Tag: long term care

Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill

By Susan Jaffe  | Kaiser Health News | January 18, 2018 | This KHN story also ran on     

Colin Campbell    (Heidi de Marco/KHN)

Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,”he said.

Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or “Lou Gehrig’s disease,” which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.

The former computer systems manager has Medicare coverage because of his disability, but no fewer than 14 home health care providers have told him he can’t use it to pay for their services. That’s an incorrect but common belief….  [Continued at Kaiser Health News and NPR]…

New Regulations Would Require Modernizing Nursing Home Care

By Susan Jaffe | July 13, 2015  | Kaiser Health News in collaboration with   nprlogo_138x46

After nearly 30 years, the Obama administration wants to modernize the rules nursing homes must follow to qualify for Medicare and Medicaid payments.

The hundreds of pages of proposed changes cover everything from meal times to use of antipsychotic drugs to staffing. Some are required by the Affordable Care Act and other recent federal laws, as well as the president’s executive order directing agencies to simplify regulations and minimize the costs of compliance.

“Today’s measures set high standards for quality and safety in nursing homes and long-term care facilities,” said Health and Human Services Secretary Sylvia M. Burwell. “When a family makes the decision for a loved one to be placed in a nursing home or long-term care facility, they need to know that their loved one’s health and safety are priorities.”

Officials announced the update as the White House Conference on Aging convenes Monday. The once-a-decade conclave sets the agenda for meeting the diverse needs of older Americans, including long-term care options. This month also marks the 50th anniversary of the Medicare and Medicaid programs, which cover almost 125 million older, disabled or low-income Americans. Medicare and Medicaid beneficiaries make up the majority of residents in the country’s more than 15,000 long-term care facilities. [MORE from Kaiser Health News and NPR]…

Officials Weigh Options To Hold Down Medicare Costs For Hospice

By Susan Jaffe  | April 23, 2015 |  Kaiser Health News and also published in

Medicare officials are considering changes in the hospice benefit to stop the federal government from paying twice for care given to dying patients. But patient advocates and hospice providers fear a new policy could make the often difficult decision to move into hospice care even tougher.hospicecare
Patients are eligible for hospice care when doctors determine they have no more than six months to live. They agree to forgo curative treatment for their terminal illness and instead receive palliative or comfort care. However, they are also still allowed Medicare coverage for health problems not related to their terminal illness, including chronic health conditions or for accidental injuries.
Medicare pays a set amount to the hospice provider for all treatment and services related to the terminal illness, including doctor’s visits, nursing home stays, hospitalization, medical equipment and drugs. If a patient needs treatment that hospice doesn’t provide because it is not related to the terminal illness — or the patient seeks care outside of hospice — Medicare pays the non-hospice providers. The problem is that sometimes Medicare pays for care outside the hospice benefit that it already paid hospice to cover.
To reduce the chances of these duplicative payments, Medicare officials have announced that they are examining whether to assume “virtually all” the care hospice patients receive should be covered under the hospice benefit….
Seniors’ advocates are worried that putting all coverage under the hospice benefit will create obstacles for patients. Instead, Medicare should go after hospice providers who are shifting costs to other providers that Medicare expects hospice to cover, said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy, who urged the government to protect hospice patients’ access to non-hospice care….”If your blood sugar gets out of control, that could hasten your death,” she said. “But people shouldn’t be rushed off to die because they’ve elected the hospice benefit.”  [More from KHN] [More in USA Today]
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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] …

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 wapo

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]…

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 Human 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

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Younger, Disabled Medicare Beneficiaries Have Trouble Getting Supplementary Insurance

By Susan Jaffe   KAISER HEALTH NEWS  | March 7, 2011   This story was produced in collaboration with  

Joe Hobson, 63, crosses the street in front of his Arlington apartment. (Jessica Marcy / Kaiser Health News).

One night three years ago, Joe Hobson finished reading a book, went to sleep and woke up blind. The problem,a rare hereditary disease, forced him to give up his 20-year communications job, along withits generous health insurance. Now 63, the Arlington man is covered by Medicare, the federal program for elderly and disabled Americans.

Like many people with Medicare, Hobson would like to buy supplemental, or Medigap, insurance to help cover his out-of-pocket costs, such as co-payments and deductibles. But Medigap prices can be prohibitive for disabled beneficiaries younger than 65. The cheapest plan for such people in Northern Virginia is $338 a month, according to Brad Rothermel,an Annandale insurance agent who has helped Hobson look for a policy. That’s three times the premium of a plan with much better benefits that is available to a 65-year-old. And the private insurers that offer Medigap policies are free to reject Hobson or charge him extra because of his preexisting health conditions.[Continued in KHN]  andin The Washington Post]

 

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