Diagnostic Related Group Codes or DRGs

DRGs were first developed at Yale University in 1975 for the purpose of grouping together patients with similar treatments and conditions for comparative studies. On October 1, 1983, DRGs were adopted by Medicare as a basis of payment for inpatient hospital services in order to attempt to control hospital costs. Since then, the original DRG system has been changed and advanced by various companies and agencies.  DRG represents a rather generic term.  

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.   ICD-10-CM contains over 68,000 codes. 

Surprise? Researchers Find that Hospice Use Not Increasing Despite Record Use of Advance Directives

According to an article published in McNight's Long Term Care News, seniors are completing advance directives in record numbers, but this is not having the expected effect of shifting people from hospitals to hospices in their last days, say researchers from the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System. 

About 47% of elderly people had completed a living will as of 2000, and that increased to 72% by 2010, according to data from the Health and Retirement Study, a national survey done by the University of Michigan Institute for Social Research, on behalf of the National Institute of Aging.  During that same period, hospitalization rates increased in the last two years of life, the investigators found. The proportion of people dying in the hospital did decrease from 45% to 35%, but the researchers determined this had little to do with advance directives. This could be because directives focus more on the type of care rather than the setting where it is provided, they surmised.

“These are really devices that ensure people's preferences get respected, not devices that can control whether a person chooses to be hospitalized before death,"  researcher Maria Silveira, M.D., MA, MPH told McNight.

The article reports that among those who have completed a living will, most have both explained their treatment preferences and appointed a surrogate to make care decisions for them, according to the findings in the Journal of the American Geriatrics Society.  Advance directives commonly cover extreme decisions such as use of feeding tubes, but they do not provide much guidance for “gray area” end-of-life choices, such as when to administer antibiotics, another recent study found.

There is, of course, another possible explanation:  hospitals routinely transfer patients from a hospital to a skilled nursing facility at the end of a Medicare benefit, in order to continue Medicare covered treatment. These transfers are often made without advice, or informed consent after exploring alternatives.  Perhaps the disparity is best explained by institutions perpetuating institutional care and treatment.

Empowering Nurse Practitioners Could Reduce Hospitalizations From SNFs

According to an article in McNight's Long Term Care News, granting more authority to nurse practitioners (NPs) can help reduce hospitalization of skilled nursing facility residents.

The article reports the results of studies demonstrating that States that allow NPs to practice to the fullest extent of their training without a supervising physician have lower hospitalization rates across a range of groups in addition to SNF residents. These groups include inpatient rehabilitation patients and dual-eligible Medicare and Medicaid beneficiaries.

The American Association of Nurse Practitioners tracks state laws that allow NPs full, reduced or restricted scope of practice. There were 17 states allowing full practice as of January 2013.

Though there exists a correlation, the findings do not prove that allowing full scope of practice causes SNF hospitalization rates to improve, study authors pointed out. However, previous research also has shown that full scope of practice is associated with fewer hospitalizations, lower healthcare costs and better outcomes, they noted. Their findings contradict the American Medical Association and other physician groups, which have said care quality is likely to decline when a nurse practitioner, rather than a doctor, takes a lead role.

The results of this study should encourage nursing groups and other stakeholders to press for full scope of practice laws, the researchers concluded. They recommended that NPs form coalitions with nursing home associations and other groups to advocate for these policies.

This blog post is dedicated to a client NP who only recently provided me a solution to a persistent eye condition that defied treatment by two other physicians.

   

Ohio Ranks Poorly on Long-Term Care Services Scorecard

A new report ranks states on the quality and accessibility of their long-term care services and concludes there is a lot of room for improvement. The 2014 State Long-Term Services and Supports Scorecard finds that quality of care varies enormously across the states, but affordability is a big issue nationally.

The scorecard, a collaboration between the AARP, The Commonwealth Fund, and The SCAN Foundation, measured states’ long-term care system performance in five areas: affordability and access, choice of setting and provider, quality of life and quality of care, support for family caregivers, and effective transitions between care settings. Minnesota, Washington, Oregon, and Colorado ranked the highest while Kentucky, Alabama, Mississippi, and Tennessee ranked the lowest. The groups conducted a similar study in 2011.

According to the report, even in the highest-ranking states the cost of long-term care is unaffordable for middle-income families. The report notes that "on average, nursing home costs would consume 246 percent of the median annual household income of older adults."

States with a Medicaid system that functioned as an adequate safety net – reaching those with low and moderate incomes -- ranked higher on the scorecard, indicating that state public policy is important to improving care overall. The scorecard concludes that while some progress is being made, it is not enough to meet the needs of the growing elderly population.

The state of Ohio ranked 44th overall, ranking 42nd in affordability and access, but faring slightly better, 39th, in quality of life and quality of care.  Given these poor rankings, it is fortunate, perhaps, that Ohio's highest ranking came in securing effective transitions, which in part, considers the effectiveness of the state in avoiding unnecessary institutionalization.  

To see where each state ranks, click here.

5 Tips on Deciding Whether to Buy Long-Term Care Insurance

Alliance for Health Reform

One of the most difficult decisions in long-term care planning is whether to purchase long-term care insurance (LTCI) and which of the wide variety of products to purchase.

On the one hand LTCI premiums are high, they may be raised in the future, and  if you are purchasing policies in your 50s and 60s, the need is probably many decades in the future. Traditional LTCI also pays nothing to your family if you pass away without needing long term care, and may not even be there when needed if future price increases make keeping the policy impossible. On the other, many are saved by their LTCI, able to choose their own care setting rather than rely on what is covered by Medicaid in their state, more comfortable hiring necessary help if doing so doesn't mean dipping in to their savings, and able to protect an inheritance for their children and grandchildren.

Here are a few tips that should help you make the decision whether to purchase LTCI and what products to consider:

1. Can you afford LTCI? Can you "self-insure"? There are a few rules of thumb that can help determine whether you are in the target market for LTCI. You need to have enough savings and income to afford the premiums but not so much that you can easily pay your costs of care. If you are a couple whose net worth is more than $1 million but less than $3 million, or a single person with half these amounts, you are a candidate for LTCI. (Some LTCI brokers will tell you that there's no upper limit since even wealthy people may prefer to use LTCI rather than dip into their savings.) You could also look at this from the point of view of income. If you can pay the premiums without affecting your style of living or dipping into savings, then you can afford LTCI.
2. Decide now once and for all. Unless your financial situation is likely to change in the future, the best time to purchase LTCI is now. Every year you wait, you will face higher premiums and run the risk that a health care event will make you ineligible for LTCI.
3. Assess your own feelings. First, if you or your spouse were to need care at home, would you be reasonably comfortable using up some of your savings to pay for care? Or would you exhaust yourself providing the care yourself instead, whether due to fear of running out of funds or wanting to leave an inheritance? If you can do this thought experiment, in the end, would you feel worse having paid premiums over the years for insurance you did not use or paying out-of-pocket for care that could have been covered by insurance?
4. Use an LTCI specialist. LTCI is one of the most complicated insurance products available, with policies offering a variety of benefit levels and conditions for payment. Some insurance companies have raised premium rates on existing policies while others have not. Some honor claims readily and others have put up difficult roadblocks. And there is a proliferation of hybrid policies that merge LTCI with life insurance. You need someone who specializes in the field to guide you through all of these options.
5. Read up. You may have noticed that this article hasn't addressed actual insurance policies and benefit choices. In part this is because, as noted above, you need an expert. But before meeting with the expert, do a little of your own research. Start with ElderLawAnswers' collection of articles on LTCI, such as "Questions to Ask Before Buying Long-Term Care Insurance" and "How Much Long-Term Care Insurance Should You Purchase?" 

While these tips won't completely eliminate the difficult decision that all baby boomers are facing, we hope that this framework will help focus its consideration.

Caregiver Weds Man Then Depletes His Estate Leaving His Family Nothing

Proper planning for single seniors includes protecting the estate from control by third parties. A recent case illustrates how difficult it can be to protect a loved one from finacial abuse. Frank Calcaterra was in his 80s in 2008 when his family hired a home care company to help the former metro Detroit funeral home owner look after his ailing wife Jonnie, who had dementia.  Kentucky-based ResCare sent Tangie Coleman, who, at the time, had a warrant out for her arrest, records show.  It was later discovered that she lied on her application with ResCare.

Jonnie’s jewelry soon began to disappear.  When Jonnie Calcaterra died in a nursing home in January 2012, Coleman and her mother were living in Frank Calcaterra’s lakefront home in Waterford and he was sleeping in the basement.

A few months later, Coleman married Calcaterra in Ohio, without his family’s knowledge. Frank Calcaterra’s sizable fortune soon disappeared.  Estimates from court filings put the loss at anywhere from $500,000 to more than $1.5 million.  On Oct. 25, 2012, when Coleman, who was 35, and Frank Calcaterra, who was 86, were married in Ohio, at least two complaints alleging financial exploitation had already been filed against Coleman with the Michigan Department of Human Services’ division of Adult Protective Services.

When Frank Calcaterra’s daughters removed him from his home, less than a year later, he was 10 pounds lighter and destitute. He did not have a single bank account maintaining a positive bank balance or a valid credit card. Coleman was driving him to a check cashing storefront with his monthly Social Security check.

The case highlights what experts say is a significant and growing problem in the U.S. — financial exploitation of elderly people by caregivers. Many cases go unreported and accurate estimates are hard to pin down, but studies suggest there are at least tens of thousands of such cases each year.

In May of this year, a judge appointed a conservator for Calcaterra, citing fraud and financial exploitation, which Coleman denies.  Calcaterra’s court-appointed conservator, is seeking to annul the marriage, alleging it was a fraud Coleman perpetrated “solely for her financial gain.”

Calcaterra’s daughters are looking for answers and accountability, too. They’re unhappy the state failed to act and that it has been difficult to get police agencies to launch criminal investigations, with some officials saying the 2012 marriage mades the case a civil matter.

“Our concern is that no other family ever go through this,” said Calcaterra’s daughter Charlotte Knutson, who lives in Minnesota told a reporter for the Detroit Free Press.

Sgt. Brent Ross of Waterford Police recently closed a criminal investigation.  “There is still no evidence that Tangie ever forged a specific check although it may be inferred,” Ross reportedly explained to the family throught their attorney via email. “Perhaps the checks were forged, but they could have been forged by anyone.”

Coleman, who declined to discuss her history with Calcaterra during a brief encounter with a Free Press reporter, denied wrongdoing in an answer she filed to the annulment/divorce petition.  She claims Calcaterra gave her permission to sign his name to checks and his daughters are biased against her because she is black.  “Frank always gave me stacks of money ... and always promised to take care of me,” said Coleman, whose Facebook page featured photos of her fanning a stack of $100 bills.

“They kidnapped my husband,” Coleman said in a court filing. “I want him back.”

Records show Coleman was married when she was hired to help Calcaterra, but got divorced on Oct. 11, 2012 — two weeks before her marriage to Calcaterra. Of the many checks drawn on Calcaterra’s bank account in 2011, more than 20 totaling more than $10,000 were payable to Coleman’s husband at the time, for services such as painting, lawn care and moving.

Calcaterra, who spoke to a Free Press reporter with his daughters present, said Coleman told him she needed to marry him in order to receive a significant legal settlement resulting from a lawsuit she brought against an Oakland County police department for an alleged police assault against her. Calcaterra had earlier given her money to hire a lawyer.

“They went to court and got a settlement,” Calcaterra said. But Coleman told him officials told her she is a spendthrift, and in order to be paid the settlement she first had to get married so she would have someone to watch over how she handled the money.  “That’s why we got married,” Calcaterra said. “I don’t think there ever was a police report of this ever happening.”

There also is no record of any such lawsuit.

As might be expected, the family has filed a lawsuit against ResCare.

Text messages and handwritten notes exchanged between Calcaterra and Coleman show he was smitten with her. And Calcaterra pushed back hard when his daughters tried to convince him he was being used.

To read the full USA Today article, which includes practical precautions family members can implement, go here.

To read the Detroit Free Press article, go here.

Update: CMS May NOT Force the Dying to Spend Their Final Days Jumping Through Hoops to Get Needed Medications

Following an outcry from patient advocates, the Centers for Medicare and Medicaid Services (CMS) has revised earlier guidance that required hospice patients covered by Medicare Part D plans to get prior authorization of all their drugs.

As previously reported on May 14, 2014, Part D plans sometimes pay for medications that should be covered under Medicare’s hospice benefit.  In an effort to prevent this, in March CMS issued guidance requiring Part D plans to initially deny payment for all prescribed medications for hospice patients, forcing dying patients or their families to appeal the denials in order to get Part D payment for their medications, many of which they were taking before they enrolled in hospice. 

“This burden-shifting to the dying patient is illogical and immoral,” concluded the Center for Medicare Advocacy.  On June 11, the Center joined 26 other organizations in calling on CMS to replace its guidance with a more suitable solution.

Their concerns were heard.  On June 25, 2014, CMS met with a number of these groups to discuss the implementation of the guidance, and on July 18 the agency issued new guidance that supersedes portions of the earlier guidance.  Now, rather than requiring prior authorization for all medications, CMS will only “strongly encourage” Part D programs to place prior authorization requirements on four categories of prescription drugs that are typically used to treat symptoms during the end of life: analgesics, antinauseants, laxatives, and antianxiety drugs.  In making the change, CMS said “we recognize that the operational challenges associated with prior authorizing all drugs for beneficiaries who have elected hospice to determine whether the drug is coverable under Part D have created difficulties for Part D sponsors and hospice providers, and in some cases, barriers to access for beneficiaries."

“This action by CMS will bring marked relief to hospice patients and their providers who have been dealing with the previous policy under which all drugs processed through Part D for hospice patients were subject to prior authorization,” said Andrea Devoti, board chair of the National Association for Home Care & Hospice, said in a press release.

However, the Center for Medicare Advocacy was somewhat more restrained in its praise.  While calling the replacement guidance "significantly better than the original," the Center said CMS still “relies upon the good will and prompt diligence of hospice providers, pharmacies, and Part D Plan Sponsors to ensure Medicare beneficiaries do not lose access to medications necessary to prevent pain, nausea, constipation, and anxiety.”  The Center also expressed concern that there are no time frames to ensure that these players act expeditiously, and there is no real appeal process for terminally ill patients whose medications are not meeting their needs. 

For the CMS memorandum containing the new guidance, click here. 

Ohio Supreme Court Hears Arguments in Medicaid Pre-Eligibility Transfer Case

Does federal Medicaid law allow the unlimited transfer of assets between spouses after one spouse is institutionalized, but before Medicaid eligibility is determined?  The answer to that question will greatly impact planning opportunities for Ohio families.  On Wednesday, August 20, 2014, the Supreme Court of Ohio heard oral arguments in a case that turns on this question.  Estate of Atkinson v. Ohio Department of Job and Family Services, No. 2013-1773.

In 2000 Marcella Atkinson and her husband transferred their home into a revocable living trust. In April 2011, Mrs. Atkinson entered a nursing home and soon applied for Medicaid benefits. In August 2011, the home was removed from the trust and placed in Mrs. Atkinson's name. The next day, Mrs. Atkinson transferred the house to her husband. The state determined an improper transfer had occurred and imposed a penalty period.  Mrs. Atkinson passed away, and her estate appealed to court, losing at both the trial court and the Ohio Court of Appeals. 

During the 40 minutes of oral arguments (available on video here) before the state’s high court, the attorney for the estate, Maura L. Hughes, maintained that both federal and state Medicaid law clearly allow unlimited transfers up to the point of Medicaid’s eligibility determination, and that both the Sixth Circuit Court of Appeals and the Department of Health and Human Services (HHS) support this reading of the statutes.    

Stephen P. Carney, the attorney for the state, told the justices that both the Sixth Circuit and HHS “got it wrong,” and that “the curtain comes down on unlimited transfers at the date of institutionalization.”  If couples are allowed to continue reallocating their assets after the date of institutionalization, he argues, they will be able to easily protect assets through “various tricks,” such as annuities. “If you can still do unlimited spousal transfers even after institutionalization, then you could take 200, 300, $400,000 as in some of our other cases and convert it from what’s a shared resource into this protected income stream for the community spouse.” 

Some justices appeared surprised at Carney’s suggestion that they should second-guess both the Sixth Circuit and HHS (which weighed in on the Sixth Circuit case).  One justice asked attorney Hughes whether the state is bound by the Sixth Circuit’s decision, in which, coincidentally, the appellant’s name was Hughes. 

“I believe they are, your honor,” said Hughes. “My understanding is that they are not actually following it now.  There was a U.S. district court case filed last week alleging that the state has been holding for this case in hopes of getting a second bite at the apple and having you come out in the opposite direction from the Hughes decision.”

For the Supreme Court of Ohio’s oral argument preview on the case, click here.

For detailed case information, click here.

Is Health Care Reform Hazardous To Your Health?

Regardless of your position on the Affordable Health Care Act, it is at one time both fascinating, and troubling, to witness the scope and pace of the major transformations taking place in the medical system. The transition to greater utilization of Skilled Nursing Facilities for rehabilitation following expiration of Medicare Benefits has caused much concern, for example.

Now,  John C. Goodman, one of the nation’s leading thinkers on health policy suggests bluntly that some of these changes are hazardous to your health.  Mr. Goodman's opinions are worthy of consideration. He is a Senior Fellow at the Independent Institute and author of the widely acclaimed book, Priceless: Curing the Healthcare Crisis. The Wall Street Journal calls Dr. Goodman "the father of Health Savings Accounts."

Dr Goodman, in an article entitled, "Is Obamacare Hazardous to Your Health," and published 8/15/2014 in Forbes, writes:

The Obama administration wants to change the practice of medicine.  Marcus Welby is out. Working in teams is in – especially in large practices owned by hospitals. Along the way, doctors are being subjected to pay-for-performance protocols and other forms of managed/integrated/coordinated care. 

How is all that working?  Not well at all.

A new study, which will soon appear in Health Affairs, showed these unexpected results: Practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19 physicians. 

I say “unexpected” because virtually everyone in the health policy community has bought into the idea that good medicine is medicine practiced in teams – rather than solo – and it is medicine that centers on medical homes  and follows protocols where physicians are rewarded for the “value they create” not the number of things they do. “Value” of course is determined by some bureaucracy somewhere. 

When I say “everybody” has bought into this idea I really mean everybody who is anybody except for … well … except for doctors who actually treat real patients. Whereas two thirds of doctors worked in private practice a few years ago, more than half of all doctors work for hospitals today. Medicare pays doctors more for the same procedures if billed as a hospital employee than if billed directly by a solo practitioner, perhaps to encourage the demise of private practice. 

Yet the Health Affairs study couldn’t be clearer. Practices owned by hospitals had 50 percent more preventable admissions than practices owned by physicians (regardless of size). 

The larger practices as well as hospital-based practices made greater use of medical homes, were more likely to be rewarded by pay-for-performance formulas and did better on performance measures that focused on inputs, not outputs. So why were the results so bad?

For the full article, click here.

Entire Value of Property in Which Medicaid Recipient Had Life Estate is Recoverable in Idaho

The Idaho Supreme Court has ruled that the state may recover Medicaid benefits from the entire value of a property that a Medicaid recipient transferred to his daughter while retaining a life estate for himself. In re Estate of Peterson (Idaho, No. 40615, Aug. 13, 2014).

Melvin Peterson deeded property to his daughter, retaining a life estate for himself. He then applied for Medicaid benefits. When he died, Mr. Peterson had received a total of $171,386.94 in Medicaid benefits.

The state filed a claim against the estate to recover the Medicaid benefits it paid for Mr. Peterson's care. Under Idaho law, the state may recover any property that passes outside of probate, including any property that that the Medicaid recipient had a legal interest in that passes to a survivor through a life estate or "other arrangement." The trial court ruled that the life estate remainder interest, but not the retained life estate, was an estate asset, and the appeals court affirmed. The estate appealed, arguing Mr. Peterson had no interest in the life estate at his death, so it could not be subject to recovery.

The Idaho Supreme Court affirms in part holding that both the life estate and the remainder interest were estate assets subject to Medicaid recovery. The court determines that Mr. Peterson's life estate interest in the property was transferred to his daughter when he died, and under state law "when assets of a Medicaid recipient are conveyed to a survivor, heir or assign by the termination of a 'life estate,' the assets remain part of the recipient’s 'estate'" for purposes of Medicaid recovery. In addition, the court rules that the remainder interest Mr. Peterson's daughter received is also part of Mr. Peterson's estate as an "other arrangement."

For the full text of this decision, go to: http://www.isc.idaho.gov/opinions/40615.pdf