More than 50% of Dual-eligibles Steered to Low-rated Nursing Homes

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Accepting the risks of the current health care system, for seniors, their families, and caregivers, often includes accepting the risks of referral to a nursing home after Medicare hospital benefits expire. Most assume that the transition is, like other aspects of health care, handled carefully and competently, and with the patient's best interest being paramount.  Unfortunately, that assumption is dangerously incorrect.

A recent study found that seniors who are eligible for both Medicare and Medicaid are more likely to wind up in low-quality skilled nursing facilities rather than available higher quality alternatives.  The authors summarize by concluding "(duals) are concentrated in lower quality [with ratings from 1 or 2 of five stars] nursing homes, relative to those not on Medicaid." Implicit is that Medicaid residents find themselves in the lowest quality facilities.

The study is significant because "dual eligible" seniors have, or should have, access to the widest variety of institutions, since they can be referred to both institutions accepting Medicaid and Medicare, and are not excluded from either those that don't accept Medicaid, or Medicaid-only facilities (the latter characterization is often misnomer since most institutions will accept both, but some institutions become Medicaid-primarily, or Medicaid-only). Medicaid residents often find themselves relegated to  the lowest quality facilities. The results of the study are the subject of an article published in McKnight's Long-term Care News. 

The study identified patient education and proximity to quality skilled nursing facilities as key reasons for the disparity.   This blog has repeatedly warned that the proximity of a care choice to the resident's home, or family, or hospital is a poor bases upon which to select a care provider.  

The study is published in the Journal of Applied Gerontology. According to the study's authors, the solutions are is not limited to investment in formal education and relocating high-quality facilities into areas where dual-eligible beneficiaries live. Rather, experts suggest that health care leaders should work to better disseminate information on high-quality care options to duals, and to improve lagging nursing homes in low-income areas:

“More interactions among nursing home leaders from both high-quality and low-quality facilities can help identify ways to improve low-quality facilities in poorer neighborhoods,” lead author Hari Sharma, Ph.D., an assistant professor in the University of Iowa’s Department of Health Management and Policy, told McKnight’s on Thursday.

Sharma and colleagues reached their conclusions based on nursing home quality data from 2009 — the first year after Five-Star ratings were made public, before facilities had a chance to substantially improve scores (by 2011, a large proportion of SNFs were rated as four or five stars, authors wrote). They found that duals were 9.7 percentage points more likely than non-duals to be admitted to a SNF rated as one or two stars (50.7% compared to 40.9% for non-duals).  

Authors note that healthcare leaders must find ways to address those additional factors that contribute to disparity. For instance, hospitals might work to steer duals to high quality nursing homes, Sharma said. Another important takeaway for SNF leaders from the study is the need to form partnerships with legislators to help eradicate inequalities:

“Our research highlights the need to invest more resources to improve existing low-quality nursing homes in areas that do not have many alternatives. Since investment of additional resources requires the commitment from both policymakers and nursing home leaders, it is imperative that both sides actively work together to improve existing low-quality nursing homes.”

For those planning to "Age in Place," this study provides more evidence for justification, and illustrates the importance of educating caregivers and fiduciaries regarding the workings of the health care and legals systems.   

Feds Release New Quality Data Online

McKnight's Long Term Care News reports that the federal government has released new data on the quality of care delivered in skilled nursing facilities.  Centers for Medicare & Medicaid (CMS)  added five brand new quality-related measures to Nursing Home Compare. 

Transparency of outcomes “continues to intensify,” with this posting of the inaugural SNF Quality Reporting Program (QRP) measures, said Amy Stewart, RN, curriculum development specialist with the American Association of Directors of Nursing Services.  She encouraged nursing homes to check their scores on the five newly published SNF measures as soon as possible to know what the potential clients are seeing, and be ready to discuss the results. Scores will be of more interest than ever before to hospitals and other healthcare entities looking to partner with SNFs.

The five quality measures included in this latest release include:

• Percent of residents that developed new or worsening pressure ulcers during their stay in an SNF (1.7% is the nationwide rate in SNFs according to CMS);
• Percentage of patients whose activities of daily living and thinking skills were assessed and related goals were included in treatment plan (95.8% nationally according to CMS);
• Percentage of patients that experienced a fall resulting in a major injury during their stay in a SNF (0.9% nationally according to CMS);
• Medicare spending per beneficiary for patients in SNFs (showing whether Medicare spends more, less or about the same, per episode of care for a patient treated in a SNF compared to how much Medicare spends on an episode of care across all SNFs nationally);
• Rate of successful return to home or community from a SNF (48.57% nationally according to CMS).

CMS decided not to include a sixth quality measure it had previously planned to employ: Potentially preventable 30-day post-discharge readmission. Instead, the agency will allow for additional time to test and determine if there are modifications needed to better display this measure.

CMS has posted a FAQ (Frequently Asked Questions) on its website to answer some of the most common questions related to this release.

While some measures may seem duplicative of those used in the Five-Star Rating System, which includes all residents, these SNF QRP measures are specific to Medicare Part A residents only.

Man Transported to SNF But Dropped Off at Wrong Location Found Alive Three Days Later

Among the inherent risks of institutional care is transport error.  An object lesson comes in the recent story of an Illinois man  who was dropped off at an intersection nearly ten 10 miles from the nursing home where he was supposed to be admitted.  He was found nearby in a ditch in a three days after.

Michael Bennett, 66, was in the process of being transferred from the Chicago Behavioral Hospital in Des Plaines, IL, to Westwood Nursing Home in Chicago. He was left at an intersection in Des Plaines approximately 10 miles away from the nursing home, according to authorities.  Illinois State Police issued a missing and endangered alert for Bennett. After seeing the alert, a citizen spotted Bennett curled up in a ditch three days later. Bennett was taken to a local hospital for evaluation.

The behavioral hospital is responsible for transporting discharged patients,  An administrator at Westwood told local reporters he was “mystified” that the driver didn't attempt to escort Bennett inside the nursing home, or notice that the facility was not located at the intersection.

The hospital had no comment on the incident.

To read other articles regarding the risks of transport, go here and here.

Congress Considering Removing Medicaid Eligibility Planning Opportunities- Spousal Income Annuities Targeted

Congress is considering making it harder to qualify for Medicaid if a community spouse has an annuity.  The change is part of an effort to close what Congress considers "loopholes" in Medicaid law.

The proposed bill aims to prevent married couples from using assets to purchase an annuity for the community spouse, so that the institutionalized spouse can apply for Medicaid. The bill would count half of the income from a community spouse's annuity as income available to the institutionalized spouse for purposes of Medicaid eligibility. The House Energy and Commerce Committee held a hearing on February 1, 2017, to consider the changes.  It is unclear how eligibility will be changed since income can not be "liquidated" to pay for care.  Regardless, the proposed changes would mean that married couples would have one less tool available to create an adequate safety net for a community spouse affected by nursing home spend down.  

Along with limiting spousal annuities, Congress is also considering bills to count lottery winnings as income and require Medicaid applicants to prove U.S. citizenship or residency before receiving benefits.

For more information about the proposed legislation, click here.

Patient Discharged to Nursing Home 300 Miles Away

McKnight's has reported that a Georgia hospital discharged and transported a patient to a nursing home 300 miles away, resulting in a lawsuit filed by the patient's sister. 

Johnny Lee Bryant was admitted to Doctors Hospital in Augusta, GA, in early January 2015 from  a nearby long-term care facility. He was treated at the hospital for sepsis and pneumonia for less than two weeks before he was discharged.

Instead of returning to the nearby facility, Bryant was transported by Gold Cross EMS to a nursing home nearly 300 miles away. Once there, the nursing home refused to admit Bryant.   Bryant was eventually taken back to Augusta and admitted to a different hospital, where he died in February 2015.

The lawsuit, filed by Bryant's sister accuses the hospital, the ambulance company and Hetal Thakore, M.D., of negligence, wrongful death and causing emotional distress.

For more information, go here. 

Bill Offers Tax Credit for Aging In Place Improvements

Making your home more accessible for your long term care needs may soon be incentivized by a $30,000 tax credit.

Rep. Patrick Murphy, D-Fla., recently introduced H.R. 5254, entitled, “Senior Accessible Housing Act,” which would incentivize individuals 60 years of age and older to “age in place” by way of a $30,000 tax credit for home modifications. Potential modifications include the widening of doorways and the installation of ramps, handrails, grab bars and non-slip flooring.

The Congressional Research Service (CRS) summary of the Bill reads as follows:

This bill amends the Internal Revenue Code to create a nonrefundable personal tax credit for senior citizens who modify their residences to enhance their ability to remain living safely, independently, and comfortably in the residences.  

The credit applies to up to $30,000 of the expenses that individuals who are at least 60 years old incur over their lifetime to make modifications to their residences, including: 

•  the installation of entrance and exit ramps;

• the widening of doorways;

• the installation of handrails or grab bars

• the installation of non-slip flooring, and;

• other modifications that the Internal Revenue Service (IRS) includes on a list of modifications that would enhance the ability of the individuals to remain living safely, independently, and comfortably in their residences.

The IRS must establish and maintain the list of acceptable modifications after consulting with the Department of Health and Human Services (HHS) and receiving input from the public. 

The Bill and credit would certainly be more meaningful if current HHS policy was not hostile to home bound health care or home bound hospice care.  For more information regarding HHS policy of actively discouraging use of the Medicare home health care and hospice benefits, go here and here.  Regardless, the Bill currently has 19 co-sponsors.

To follow activity on the bill, go here.

To read the text of the bill, go here. 

Incorrect Denial of Medicaid Benefits Not a Defense to Nursing Home Claim on Contract

A recent case illustrates that seniors, their families, and caregivers should not rely upon institutions or the state to plan for their care; the results are often unpredictable and damaging. A New York trial court has held that the fact that Medicaid wrongly denied benefits to a nursing home resident is not a defense in a breach-of-contract claim against the resident, who died leaving an unpaid bill. East End Healthcare v. Gegenheimer (N.Y. Sup. Ct., Suffolk Cty., No. 12-21672, June 29, 2015).

Anna Amico entered a nursing home and signed an admission agreement guaranteeing payment for services.  She had a reverse mortgage, and little in the way of resources, so she applied for Medicaid.  Her niece, Joan Gegenheimer, withdrew money from Ms. Amico's reverse mortgage line of credit account shortly after Ms. Amico entered the nursing home.  The proceeds were placed in a joint bank account between Amico and her niece.  The niece withdrew some funds to pay for Ms. Amico's needs at the home.  Substantial funds were turned over to Ms. Amico, who, knowing she was terminal, paid off debts to families and friends.  When Ms. Amico applied for Medicaid benefits, the state assessed a penalty period because of the transfer. Ms. Amico died owing an amount to the nursing home, which, because of the penalty period, was equal to the amount withdrawn.

Ms. Amico died before the Medicaid determination was made, and therefore, no one filed an appeal of the denial.

The nursing home sued the niece, Ms. Gegenheimer in her capacity as executrix of Ms. Amico's estate, for breach of contract and fraudulent conveyance. Ms. Gegenheimer argued that she withdrew the money from Ms. Amico's reverse mortgage account for Ms. Amico and did not keep any of the money. According to Ms. Gegenheimer, Medicaid improperly denied coverage to Ms. Amico because it counted the money in the reverse mortgage line of credit as an available resource.  The nursing home moved for summary judgment.

The New York Supreme Court, Suffolk County, granted the nursing home summary judgment on the breach-of-contract claim, but denied summary judgment on the fraudulent conveyance claim. The court held that any mistake by the state in considering Ms. Amico's reverse mortgage line of credit funds as an asset that led to the denial of Medicaid benefits is not a defense, because Ms. Amico signed a contract expressly agreeing to make private payments. The court also ruled that because there was no evidence introduced that Ms. Gegenheimer kept the money that she withdrew from Ms. Amico's account, or that the nursing home sent Ms. Amico a bill for her services, there remains  triable issues of fact as to whether Ms. Gegenheimer or Ms. Amico believed that the use of funds would make Ms. Amico insolvent.  The case was remanded to trial court for further proceedings.  

For the full text of this decision, go here.

Ambulance Driver Charged with Homicide in Death of Nursing Home Resident

McKnight's reports that the New York Attorney's General office has indicted a former medical transport driver for criminally negligent homicide related to the death of a nursing home resident.  

Driver Juan Garcia was working for Maeleen Ambulette Transport Inc. while transporting an elderly nursing home resident back to the facility from a dialysis appointment, when he came to an abrupt stop. The resident apparently was thrown from her wheelchair in the August 2010 incident. Garcia, 49, has admitted he had not buckled the resident's seatbelt, according to the attorney general's office.

Even though a certified nursing assistant in the ambulette asked Garcia to take the resident to the hospital, he proceeded to drive to the Gold Crest Care Center, the charges state. The resident subsequently underwent surgery for a fractured hip and died about a month later from complications.

“Had [Garcia] taken the most basic safety precautions, this vulnerable nursing home resident would not have died in this horrific way,” Attorney General Eric T. Schneiderman stated.  Garcia was arraigned in Bronx County Supreme Court and released on his own recognizance, according to Schneiderman's office. He faces up to four years in prison if convicted.