Study Confirms that Quality of Care Higher in Non-Profit Nursing Homes

Older adults who reside in for-profit nursing homes are nearly twice as likely to have health problems linked to poor care than those in nonprofit nursing homes and those who live in private homes.  This is the conclusion of newly released research published in the Journal of Gerontology. 

According to a press release from the University of Illinois at Chicago, the researchers, led by Lee Friedman, associate professor of environmental and occupational health sciences in the University of Illinois at Chicago School of Public Health, also found that community-dwelling adults 60 years old and older who need assistance with tasks related to daily living but do not live in a nursing home had the fewest number of clinical signs of neglect compared with those living in any type of nursing facility.

"We saw more -- and more serious -- diagnoses among residents of for-profit facilities that were consistent with severe clinical signs of neglect, including severe dehydration in clients with feeding tubes which should have been managed, clients with stage 3 and 4 bed sores, broken catheters and feeding tubes, and clients whose medication for chronic conditions was not being managed properly," said study leader Lee Friedman in the press release.  Friedman added that substandard care falls within the definition of elder abuse.

The study included more than 1,100 people, aged 60 and older, who were seen in five Chicago-area hospitals between 2007 and 2011 for health problems that could be related to poor care.

Along with finding that neglect-related health problems were more common in for-profit nursing homes than in nonprofits, the researchers also found that community-dwelling patients had fewer of these problems than those in any type of nursing home.  Community-dwelling patients need help with daily living but live in private homes, often with family members or friends.

According to the researchers:

"For-profit nursing facilities pay their high-level administrators more, and so the people actually providing the care are paid less than those working at nonprofit places, so staff at for-profit facilities are underpaid and need to take care of more residents, which leads to low morale for staff, and it's the residents who suffer."

Friedman said more oversight of nursing homes is needed, along with improved screening and reporting of suspected neglect.

This study is unique in that it also included consideration of community based health care residents.  The conclusion that non-profit homes are superior to their for-profit competitors, however, is well established. According to the report:

"As reported in prior research, for-profit facilities caring for the patients in this study were  significantly inferior across nearly all staffing, capacity, and deficiency measures. Furthermore, the most serious clinical signs were consistently more prevalent among residents of for-profit facilities, including dehydration with presence of gastrostomy, not being provided basic medications to manage chronic conditions, stage 3 or 4 pressure ulcers, and complications with urinary catheters and feeding tubes.

Many studies show that neglect is the most common form of elder mistreatment but is more likely to be overlooked because of its muted nature, although the outcomes of neglect can be as pernicious as physical abuse. 

Aging in Place requires planning and accurate information.  Implementing an objective to remain at home, a senior or family member acting on his or her behalf may nonetheless be forced to institutional care, even if for only a short period of time.  Selecting the institution most likely to provide positive health outcomes is paramount, as is acknowledgement that short-term institutional care can result in long term institutional care if health outcomes are negative.

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.

2019 Medicare Advantage Plans Incorporate Long Term Care, Aging in Place Benefits

Some Medicare Advantage Plan (hereafter simply "Plan") issuers are quietly and carefully adding home-based and community-based long-term care (LTC) benefits for 2019, according to Allison Bell, ThinkAdvisor's insurance editor. According to an excellent ThinkAdvisor article, officials at the Centers for Medicare and Medicaid Services (CMS). estimate that about 1.5 million of the 2019 enrollees, or 7.5% of Medicare Advantage plan enrollees, may have access either to support services in the home or community, or to extra benefits designed to help enrollees cope with the burden of diabetes or other chronic conditions. CMS officials have not, however, estimated how many enrollees might have access solely to the new home- or community-based services.  

A previous blog article discussed these changes; see the article entitled, "Trump Administration Embraces Aging In Place- 2019 Advantage Plans Permitted to Incorporate Long Term Care," available by clicking here. 

In Arizona and California, for example, units of Anthem Inc. are openly stating that they will use the new flexibility to beef up the benefits offered by some plans.  Enrollees in certain Anthem plans will have access to what amount to LTC benefits provided for a short period of time:

• Three meals delivered per day for up to 42 days.
• Four four-hour shifts of in-home assistance with daily living activities, such as laundry.
• 40 hours of respite care for caregivers per year.
• One visit per week for adult day care center services, for older adults who need supervision.
• Health care appointment transportation services.

Traditionally, commercial insurers have referred to benefits for small amounts of LTC-type services with terms such as “convalescent care benefits,” or “short-term care benefits.”  SCAN Health Plans of Long Beach, California, says it will offer new in-home benefits through most plans in Southern California, but it’s not easy to tell which new benefits will be related to the new rules.

UnitedHealth Group Inc.’s UnitedHealthcare unit says it will make telemedicine services available to 1.7 million enrollees through phones and computers, and health-related transportation services available to 1.7 million enrollees. The company is also offering a care management and care planning service for caregivers to most of its Medicare Advantage plans. It’s not clear from the company’s 2019 plan announcement whether those beneits are related to the new CMS rules.

Lack of clarity is a real problem. Unfortunately, for someone looking at the CMS 2019 Plan Information or even the plan issuers’ own benefits summary sheets, it is not easy to tell which plans will take advantage of the new CMS benefits flexibility.  Moreover, the value of these additional services, and possible resulting costs are difficult for a lay person to evaluate.  For these reasons, we strongly urge clients to establish a relationship with a trusted advisor.  Locally, many of our clients use the advisors at Harding, Harding & Associates. 

Traditionally, Medicaid has been the government health program that pays for nursing home care.  Federal rules have blocked Medicare from paying for long-term care.  Medicare has paid for skilled nursing care for people recovering from serious acute health care problems, and promised to pay for limited home health care services.

But Medicare has not paid for nursing home care for people who are in a nursing home simply because they are frail or have trouble with the activities of daily living, such as bathing or eating.  Medicare has also avoided paying for other types of in-home services, such as help with cleaning or laundry, that might help keep older people in their homes.

In May, CMS said it would change Medicare Advantage benefits rules, to give issuers ways to offer new benefits for the “social determinants of care” that might help reduce overall medical spending.  Officials suggested, for example, that, in some cases, spending a little money on transportation services or meal delivery for someone with serious health problems might be a good way to avoid spending a lot of money on hospital care. 

CMS Announces 2019 Medicare Premiums and Deductibles

On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.

Medicare Part B Premiums/Deductibles

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.  

The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019, an increase of $1.50 from $134 in 2018. An estimated 2 million Medicare beneficiaries (about 3.5%) will pay less than the full Part B standard monthly premium amount in 2019 due to the statutory hold harmless provision, which limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits. The annual deductible for all Medicare Part B beneficiaries is $185 in 2019, an increase of $2 from the annual deductible $183 in 2018. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts (IRMAA) affect roughly 5 percent of people with Medicare Part B.  The total premiums for high income beneficiaries for 2019 are shown in the following table:

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Medicare Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,364 in 2019, an increase of $24 from $1,340 in 2018. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2019, beneficiaries must pay a coinsurance amount of $341 per day for the 61st through 90th day of a hospitalization ($335 in 2018) in a benefit period and $682 per day for lifetime reserve days ($670 in 2018). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $170.50 in 2019 ($167.50 in 2018).

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $240 in 2019, an $8 increase from 2018. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $437 a month, a $15 increase from 2018.

For more information on the 2019 Medicare Parts A and B premiums and deductibles (CMS-8068-N, CMS-8069-N, CMS-8070-N), please visit https://www.federalregister.gov/public-inspection.

Social Security Announces 2019 Changes

The Social Security Administration (SSA) has released the 2019 benefit changes.   Based on the increase in the Consumer Price Index (CPI-W) from the third quarter of 2017 through the third quarter of 2018, Social Security and Supplemental Security Income (SSI) beneficiaries will receive a 2.8 percent increase or COLA for the year 2019. 

SSA also announced an increase in the SSA taxable maximum amount to $132,900. The indivdiual's amount for SSI for 2019 will increase to $771 per month. 

The tax rate for most people is 7.65%, the combined rate for Social Security and Medicare. The Social Security portion (OASDI) is 6.20% on earnings up to the applicable taxable maximum amount. The Medicare portion (HI) is 1.45% on all earnings. Also, as of January 2013, individuals with earned income of more than $200,000 ($250,000 for married couples filing jointly) pay an additional 0.9 percent in Medicare taxes (not reflected in the 7.65% combined rate reported above). 

The detailed fact sheet is available here.

Declining SNF Utilization

There is increasing evidence that either (1) utilization of nursing homes is rapidly diminishing, or (2) utilization of nursing homes has reached saturation, and competition is closing less competitive operations.  One would like to think that seniors and their families are implementing "Aging in Place" planning in order to avoid institutionalization. The issue is complicated, however, and although what is occurring is demonstrable, the underlying causes are unclear. 

The New York Times recently published an article discussing the phenomenon entitled "In the Nursing Home, Empty Beds and Quiet Halls,"explaining that a once vibrant facility now stands closed due to a drop in demand.  According to the article, "[t]he most recent quarterly survey from the National Investment Center for Seniors Housing and Care reported that nearly one nursing home bed in five now goes unused. ... Occupancy has reached 81.7 percent, the lowest level since the research organization began tracking this data in 2011, when it was nearly 87 percent."  

The occupancy rate for skilled care nursing homes has been trending downward, and as a result facilities close.  According to the article, somewhere between 200-300  close annually.  The article  offers some possible explanations for the phenomenon given the number of baby boomers that one might think would cause an increase in demand.  The article suggests the decreasing utilization is caused by:  

• Increased regulations and more financial belt-tightening;
• Hospitals' use of observation status,which affects Medicare coverage for subsequent SNF care;
• More surgeries on an out-patient basis;
• Increasing number of Medicare Advantage plans;
• Increased competition through other housing options;
• The shift to Medicaid covering care in the community, with "Money Follows the Person [having] moved more than 75,000 residents out of nursing homes and back into community settings."

The article speculates whether this trend will reverse itself once the boomers start reaching age 80 and beyond. The article also discusses whether the lower demand provides more options for those in need of nursing home care.

Conservator Owes Duty to Nursing Home to Timely Apply for Medicaid

A Connecticut appeals court has held that a nursing home resident's conservator owes a duty of care to the nursing home to timely apply for Medicaid on behalf of the resident. Bloomfield Health Care Center of Connecticut, LLC v. Doyon (Conn. App. Ct., No. AC 40281, Oct. 9, 2018).

A nursing home petitioned the court to appoint a conservator for one of its residents, Samuel Johnson, to assist him with his Medicaid application. The court appointed Jason Doyon as conservator in April 2014. Mr. Doyon waited nine months to file a Medicaid application on Mr. Johnson's behalf. The state denied Mr. Johnson's first Medicaid application due to lack of information. Mr. Doyon filed a second application, which the state approved, but Mr. Johnson did not receive any Medicaid benefits before May 2015.

The nursing home sued Mr. Doyon for negligence in failing to apply for and obtain Medicaid benefits on behalf of Mr. Johnson in a timely manner. Mr. Doyon asked for summary judgment, arguing that he did not owe a duty of care to the nursing home. The trial court granted Mr. Doyon summary, holding that the conservator owed no duty to the nursing home.  The nursing home appealed the lower court's judgment.

The Connecticut Court of Appeals reversed.  The court held that Mr. Doyon owed the nursing home a duty of care. The court rules that it was "readily foreseeable that, if [Mr. Doyon] failed to timely obtain Medicaid benefits for [Mr.] Johnson, the [nursing home] would suffer harm as a result because it would not be reimbursed for the cost of [Mr.] Johnson’s care." The court also concludes that "the benefits of encouraging conservators to carry out their duties with care and preventing financial harm outweigh any corresponding minimal increase in litigation."

The decision continues a trend of decisions favoring nursing homes when eligibility applications for Medicaid are not timely or properly prosecuted.  The decision should also concern family caregivers; the trend might foreshadow greater success on the part of nursing homes in disputes with family members who act as fiduciaries without court appointment.  Family often acts in court-appointed roles, or more informal roles without careful consideration of the liabilities of service. The bottom line is that Medicaid applications should be taken seriously, and the applications completed and submitted as quickly as possible.   

Wealthy Nursing Home Residents Would Prefer to Age in Place- Would Pay Family For Care

A new survey of wealthy seniors suggests that many of nursing homes’ potential residents would prefer to receive long-term care at home, and would be willing to pay their own family members for it.

That’s according to responses of more than 1,000 U.S. adults, age 50 or older, with an annual household income of $150,000 or more. The Harris Poll, conducted on behalf of the Nationwide Retirement Institute, found that about 71% of seniors would prefer to rely on a family member for long-term care. And 70% of those surveyed would not expect that help, unless they were able to pay relatives.

About 56% of respondents said that they “would rather die” than live in a nursing home, and 47% said they’re worried about becoming a burden to their families.

“Affluent adults fear nursing homes but are concerned their care needs will challenge their family if they require caregivers,” Nationwide VP Holly Snyder said in a press release.

About 77% of respondents said, if needed, they’d most prefer to receive long-term care at home. That’s compared to 1% preferring to receive skilled care in a nursing home. Reasons for those worries included loss of control of their lives (68%), detachment from the community (32%) and seeing family less often (30%).

More details from the seventh annual survey can be found on Nationwide’s website here.

A Military App for Military Moms and Dads - Babies on the Homefront App is Military Parent Approved

[The following article is penned by Jennifer Novak, Senior Writer and Training Specialist for Military Family Projects and reprinted with permission of USAA] 

Babies on the Homefront is so much more than messaging—it’s designed to strengthen the bond separated service members have with their families. And it works! 

As the wife of a service member, I can tell you that separations are hard. But they were even harder for my children. Every separation and transition caused an enormous amount of pain for our little ones. With a background in early childhood, I know that these moments of stress, worry, and feelings of loss can have a profound impact on children’s development and well-being--including how fast their brain grows! As a mother, I knew it was important to provide my children with a sense of security and to help maintain the connection they felt with their father while he was away.  

My husband’s time as an active duty service member was full days, weeks, and months of separation due to deployment, training, work-ups, changes in work schedules--not to mention all the moving from one duty station to another! Babies on the Homefront is designed to keep up with the many transitions military families go through and to maximize the relationship that can be maintained long distance. Through secure messaging, creative baby games, sharing updates, and finding answers to all your parenting questions, this app has been a great tool for keeping my husband in the know.   

Never Miss a Beat 

“When do you think we will get to talk to Daddy again?” is a question that came up all too frequently in my military family. Depending on the type of separation, the ability to talk to their father could change dramatically. A week-long training out of town might still mean daily video calls, but a work-up at sea? They may not see him or hear his voice the entire time he was gone. It’s important for babies and toddlers to stay connected with the active duty parent as much as possible during deployment. A young child needs to know that his parent remains an important part of the family and that he is held in his parent’s heart and mind. 

Through the app, you can make the parent away part of a daily or weekly routine. Gather around the app to look at shared photos and videos. Even if the parent is unable to call home as planned, record a video message that can be watched later instead. The parent at home can share memories of the deployed parent, including times that the parent spent with the young child. These stories can paint a vivid and loving picture of the deployed parent and the special role that parent played, and continues to play, in the child’s life. 

Capturing Milestone Moments 

The shared media gallery is more than a space to upload photos – it’s an opportunity to build a shared visual story of both photo and video content that can help keep the parent in the mind of the child and the child in the mind of the parent. While sharing moments is easier than ever with email and social media, there are still drawbacks – the military email system is often unreliable and isn’t a baby-friendly way of communicating. Staying connected through social media means forgoing privacy for the sake of staying in touch. This app has a safe and secure way to capture, upload, and share photos with service members away from home. Each photo and video is saved and collected in a timeline so that they can be replayed again and again. 

The Right Answers at the Right Time 

No matter how well I thought we had prepared our children – by being honest about what to expect, by talking to them about what was happening, by telling them about what daddy was doing when he was away – every separation and transition came with challenging behaviors and parenting challenges. I’ve looked for answers in parenting books, websites, apps, forums, and newsletters. Babies on the Homefront gives you access to parenting resources right in the app. The extensive in-app library provides quick resources and age-based tips for parents to learn more about child development, milestones, self-care, and resources for how to prepare for separations and reunifications.   

Play Together, Stay Together 

As your one-stop parenting app, Babies on the Homefront is filled with interactive game ideas and playful activities for babies and toddlers. Play simple touch screen games together designed to help young children learn or watch video clips demonstrating new activities and play ideas. Playing together is one of the best ways to encourage learning, to stimulate growth and development, and to help your child feel safe, loved, and special. There is no shortage of ideas to keep you and your young ones moving and learning at any age.   

This app is the perfect solution for military families to stay connected. The needs of the military will always require family separations, but with Babies on the Homefront, you have the power to make this a little easier on our little ones and to strengthen the relationships parents have with their children and each other. This isn’t just good for children – it also empowers our fighting force through the security of knowing they can maintain their relationships with their children, even when they are away.  

You can learn more about the app, and/or download the app here. 

Veterans to Receive "Combat-Injured Veterans Tax Fairness Act" Letters

In 2016, Congress passed a law known as the Combat-Injured Veterans Tax Fairness Act. The law entitles more than 133,000 injured veterans to tax refunds as far back as 1991. The objective of the law is to ensure that veterans who suffer service-ending combat-related injuries aren’t taxed on the severance payment they receive from Department of Defense (DOD).

The DOD is just beginning to send letters to the eligible veterans with information explaining how to claim the tax refunds. The letters will provide an explanation of a simplified method for claiming the refund, and explain the time limits for making the claims.

The amount of time for claiming the tax refunds is limited.  Veterans who have claims for refunds can amend their tax returns claiming the refund in the normal limitations period for filing amended tax returns, or three years.  Obviously, some of these amended returns are already time barred.  The law gives veterans an alternative time frame, or one year from the date of the letter from DOD. In other words, veterans can make a claim for the refund for one year from the date of their letter from the DOD, or within three years of the original filing deadline for the return, whichever expires later.

There are a couple of ways a veteran can claim the refund.  A veteran can either send in a claim based on the actual amount of the disability severance payment received by filling out Form 1040X, but a veteran must carefully follow the instructions for making the claim.  Alternately, a veteran can opt for a simplified method. The veteran can simply choose to claim a standard refund amount based on the calendar year in which the veteran received the severance payment. The veteran then writes “Disability Severance Payment” on line 15 of Form 1040X and enters on lines 15 and 22 the standard refund amount listed below that applies:

• $1,750 for tax years 1991 – 2005
• $2,400 for tax years 2006 – 2010
• $3,200 for tax years 2011 – 2016

For more information talk with your tax attorney or go here.