By Susan Jaffe | April 23, 2015 | Kaiser Health News and also published in 
Category: Long term care
Aging In Rural America
For older Americans, accessing high-quality care can be a challenge. For those in rural communities, it’s even harder.
By SUSAN JAFFE Health Affairs January 2015 Volume 34, Number 1
Care in rural America: Dr. Robert Wergin goes over medications with Sharon Stutzman at the Milford Family Medical Center in rural Nebraska.
In the southeastern Nebraska town of 
Milford, population 2,100, Dr. Robert Wergin understands it’s not easy for some of his older patients to get to his office. Some may live on isolated farmsteads several miles out of town, and if they don’t drive, their son or daughter—if nearby—may have to take time off from work to bring them to their appointments because there’s no public transportation. Massive snowstorms are nothing special but still cause a wave of cancellations.
In addition to these challenges, rural America’s elderly tend to be poorer, have higher levels of chronic disease, and have a dwindling supply of health care providers, compared to their peers in urban communities, explains Brad Gibbens, deputy director of the University of North Dakota’s Center for Rural Health, in Grand Forks. And their support system is shrinking, as more young adults seeking job opportunities head out to urban areas. “The elderly [rural] population tends to stay put because that’s where they’ve lived all their lives, and there isn’t really an economic beacon that’s pulling them to another area,” he says. [Continued in Health Affairs, and PDF here]…
Disabled Vt. Senior Wins Medicare Coverage After 2nd Lawsuit
By Susan Jaffe | Kaiser Health News in collaboration with National Public Radio | October 30, 2014
A disabled senior with serious health problems who successfully challenged Medicare for denying her home health care coverage has racked up another win against the government.
In her latest federal lawsuit filed in June, Glenda Jimmo, 78, argued Medicare should have paid for the nursing care and other skilled services she received at her home during 2007. On Wednesday, Medicare officials agreed, invalidating an April ruling that she was not entitled to coverage because her condition had stabilized and she was not improving. “I won,” said Jimmo, who is receiving rehab therapy at a Vermont nursing home and hopes to return home soon. 
“I’m very pleased. It makes me feel America is still in good shape.”
The settlement doesn’t mention that Jimmo was the lead plaintiff in a 2011 class-action lawsuit seeking to eliminate the so-called “improvement standard” as a criteria for Medicare coverage. In the 2012 settlement that bears her name, the government agreed that improvement was not required and allowed many Medicare beneficiaries with chronic conditions and disabilities to appeal claims that had been denied because they were unlikely to get better. [MORE from Kaiser Health News and NPR] …
Disabled Vt. Senior Who Led Class Action Suit Sues Medicare — Again
By Susan Jaffe | Kaiser Health News in collaboration with National Public Radio | October 27, 2014
A 78-year-old Vermont mother of four who helped change Medicare coverage for millions of other seniors is still fighting to persuade the government to pay for her own care.
Glenda Jimmo, who is legally blind and has a partially amputated leg due to complications from diabetes, was the lead plaintiff in a 2011 class-action lawsuit seeking to broaden Medicare’s criteria for covering physical therapy and other care delivered by skilled professionals. In 2012, the government agreed to settle the case, saying that people cannot be denied coverage solely because they have reached a plateau and are not getting better.
The landmark settlement was a victory for Medicare beneficiaries with chronic conditions and disabilities who had been frequently denied coverage under what is known as “the improvement standard” —a judgment about whether they are likely to improve if they get additional treatment. It also gave seniors a second chance to appeal for coverage if their claims had been denied because they were not improving.
Jimmo was one of the first seniors to appeal her original claim for home health care under the settlement that bears her name. But in April, the Medicare Appeals Council, the highest appeals level, upheld the denial. The judges said they agreed with the original ruling that her condition was not improving — criteria the settlement was supposed to eliminate.
After running out of options appealing to Medicare, her lawyers filed a second federal lawsuit in June to compel the government to keep its promise not to use the improvement standard as a criterion for coverage.The council’s decision makes no sense to Judith Stein, executive director of the Center for Medicare Advocacy, which filed the original class action lawsuit with Vermont Legal Aid and helped negotiate the Jimmo settlement. “People shouldn’t have to decline in order to get the care they need,” Stein said. [MORE from Kaiser Health News and NPR] …
Hospitals Required To Tell Patients Of Observation Care Status
By Susan Jaffe | September 30, 2014
Connecticut Health Investigative Team and The Hartford Courant
Starting Wednesday, a new state law requires Connecticut hospitals to tell all patients when 
they are being kept in the hospital for observation instead of being admitted and to warn them about the financial consequences.
Anyone who goes to the hospital can be placed on observation status, so that doctors can determine what’s wrong, and decide whether the patient is sick enough to be admitted or well enough to go home. Observation patients may receive diagnostic tests, medications, some treatment, and other outpatient services. Depending on their insurance, they can be 
charged a share of the cost. In addition to hospital bills, Medicare observation patients whose doctors order follow-up nursing home care will have to pay the nursing home themselves. Medicare covers nursing homes only after seniors are admitted to the hospital and stay through three consecutive midnights. A month in a Connecticut nursing home can cost as much as $15,000.
Medicare does not require hospitals to tell patients when they are getting observation care and what it means. And the number of Medicare observation patients is growing rapidly — 88 percent in the past six years, to 1.8 million nationally in 2012, according to the Medicare Payment Advisory Commission, an independent government agency.
…Meanwhile, more states are trying to address the situation. Connecticut becomes at least the third state in the nation, after New York and Maryland to require notification for observation status. Massachusetts, New Jersey and Pennsylvania are considering similar laws. CONTINUED in Connecticut Health Investigative Team CONTINUED in The Courant …
You’re Being Observed In The Hospital? Patients With Private Insurance Better Off Than Seniors
By Susan Jaffe KAISER HEALTH NEWS | September 11, 2014 | This KHN story also ran in 
An increasing number of seniors who spend time in the hospital are surprised to learn that they were not “admitted” patients — even though they may have stayed overnight in a hospital bed and received treatment, diagnostic tests and drugs.
Because they were not considered sick enough to require admission but also were not healthy enough to go home, they were kept for observation care, a type of outpatient service. The distinction between inpatient status and outpatient status matters: Seniors must have three consecutive days as admitted patients to qualify for Medicare coverage for follow-up nursing home care, and no amount of observation time counts for that three-day tally. That leaves some observation patients with a tough choice: Pay the nursing home bill themselves — often tens of thousands of dollars – or go home without the care their doctor prescribed and recover as best they can.
But most observation patients with private health insurance don’t face such tough choices. Private insurance policies generally pay for nursing home coverage whether a patient had been admitted or not. Here’s a primer comparing how Medicare and private insurers handle observation care. [Continued in KHN] [Continued in Washington Post]…
Medicare Modifies Controversial Hospice Drug Rule
By Susan Jaffe | July 18th, 2014 | KAISER HEALTH NEWS
In response to strong criticism, Medicare officials are modifying rules intended to prevent the agency from paying twice for the same prescriptions for seniors receiving hospice care.
Under the rules that took effect in May, hospice patients or their families could not fill prescriptions through their Part D drug plans until first confirming that the prescriptions were not covered by hospice providers. Drugs related to palliative and comfort care are supposed to be covered under the fixed rate payments to the hospice.
Medicare announced Friday that the rules would be revised so that the additional authorization would be required for only four types of medications: pain relievers, anti-nauseants, laxatives, and anti-anxiety drugs that are “nearly always” considered hospice-related.
“Medicare really tried to address our concerns quickly and effectively,” said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy. [MORE] …
PCORI, NIH Announce Plans For $30 Million Study On Falls
By Susan Jaffe June 5,2014 KAISER HEALTH NEWS in collaboration with
The nation’s largest and most intensive study of how to best prevent seniors’ injuries from falling will begin next year under a $30 million grant announced Wednesday by the Patient-Centered Outcomes Research Institute and the National Institutes of Health. A diverse group of 6,000 adults over age 75 or their caregivers will be recruited around the country to participate in the study.
More than 18,000 seniors died as the result of falls in 2010, and thousands more are injured every year, according to the federal Centers for Disease Control and Prevention.
“A serious fall that leads to a bone fracture or hospitalization has been demonstrated to be one of the most devastating events in the life of an older person, comparable to a serious stroke,” said Dr. Thomas Gill, a geriatrician and professor at Yale School of Medicine and one of the study’s three principal investigators. [More from KHN] [More from Washington Post]…
Medicare Seeks To Stop Overpayments For Hospice Patients’ Drugs
By Susan Jaffe May 1,2014 KAISER HEALTH NEWS in collaboration with
New Medicare guidance taking effect today aims to stop the federal government from paying millions of dollars to hospice organizations and drug insurance plans for the same prescriptions for seniors. But the changes may make it more difficult for dying patients to get some medications, senior advocates and hospice providers say.
The new measures direct insurers not to pay for any prescriptions for hospice patients until they receive confirmation that the drugs are not covered instead by the hospice provider. Requiring additional authorization for these prescriptions will “prevent duplicate payments for drugs covered under the hospice benefit,” Medicare officials told hospice providers and insurers in a conference call three weeks ago. [More from KHN] [More from Washington Post]…
A Quiet ‘Sea Change’ in Medicare
By Susan Jaffe | March 25, 2014, 5:00 am 
Ever since Cindy Hasz opened her geriatric care management business in San Diego 13 years ago, she has been fighting a losing battle for clients unable to get Medicare coverage for physical therapy because they “plateaued” and were not were not getting better.
“It has been standard operating procedure that patients will be discontinued from therapy services because they are not improving,” she said.
Glenda Jimmo at home in Lincoln, Vt., in 2012. (Paul O. Boisvert for The New York Times)
No more. In January, Medicare officials updated the agency’s policy manual — the rule book for everything Medicare does — to erase any notion that improvement is necessary to receive coverage for skilled care. That means Medicare now will pay for physical therapy, nursing care and other services for beneficiaries with chronic diseases like multiple sclerosis, Parkinson’s or Alzheimer’s disease in order to maintain their condition and prevent deterioration.
Articles most frequently emailed by NYTimes.com readers March 25, 2014 (click to enlarge)
But don’t look for an announcement about the changes in the mail, or even a prominent notice on the Medicare website. Medicare officials were required to inform health care providers, bill processors, auditors, Medicare Advantage plans, the 800-MEDICARE information line and appeals judges — but not beneficiaries. MORE…
Link
By Susan Jaffe | March 7, 2014 | Kaiser Health News in collaboration with 
Federal efforts to strengthen inspections of the nation’s nursing homes are gaining momentum after a government probe uncovered instances of substandard care.
The March 3 report by the HHS Inspector General found that an estimated one-third of residents suffered harm because of substandard care and that the chances of nursing home inspectors discovering these “adverse events” are “slim to none,” said Ruth Ann Dorrill, a deputy regional director for the inspector general and the manager of the investigation.
Nearly 60 percent of these incidents were preventable — including injuries due to falls or medication errors — and more than half of residents were hospitalized as a result, costing Medicare an estimated $2.8 billion in 2011, according to investigators. In 6 percent of the cases, poor care contributed to residents’ deaths….
After reviewing a September draft of the IG report, Medicare officials became interested in using the IG’s investigative techniques, methods not normally used in measuring nursing home quality, Dorrill said. [More from KHN] [More from Washington Post]
Link
By Susan Jaffe | February 28, 2014 | Kaiser Health News produced in collaboration with
It used to be difficult for Edith Couturier, an 85-year-old resident of the District of Columbia, to explain to her adult children on the West Coast all the details of her medical appointments. But now she doesn’t go alone — she takes along a volunteer “medical note taker.”
“There are four ears listening to what the doctor says,” said Couturier. That second set of ears belongs to Sharon Wolozin, who takes notes the old-fashioned way – with pen and paper – and then reads some of the main points aloud to confirm them with the doctor.
Wolozin is a volunteer for the Northwest Neighbors Village in Washington, D.C., one of the more than 200 “villages” across the United States. These neighborhood membership organizations provide volunteers and other resources to help with everything from transportation and snow shoveling to hanging curtains and solving computer glitches.
But as many of the Northwest Neighbors’ 210 dues-paying members “age in place” – the village movement’s top goal — some need more than just a ride to the doctor, said executive director Marianna Blagburn.
[More in KHN] [More in USA Today]
Link
By Susan Jaffe | Sept. 17, 2013 | KAISER HEALTH NEWS in collaboration with 
The U. S. Department of Labor issued new rules Tuesday that mandate home health care agencies pay their workers the minimum wage and receive overtime pay starting in 2015.
“Almost 2 million home care workers are doing critical work, providing services to people with disabilities and senior citizens who want to live in community settings and age in place in their familiar surroundings,” said Secretary of Labor Thomas Perez.
But when it comes to getting paid, they are “lumped into the same category as teenage babysitters,” he said. “This is wrong and this is unfair.”
For nearly 40 years, home care workers had been exempted from the pay rules because their services were considered “companionship.” But advocates, including organized labor organizations, had argued that these workers were often doing much more, providing assistance with dressing, eating and other daily activities. [More from KHN or Washington Post]
Link
By Susan Jaffe and Kaiser Health News in partnership with
A commission created by Congress to address the country’s surging need for long-term health care released recommendations Friday but did not reach a consensus on how to pay for these often expensive services.
The proposals were part of a report that received bipartisan support from nine of the 15 commissioners, five Republicans and four Democrats. It also was rejected by a bipartisan minority, five Democrats and a Republican.
The three-page summary of recommendations tackles a wide-ranging list of concerns but offers few specific remedies. Among its many proposals, the panel calls for supporting criminal background checks for long-term care workers, ensuring that family caregivers are included in care planning, using more technology to share information; revising scope of practice rules to allow nurses and others to provide medical services and improving working conditions and opportunities for direct care workers. [MORE from KHN ] [MORE from NewsHour]
How to Fix Long-Term Care in U.S.? Panel Releases Some Ideas
Link
By Susan Jaffe | June 28, 2013 | KAISER HEALTH NEWS
The Commission on Long-Term Care held its first meeting Thursday on Capitol Hill with some members acknowledging that their late start adds to their challenges in offering Congress recommendations on how to finance the expensive services for seniors and disabled Americans.
The panel is
hobbled with a meager budget and staffing, and it is facing a three-month deadline for its report. Speakers at the meeting reminded the commission that the effort is daunting.
The commission heard a litany of statistics from four experts who explained how the nation’s growing population of seniors will become more dependent on long-term care services. But the rising cost of those services threatens to deplete individuals’ savings and add to the nation’s budget problems because of the expenses borne by Medicare and Medicaid. MORE
FAQ: Medicare Beneficiaries May See Increased Access To Physical Therapy Or Some Other Services
By Susan Jaffe | June 25, 2013 | Kaiser Health News in collaboration with
For years, seniors in Medicare have been told that if they don’t improve when getting physical therapy or other skilled care, that care won’t be paid for. No progress, no Medicare coverage — unless the problem got worse, in which case the treatment could resume.
This frustrating Catch-22 spurred a class-action lawsuit against Health and Hu
man Services Secretary Kathleen Sebelius. In January, a federal judge approved a settlement in which the government agreed that this “improvement standard” is not necessary to receive coverage.
“This will help a lot of older or disabled people who clearly need the skilled care and aren’t getting it because they will not get better,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which helped bring the lawsuit. “The settlement recognizes that Medicare will pay for care to maintain their condition and prevent backsliding.”
Yet providers may not know about the settlement yet and may still be telling patients, incorrectly, that Medicare won’t cover treatment if there’s no improvement. MORE
…
Link
Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care
By May 3, 2013 | KAISER HEALTH NEWS in collaboration with 
“This trend concerns us because of the potential financial impact on Medicare beneficiaries,” officials wrote in an announcement April 26. Patients must spend three consecutive inpatient days in the hospital before Medicare will cover nursing home care ordered by a doctor.
…The reaction from patient advocates, doctors and hospitals has been swift and surprisingly unanimous: it’s a bad idea. MORE
Link
By SUSAN JAFFE
Ellen Gorman, 72, a New York psychotherapist, can’t walk very far and gets around the city mainly by taxi, “which is really expensive,” she said. Twice since 2008 her physical therapy was discontinued because she wasn’t progressing. But after a knee replacement last year, she is getting physical therapy again, exercising with her therapist and building up her endurance by walking in the hallway of her Manhattan apartment building. Because of an
action by Congress and a recent court settlement, Medicare probably won’t cut off Ms. Gorman’s physical therapy again should her progress level off — for as long as her doctor says it is medically necessary.
Congress continued for another year a little-known process that allows exceptions to what Medicare pays for physical, occupational and speech therapy. ….In addition, the settlement of a class-action lawsuit last month now means that Medicare is prohibited from denying patients coverage for skilled nursing care, home health services or outpatient therapy because they had reached a “plateau,” and their conditions were not improving. That will allow people with Medicare who have chronic health problems and disabilities to get the therapy and other skilled care that they need for as long as they need it, if they meet other coverage criteria. MORE
Link
Insurance Commissioners Reject Calls To Limit Seniors’ Medigap Policies
By Susan Jaffe KAISER HEALTH NEWS in collaboration with 
Dec. 6, 2012
The nation’s insurance commissioners have some stern advice about proposals to shrink Medicare spending by asking seniors with supplemental Medigap policies to pay more out of pocket for their health care: Don’t do it.
The health law requires the National Association of Insurance Commissioners to advise the administration about whether seniors would use fewer Medicare services — and therefore, cost the government less money — if the most popular Medigap plans were less generous.
“Everything we’ve looked at has shown that increasing cost-sharing does stop people from seeking medical care,” said Bonnie Burns, a training and policy specialist at California Health Advocates who serves on an NAIC committee that has studied the issue for more than a year. “The problem is they stop using both necessary and unnecessary care.” [More in The Washington Post] or longer version from Kaiser Health News]
Link
Medicare pilot program meant to revise policy that leaves seniors with costly bill
By August 9, 2012 | KAISER HEALTH NEWS produced in collaboration with
Concerned that a growing number of seniors have been unexpectedly forced to pay thousands of dollars for nursing home care after a stay in a hospital, Medicare has launched a pilot project to test whether it can relax hospital-payment rules to help the 
growing number of seniors who are shelling out thousands of dollars for follow-up nursing-home care.
The issue involves what should be an easy question: Is the Medicare beneficiary an inpatient or an observation patient? The answer can mean the difference between Medicare-covered follow-up nursing-home care or a senior facing an unexpected whopper of a bill. [Continued in The Washington Post and in KHN]
Link
MEDICARE TIP SHEET July 17, 2012 Published by Association of Health Care Journalists
Don’t look only to Washington policymakers for strategies to control medical costs and improve care for our aging population. New pilot projects that could accomplish these goals, which are at the heart of health reform, are being tested in communities across the country. In this tip sheet, reporter Susan Jaffe provides an overview of projects sponsored by the Center for Medicare and Medicaid Innovation, directs journalists to helpful resources and supplies an extensive list of potential story ideas. [access requires AHCJ membership or available on request here]
Innovative Day-Care Program Seeks To Keep Frail, Low-Income Seniors In Their Homes
By Susan Jaffe | December 21, 2010 | Kaiser Health News in collaboration with 
Several mornings a week, a white van stops at Geraldine Miller’s house just east of Baltimore to pick her up for ElderPlus, a government-subsidized day-care program for adults on the campus of the Johns Hopkins Bayview Medical Center.
Because 
Miller, who is 75 and uses a walker, has trouble getting down the stairs from her second-floor apartment, the driver comes inside to help. When she feels wobbly, he lends her an arm. When she feels strong, he faces her and steps down backward on the steps so he can catch her if she falls. When it rains, he shelters her with an umbrella. This is the sort of extra care that makes ElderPlus different. ElderPlus is part of PACE, the Program for All-Inclusive Care for the Elderly, which provides comprehensive medical and social services to frail, low-income seniors with serious health problems. [Continued at Kaiser Health News or The Washington Post.] Video: “Picking Up The Pace”
… Link
Dialysis crisis followed shift by Medicaid
By Susan Jaffe | Plain Dealer Reporter | February 12, 2007
For the past year, a dialysis machine has been keeping Karletta Edwards’ mother alive, substituting for her kidneys to cleanse her blood three times a week.
But in January, shortly after Ohio’s Medicaid program transferred her, along with more
than 25,000 other low-income people in Northeast Ohio, into an HMO, something went wrong.
The state’s contracts with insurance companies are expected to save Medicaid $24 million this year, by the time some 125,000 blind, disabled or older people are placed in privately run managed care plans.
Even though the companies are paid 6.6 percent less, Medicaid’s average cost to care for the same population, state officials say the health coverage will remain the same…. Four weeks ago, Edwards received a desperate call from her mother. The transportation service that picked up Emma Hansen from her East Cleveland home and brought her to the dialysis center didn’t show up. [Continued here]
You Can Go Home Again: A move to a nursing home needn’t be forever anymore.
A new Ohio program not only supports independent living, but also saves the state money.
By Susan Jaffe | Plain Dealer Reporter | November 7, 2004
Without Ohio’s Access Success Project, Larry Fry might have lived in a nursing home for the rest of his life. The program is unwinding the gove
rnment rules and red tape that trap people in nursing homes who don’t want to be there, don’t need to be there and certainly don’t need to be driving up the state’s enormous nursing home costs (See Graphic, “Paying More for Less,” pg. 19). If it succeeds, the effort targeting 250 nursing home residents could save Ohio millions of dollars a year. Nursing home care costs an average of about $56,000 per resident a year in Ohio. Because Fry needs so little care, living on his own will save Medicaid roughly $50,000 a year. Continued in The Plain Dealer’s Sunday Magazine…