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.