republicans who furiously fought the creation of the law and won elections with the mantra of repeal and replace speak favorably of President Barack Obama’s signature domestic achievement.

Quite obviously, more people have health insurance than would otherwise have it, so you got to look at it as positive,” Sen. Charles E. Grassley (R-Iowa) said in a recent interview.  Today, Grassley is chairman of the Senate Finance Committee, the panel that would be responsible for drafting a new health-care law, and he has shown little enthusiasm for Trump’s call for congressional Republicans to produce a replacement for the ACA.

Ten years ago, Grassley was at the forefront of GOP opposition to the law, ominously pushing the debunked claim that it would allow the government to “pull the plug on grandma” by creating “death panels.”

Republicans from states that embraced the law’s Medicaid expansion also concede that it has benefited large portions of the low-income population, many of whom were previously uninsured.

For the people who are in that tranche of expanded Medicaid, I think it has been very helpful,” said Sen. Shelley Moore Capito (R-W.Va.). Nearly one-third of West Virginians are on Medicaid, and the percentage of uninsured has dropped by about 56 percent since 2013.

Passage of Obamacare has most benefited Americans who lacked coverage before its enactment — about 50 million at the time — and people with workplace-sponsored coverage, whose plans must cover benefits more generously.

The law also sought to save money for seniors by filling in Medicare’s drug coverage gap.

The public’s increasing reliance on the ACA was reflected in the dramatic failure of congressional Republicans to roll back the law or even unify around a plan to replace it as it has grown in popularity.

Soon after Trump was elected, favorable opinion of the ACA grew.

In the 2018 midterms, voters in the Republican-leaning states of Nebraska, Utah and Idaho approved ballot initiatives expanding Medicaid. The Centers for Medicare and Medicaid Services recently approved Maine’s Medicaid expansion, which was also approved via the ballot.

Even in states that have tried to reject the ACA wherever possible, the law has had a marked impact. Florida, Texas, North Carolina and Georgia — which are among the 14 states that still refuse to expand Medicaid — have the most marketplace enrollees, according to the Kaiser Family Foundation.

Democrats have often acknowledged that the ACA is not a perfect law and can be improved, particularly by making monthly premiums more affordable. But bipartisanship remains elusive as Trump and many in the GOP demand that the law be scrapped.

“There are problems with the law, and we should be working together to resolve those matters,” Waxman said. “Instead, we’re still, 10 years out, fighting over whether the law should be in effect and should be on the books at all.”

Samantha J. Gross is a state government reporter for the Miami Herald and Tampa Bay Times bureau in Tallahassee, where she covers state government and politics.  She recently wrote a great article on medical marijuana in Florida long term care homes.   Below are excerpts.

Fears over losing Medicaid and Medicare funding — because federal law still considers all marijuana use illegal — keep most nursing homes and assisted living facilities pot-free, despite recommendations from doctors to card-holding patients who reside there.

Medical marijuana is a burgeoning industry in Florida, and seniors are a burgeoning population. According to population statistics, residents 65 and older will outnumber minors nearly 2 to 1 by 2030.

Despite an environment where the Legislature is dialed in on the expansion of access to medical marijuana in all of its forms, one of the largest groups who would benefit is being left behind.

While using the drug has had success in treating chronic pain, Parkinson’s, glaucoma and other diseases that come with age, many seniors in Florida don’t have access to medical marijuana.

 One medical cannabis physician, Dr. Kelly King of Hillsborough County, called nursing homes “a real microcosm of all the problems that the elderly deal with.”

Shad Haston, CEO of the Florida Assisted Living Association, said while some private providers are administering the drug, they warn others to be cautious.

“We have told our members if they participate in Medicaid, or if they intend to participate, they should be leery of allowing it to happen,” he said.

That advice followed “some comments made by then-AG Jeff Sessions that alluded to the federal government’s concerns about it,” he said.

William Barr, the new U.S. Attorney General, spoke in his Senate confirmation hearing about the fact that several states have made laws allowing the use of medical marijuana.

Barr said the “right way to resolve” the matter is legalizing medical marijuana through the federal legislative process. As for state law, he promised not to go after states where it’s legal.

“To the extent that people are complying with the state laws, distribution and production and so forth, we’re not going to go after that,” he said.

In an effort to protect facilities that allow marijuana under their rules, a bill that recently passed through the Senate by Sen. Jeff Brandes made it known that the state cannot ban marijuana use from those places.

“I think for me, it’s making sure we recognize that Floridians have said that marijuana is a medicine and that we treat it as such,” the St. Petersburg Republican said. “That means we keep it as available as an option.”

Weiner, the doctor who prescribed medical cannabis to Crouse’s mother, travels to nursing homes and assisted living facilities to speak about how the elderly can benefit from marijuana treatments.

Since she started recommending cannabis two years ago, she says she’s weaned over 150 patients off opioids and onto medical marijuana instead. The older patients, however, are “totally screwed” by the fact that cannabis is still a federally restricted drug.

“They’re too old to remember to take the medication and nurses can’t give it to them by law. They’re at a loss, and the cost is an issue,” she said. “How does a 90-year-old know to call a company every month and get it shipped to them?”

Weiner said she also recommends cannabinoid oil or CBD, which is now legal under the 2018 Farm Bill that Congress passed in December. Florida, however, has not yet incorporated the federal statute into state law, and CBD products remain illegal. Therefore, most facilities won’t administer CBD treatment or even allow patients to take it on their own.

“[The elderly] are over-medicated, they have so many side effects from medications that cause dizziness, constipation, cognitive confusion,” Weiner said. “[Marijuana or CBD] would be a great way to substitute it for other pharmaceuticals. Until Florida incorporates what just passed in the Farm Bill into this law … it’s still in a waiting zone.”

Federal prosecutors are filing charges against six Iowa women accused of stealing drugs from residents at the nursing homes where they worked.

Prosecutors say they used their employment at nursing homes to steal painkillers including Oxycodon and Fentanyl from residents.  Charges of “acquiring a controlled substance by misrepresentation, fraud, deception, and subterfuge” were filed against:

  • Arminda Cruickshank, 36, Calvin Community and Valley View Village nursing homes in Des Moines
  • Katie Howard, 31, University Park Nursing and Rehabilitation Center in Des Moines
  • Samantha Mills, 29,  Des Moines
  • Alicia Swenson, 32, Carlisle Center for Wellness and Rehabilitation
  • Barbara Tindall, 47, Keosauqua Health Care Center and Savannah Heights in Mount Pleasant
  • Christine Weilbrenner, 30, The Bridges of Ankeny

Howard pleaded guilty to two counts in February.  She will be sentenced in July.  The five other suspects have all pleaded not guilty.

Popular Science had a great article on the #1 public health crisis–the opioid epidemic sweeping the United States.  The article shows several factors caused the crisis including the greed of the pharmaceutical companies and doctors, opioid overprescription, slow government response, and the availability of street drugs like heroin.

The largest and easiest to control is overprescription of this dangerous and addictive painkillers by doctors themselves. The medical community now recognizes the dangers opioids pose and the FDA introduced a special protocol for handling them. However, a new study, published last month in JAMA, from researchers at Johns Hopkins University shows that protocol was ignored by most doctors.

The most potent class of prescription opioids is known as transmucosal immediate-release fentanyls (TIRFs). These painkillers, which are fast-acting and powerful, are intended to help breakthrough pain in cancer patients, whose normal opioid pain relievers aren’t managing all the pain. “This is not a usual drug,” says Caleb Alexander, a Johns Hopkins professor of medicine and the corresponding author of the new study. It’s a last-resort drug. For that reason, he says, in 2011, the FDA instituted a program, known as the Risk Evaluation and Mitigation Strategy for TIRFs, or TIRF REMS.

The strategy didn’t work. Through careful analysis of the reports, which cover the years 2011 to 2017, Alexander and his colleagues found that between 34.6 and 55.4 percent of TIRF prescriptions had been given inappropriately. That’s especially troubling because TIRFs can cause a person who isn’t already “opioid tolerant”—that is, taking a specifically defined number of opioid painkillers—to overdose, because their bodies aren’t used to them.

“I think our findings raise serious concern regarding the role of manufacturers and the FDA,” Alexander says. They also suggest that far more documents currently unavailable for public and academic scrutiny might contain even more key information about the state of the opioid crisis—that’s if we can get them.

“These documents provide just a tiny peek through one window that reveals just one piece of the epidemic,” says Alexander. “There’s an enormous amount about the inner workings of the FDA and pharmaceutical manufacturers that the public hasn’t been able to see.”

The CDC estimates that 130 Americans die each day from opioid overdose, while the Substance Abuse and Mental Health Services Administration reports that millions of Americans misused prescription opioids in 2017.

In September 2018, the FDA approved a widespread REMS program covering opioid painkillers more generally, but it remains to be seen if that program will be more effective than the TIRF REMS. “The FDA’s opioid REMS activities extend far beyond the TERF products,” Alexander says, “and our findings raise questions as to the adequacy of the broader response of the FDA and manufacturers to the epidemic.”

McKnight’s had a great article on the recent decline in nursing home beds according to a recent analysis by Marcum LLP’s statistical analysis of nursing home trends between 2013 and 2017. The 72-page book is aimed at providing a practical tool for operators to establish baselines and compare themselves against the competition.

Overall occupancy percentages declined from 83.07% at the beginning of the study down to 80.24% in 2017. Almost all U.S. regions experienced decreases in patient days, driven partially by patients turning to other care options, such as home health and assisted living, the report found.

“We always know that there are sales and consolidations in the industry, but I think the shrinking reimbursement and lower occupancy levels have really caused the non-chain or the smaller nursing home groups to pause and say, ‘what am I doing here? I can’t compete in the marketplace anymore,’” Matthew Bavolack, national healthcare services leader for the firm,  told McKnight’s. “You’re seeing a lot of single-entity operators either close or sell off their operations.”

The good news: Given the current population trends, the lull in nursing home census numbers will only be temporary. Still, “the nursing home of tomorrow will not operate, look or feel anything like the nursing homes of today,” the report notes. For instance, boomers will not want to share rooms and will expect hotel-like amenities.

The industry is not going anyplace. As a matter of fact, there is going to be such a need for skilled care with an increasing number of Alzheimer’s and dementia patients and the aging population that nursing homes will have a very strong place and a strong foothold in the continuum of care. I think that’s a really important factor to take away from this,” Bavolack told McKnight’s.

Shrinking reimbursements, coupled with rising labor costs, have led to dwindling operating margins for operators, the report notes. Those pressures have subsequently diminished providers’ cash on hand and “hindered the industry’s ability to remain nimble and respond to changes in an environment that is experiencing substantial shifts.” Across the country, the days cash on hand decreased from about 18 in 2013 to 17 in 2017, a decrease of about 6%.

The report also offers nursing home operators three tips to begin preparing for what’s next, including (1) have a strong marketing team and aggressive marketing plan to attract Medicare and private-pay residents (2) offering specialty programs, such as Alzheimer’s care, to stand out from the competition and (3) modernize their environments to provide the “new style of living” expected by today’s residents and their family members.

The combined fortunes of the world’s 26 richest individuals reached $1.4 trillion last year — the same amount as the total wealth of the 3.8 billion poorest people.  The world’s billionaires are growing $2.5 billion richer every day, while the poorest half of the global population is seeing its net worth dwindle.  Billionaires, who now number a record 2,208, have more wealth than ever before, according to an Oxfam International report. The 106-page report is meant to call attention to the growing gap between rich and poor

Provider Magazine had an interesting article on the 2017 tax cuts and how the IRS rules on defining pass-through entities affect nursing home chains. This may be relevant to show how related entities with the same ownership, operation, and control are really one joint enterprise or venture on behalf of the sole entity on top of the pyramid.

At issue is that the Tax Cuts and Jobs Act enacted in 2017, which permitted owners of pass-through entities such as limited liability companies, partnerships, S corporations, and sole proprietorships to deduct 20 percent of their “qualified business income.”

In the law, Congress defined qualified business income as income from a “qualified trade or business,” which, importantly, does not include a “specified service trade or business.”  Internal Revenue Code defines specified service trade or business as:

“Any trade or business involving the performance of services in the fields of health, law, accounting, actuarial science, performing arts, consulting, athletics, financial services, brokerage services, or any trade or business where the principal asset of such trade or business is the reputation or skill of one or more of its employees or owners.”

In addition, the IRS has traditionally interpreted the Code language to include providing nursing services and physical therapy.

The one silver lining from the new rule is the possibility certain assisted living communities may qualify for the deduction based on a new example added to the regulations as a result of AHCA/NCAL’s earlier comment letter to the IRS on the rule.

The new example included in the explanation that follows:

“X is the operator of a residential facility that provides a variety of services to senior citizens who reside on campus. For residents, X offers standard domestic services including housing management and maintenance, meals, laundry, entertainment, and other similar services. In addition, X contracts with local professional health care organizations to offer residents a range of medical and health services provided at the facility, including skilled nursing care, physical and occupational therapy, speech-language pathology services, medical social services, medications, medical supplies and equipment used in the facility, ambulance transportation to the nearest supplier of needed services, and dietary counseling. X receives all of its income from residents for the costs associated with residing at the facility. Any health and medical services are billed directly by the health care providers to the senior citizens for those professional health care services even though those services are provided at the facility. X does not perform services in the field of health within the meaning of section 199A(d)(2) and paragraphs (b)(1)(i) and (b)(2)(ii) of this section.”

Sources said the boiled down version of the example above means a community or facility that meets the above description would fall outside the definition of a specified trade or business and qualify for the 20 percent deduction.

KSTP reported that the Minnesota Department of Health (MDH) substantiated allegations of neglect against Benedictine Health Center nursing home and one of its staff members. MDH officials found that a facility staff member neglected a resident which caused the resident’s death. The report says a staff member failed to deflate the tracheostomy cuff after applying a cap to the resident’s tracheostomy.

The MDH report also says the facility failed to, “document any retraining and skills competencies the (staff member) received on tracheostomy cares when rehired after a several month absence.”

Now that caregiver has to live with the guilt, shame, and regret because the facility failed to train her properly.



McKnight’s recently reported that the Government Accountability Office strongly urged the Centers for Medicare & Medicaid Services to respond to recommendations made in the GAO January 2018 report on assisted living.  It has already been more than a year!

The GAO said it will continue to monitor actions taken by the Department of Health and Human Services in response to its recommendation, one of 404 “priority recommendations” — 54 of them at HHS — that were open as of April 7. The agency said it sent letters to the heads of the HHS, Veterans Affairs, and Defense departments “urging them to continue focusing on these issues.”

The 2018 report, “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed” contained a to-do list for CMS including reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities.

Investigators recommended that CMS Administrator Seema Verma:

  1. Provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities.
  2. Establish standard Medicaid reporting requirements that all states could use to annually report information on critical incidents.
  3. Ensure that all states submit annual reports for home- and community-based services waivers on time, as required.

These all seem reasonable and CMS has somewhat addressed #1 and 2.