The Outlook for Spending on Health Care and Long-Term Care

The Outlook for Spending on Health Care and Long-Term Care (PDF; 515 KB)
Source: Congressional Budget Office
PDF of PowerPoint slides — Presentation to the National Governors Association’s Health and Human Services Committee

When Long-Term Care Becomes Wrong-Term Care

The term “long-term care” is revealing. Long-term care is usually about long-term loss: the loss of authority, money, health, and connections to family and community. Our system is based on an expert and medical model of passive consumption and limited choices. And because none of us really want this, we avoid talking about it or planning for it . . .

We need to begin an intergenerational discussion to redefine the issue in radically new - civic - terms . . .

We should talk about how we all age, not just about “the elderly”; about harnessing wisdom and building individual capacity, not just providing more/better services and care. We should talk about health and wellness, not just chronic illness; about taking personal responsibility for our retirement and for the economic health of future generations, not just how we pay the bills for the current troubled system . . .

The Grief Experiences of CNAs

By failing to acknowledge CNAs' grief, nursing homes often make it harder for workers to deal with their feelings, according to a study of how nursing assistants cope with the death that is so much a part of life in nursing homes. CNAs are often left to deal with their emotions on their own, creating a sense of emotional "disenfranchisement." Read more and comment

Tax Credits Could be Worth Thousands to Direct-Care Workers

If you're a direct-care worker or you work with direct-care workers, you might want to help spread the word about the earned income tax credit (EITC). Direct-care workers who file a federal tax return this season could be eligible for thousands of dollars in state and federal credits and refunds, mainly through the federal EITC, which will return up to $4,716 per person to eligible low-income taxpayers. As much as a quarter of all EITC funds go unclaimed each year because so many people don't know they're entitled to them.

Workers who file a federal return may also be eligible for an EITC from their state or for one of the economic stimulus payments being made this year by the federal government. The economic stimulus payments will generally range from $300 to $600 for individuals and from $600 to $1,200 for joint filers, plus $300 for each qualifying child.

The Center on Budget and Policy Priorities website has a useful section on the national EITC. Its online toolkit includes a calculator to estimate how much of a return to expect, tips on how to get taxes prepared free of charge, how to file electronically to get your money back fast, and more.

Another useful website is I-CAN, an online tax filing system that helps low-income taxpayers file their federal forms free of charge and includes information about the EITC. Taxpayers in California, Michigan, Montana, New York, and Pennsylvania can also file their state taxes free through I-CAN.

Economic Study Finds DME Competitive Bidding Program Will Reduce Competition, USA

A new economic study finds that the competitive bidding program for durable medical equipment (DME) being rolled out by the Centers for Medicare and Medicaid Services (CMS) would lead to reduced competition, lower quality of care, and higher costs.

Two Robert Morris University professors, Brian O'Roark, PhD and Stephen Foreman, PhD, conducted the study, which was released this week by the Pennsylvania Association of Medical Suppliers (PAMS).

"The limits on competition that CMS is proposing to implement will have great potential to produce higher prices and lower service quality," Foreman stated. "The franchise bidding process that CMS is implementing is at odds with everything that we know about markets, efficiency and incentives. We should be encouraging added competition in the market, not limiting it. Limits on competition like those proposed by CMS rarely, if ever, make consumers better off."

Family Caregiving: from MSU Extension

Estimates show that the United States has approximately 28.8 million caregivers. Are you one of them?

Lots of articles and information.

Innovative Program “OPENS” Doors for MI Health Care Workers, Employers

Michigan’s innovative Kent County Health Field Collaborative (HFC), through its pilot Opportunity Partnership & Empowerment Network (OPEN) program, offers exciting potential to address the “care gap” - Michigan’s rapidly growing number of elders and people with disabilities and ever-shrinking pool of caregivers. The HFC consists of a group of employers working together - along with partners from government, educational institutions, and other not-for-profits - to solve recruitment and retention challenges in health care. Together they identified the challenges employers face now and in the future with growing the workforce.According to a new case study by PHI, a nonprofit organization that supports quality long-term care by improving the quality of direct-care jobs, the OPEN program has achieved impressive results with employee retention. The OPEN program, which the HFC based on a retention model developed by The Source (a coalition of Grand Rapids area manufacturers dedicated to collaborative approaches to employee retention and advancement), saw among its key results significant drops in the overall turnover rates of direct-care workers - those who provide services and supports to elders and people living with disabilities.

Republicans scoff as Carlyle Group aims to take over nursing homes

Last year, officials in the state of Ohio expressed concerns about the purchase of the "troubled family" known as HRC Manor by The Carlyle Group, a private equity firm that includes as its directors some of the most prominent names in American politics.

Toledo-based HCR Manor Care operates 44 nursing homes caring for 5,100 people in Ohio and has been under close watch by state authorities. Officials fear that recent problems could continue under the ownership of Carlyle, which owns Dunkin' Donuts and Hertz, but it's only health care related venture is Lifecare, a nationwide chain of 21 long-term care hospitals.

"These aren't the kind of nursing homes that they can just take over and keep status quo," said Beverly Laubert, long-term care ombudsman for the Ohio Department of Aging. "When you have facilities with such quality problems, someone is going to have to fix them."

State investigators have found instances in which residents at HRC Manor Care facilities did not receive proper care, including instances in which residents didn't receive physician-ordered lab tests or the proper treatment for incontinence, hampering their ability to progress toward using the bathroom on their own.

Michigan's own ombudsman for long-term care expressed the same kinds of reservations this week, but the response she got from one side of the aisle was scoffing. Via Gongwer:

Important news for seniors: tax return and rebate

From National Council on Aging;

Call Hilary Dalin at (202) 479-6626 or email at hilary.dalin@ncoa.og for more information

Fact Sheet:

Your Clients Who Are Low-Income Social Security Recipients Must File 2007 Tax Return to Receive Economic Stimulus Check

What is the stimulus package?

• To help spur a slowing economy, the IRS will send tax rebate checks to over 130 million households beginning in May 2007 and continuing through the summer. Up to 20 million Americans who rely primarily on Social Security income qualify for a rebate check.

How do people qualify for a stimulus tax rebate check?

• Generally a person has to have more than $3,000 in income. Even if a person does not have any earned income they can still qualify for a stimulus tax rebate check if their Social Security benefits, Veteran’s Affairs (VA) benefits, and/or railroad retirement benefits equal at least $3,000 annually.

To qualify, they must file a 2007 tax return on IRS Forms 1040 or 1040A with the IRS (even if their income is normally low enough that they are not required to file).

If they file a tax return, how much are they eligible for?

• In most cases, they will get payments ranging from $300 to $600. Payments increase by $300 for families with dependent children under the age of 17, up to a maximum stimulus payment of $1,200.

By what date does the 2007 tax return have to be filed and when will the checks be received?

• The IRS encourages filing a return if possible, by the regular April 15 deadline to get the rebate check in May 2008. Those filing later than April 15, with or without a tax-filing extension, may delay receipt of the rebate check. Those who qualify for a stimulus check will receive one by the end of 2008 if they file by October 15, 2008. No rebate checks will be issued after 2008 ends.

Will the stimulus payment affect eligibility for needs-based benefits programs?

• Receiving a payment under the stimulus package does not effect eligibility for or amount of needs-based benefits programs (i.e. Food Stamps). Specifically, the payment does not count as income in the month it is received and does not count as a resource (asset) for 60 days after the month in which it was received.

Does your organization have questions about the stimulus package? (Please note: this is not intended for inquiries from consumers; We have provided contact info for consumer referrals below.)

• Contact Hilary Dalin at the National Council on Aging at hilary.dalin@ncoa.org.

Do you know a low-to-moderate income senior who needs help filing a tax return?

The Tax Counseling for the Elderly (TCE) Program provides free tax help to people age 60 and older. To find an AARP Tax Aide site call 1-888-227-7669 or visit the AARP Web site.

The Volunteer Income Tax Assistance (VITA) program provides help to low- and moderate-income taxpayers. Call 1-800-906-9887 for assistance.

Holly Robinson

Associate Staff Director

ABA Commission on Law and Aging

740 15th Street NW

Washington, DC 20005

Phone: (202) 662-8694

Email:robinsoh@staff.abanet.org

Website: www.abanet.org/aging

CMS Proposes New Rules For Redesigning Medicaid, States Have Greater Flexibility In Benefits, Cost Sharing

Two new proposed rules that would give states unprecedented flexibility in designing their own Medicaid programs, including adjusting their benefit package to more closely align with beneficiary needs and requiring increased cost sharing by enrollees, were announced by the Centers for Medicare and Medicaid Services (CMS).

The proposed rules would implement provisions of the Deficit Reduction Act of 2005 and the Tax Relief and Health Care Act of 2006. The rules are the latest in a series of regulations to implement the Administration's goals of aligning Medicaid more closely with private market insurance and giving states more control over their Medicaid benefits packages.

COMMISSION LOOKS TOWARD TECHNOLOGY TO IMPROVE LONG-TERM CARE

A report issued by the National Commission for Quality Long-Term Care warns of a coming long-term care crisis and includes recommendations to advance long-term care reform in four areas: quality, workforce, technology and finance.

As we continue to look at this report, entitled “Isolation to Integration: Recommendations to Improve Quality in Long-Term Care,” today’s article details suggestions regarding technology.

Merging Discovery With Therapy: Second Generation Memory Care Debuts

Researchers and clinicians from the Indiana University School of Medicine and the Regenstrief Institute are blurring the distinction between lab and clinic as they debut the second generation of memory care.

Building upon a care model they developed and extensively tested over the past 7 years, the focus of second generation memory care is on two groups -- patients with cognitive disorders such as Alzheimer's disease and their caregivers. Results of the clinical trial of the IU-Regenstrief care model were published in the Journal of the American Medical Association in 2006.

The initial second generation memory center -- the Healthy Aging Brain Center opens at the IU Center for Senior Health at Wishard Health Services this month.

"When we make the lab from which we develop treatments and the clinic into one entity, we are constantly learning from our patients - what works for them and what does not. Our approach to memory care is on the fast track because by eliminating the distinction between the lab and the clinic, we compress the long timeline traditionally needed to go from discovery to treatment. For us and for those we treat, who are both those with memory problems and their caregivers, this means that they will be receiving the support and care they need now," said Malaz Boustani, M.D., M.P.H., an assistant professor of medicine at Indiana University School of Medicine, an Indiana University Center for Aging Research investigator and a Regenstrief Institute research scientist.

Out of Sight, Out of Mind: Social Exclusion Behind Closed Doors

This Age Concern report details the ever tougher conditions suffered by over a million older people who "are shut out from society and ignored by government policy", and offering a practical menu of ameliorative measures

AssistGuide Information Services

much more than last time:

Large number of resources and tools for caregivers. Much useful stuff.

Families Need Help Coping With Mild Cognitive Impairment

The age related memory condition known as mild cognitive impairment (MCI) is more disruptive of day-to-day life and relationships than once believed, gerontology researchers at Virginia Tech have discovered.

Funded by the Alzheimer's Association, Karen Roberto, director of the Center for Gerontology at Virginia Tech, and Rosemary Blieszner, associate director, set out to determine the issues and needs of families responding to MCI. After interviews with 99 families, the researchers reported, "Primary family members reported that their relatives were experiencing memory-related changes that interfere with their daily activities and responsibilities, decision-making processes, and relationships."

Senator Grassley Introduces Nursing Home Transparency and Improvement Act of 2008

On February 14, 2008, Senator Charles Grassley and Senator Herb Kohl introduced the Nursing Home Transparency and Improvement Act of 2008 (S.2641). According to a related Press Release, S.2641 aims to bring more transparency to consumers regarding nursing home quality, improve enforcement, and strengthen nursing home staff training requirements.

Among other things, S.2641 would reportedly require that "special focus facility" designations be placed on the Nursing Home Compare website. S.2641 would also require that CMS develop a standardized complaint form and require more uniform reporting of nursing staff levels so that comparisons can be made across nursing homes. S.2641 would also strengthen the available penalties. For instance, S.2641 would reportedly allow the Secretary to impose civil monetary penalties of up to $100,000 for a deficiency resulting in death, $3,000-$25,000 for deficiencies at the level of actual harm or immediate jeopardy, and not more than $3,000 for other deficiencies. Finally, S.2641 would attempt to improve staff training by including dementia management and abuse prevention training as part of pre-employment training.

CMS to Hold Skilled Nursing Facility/Long-Term Care Open Door Forum

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will hold the next Skilled Nursing Facility/Long-Term Care Open Door Forum at 3:30 p.m. (EST) on February 27, 2008.

To participate by telephone, one must dial 1-800-837-1935 and reference conference ID 18796437. To participate in person, one must RSVP by 2:00 p.m. (EST) on February 25, 2008 to SNF_LTCODF-L@cms.hhs.gov, and include your name, organization, phone number, and “SNF/LTC” in the subject line. The Open Door Forum will take place at the Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. CMS asks that attendees arrive no later than 3:00 p.m. (EST).

MRSA infection

Risk factors for hospital-acquired (HA) MRSA include:

Residing in a long-term care facility. MRSA is far more prevalent in these facilities than it is in hospitals. Carriers of MRSA have the ability to spread it, even if they're not sick themselves.

Absence Of Cancer Diagnosis And Treatment In Elderly Medicaid-Insured Nursing Home Residents

UroToday.com- A study in the January 2008 issue of the Journal of the National Cancer Institute suggests that Medicaid patients in nursing home care receive limited cancer services. While the prevalence of cancer in nursing home patients is 1 in 10, according to Dr. Bradley and coauthors this population has received little attention in outcomes research.

In the U.S, Medicaid is the predominant payer for long-term residential nursing home care. These patients often have low income, frail, and more than 30% of them require assistance to perform 3 or more activities of daily living. It is reported that nursing home staff may not effectively recognize and treat cancer. The researchers used statewide Medicaid and Medicare data merged with the Michigan Tumor Registry to identify a study sample of patients with a first primary cancer diagnosis. Tumor registry patients were matched to the state Medicare Denominator file for the years 1996-2000 and all claims for inpatient, outpatient, physician, and hospice services were identified. Those with at least one year of claims history before the month of diagnosis were selected, as this permitted an estimate of patients' comorbidity burden. The researchers calculated odds ratios for late or invasive but unknown stage of cancer, death within 3 months of diagnosis, receipt of hospice services, and receipt of cancer-directed surgery.

CMS Takes Next Step To Improve Quality In Nation's Nursing Homes, USA

The Centers for Medicare & Medicaid Services (CMS) built upon historic action it took last November by making public more names of underperforming nursing homes across the country.

On November 29, 2007, the agency began publishing the names of Special Focus Facility (SFF) nursing homes that had failed to improve significantly after being given the opportunity to do so.

Once a facility is selected as an SFF, state survey agencies are responsible for conducting twice the number of standard surveys and will apply progressive enforcement until the nursing home either (a) significantly improves and is no longer identified as an SFF, (b) is granted additional time due to promising developments, or (c) is terminated from Medicare and/or Medicaid.

NAD And DSA Launch Senior Resources Listing, USA

The National Association of the Deaf (NAD) and its Senior Citizens Section together with the Deaf Seniors of America (DSA) have jointly launched a resources listing of, by, and for older deaf Americans.

With the title of 'Senior Resources', this first-ever and comprehensive listing contains items of interest to older deaf persons and their families or caregivers. The first half provides useful names, addresses, phone numbers, and websites for various types of senior housing facilities (e.g., independent/retirement, assisted living, nursing, and others of a specialized nature). The second half focuses on senior clubs having gatherings of a recurring nature, which is of particular interest to deaf seniors who travel extensively.

Half-Million Dollar Surety Bond Requirement Would Put Many Small Durable Medical Equipment Providers Out Of Business

A Senate bill introduced last week would impose a $500,000 surety bond requirement on providers of durable medical equipment (DME) under Medicare and would put thousands of small homecare companies out of business, says the American Association for Homecare.

A law passed in 1997 requires a $50,000 surety bond for DME providers as a deterrent to fraud and abuse. However, the federal government has never actually implemented the surety bond requirement for the DME sector. The Centers for Medicare and Medicaid Services has proposed that the amount increase to $65,000.

The bill introduced last week, S. 2603, called the "Medicare Fraud Prevention Act of 2008," would increase the $50,000 surety bond requirement by a factor of ten. The bill would also increase civil and criminal fines for Medicare fraud and abuse. The bill is sponsored by Senators Mel Martinez (R-Fla.), John Cornyn (R-Texas), Norm Coleman (R-Minn.), Lamar Alexander (R-Tenn.), David Vitter (R-La.) and Jim DeMint (R-S.C.).

"The impact of a half-million dollar surety bond requirement would be devastating on law-abiding small providers,"

Poor Outcomes For Nursing Home Residents Underscore Need For Nurse Staffing Ratios And Stronger Enforcement

Last week the Centers for Medicare & Medicaid Services publicly identified over 4000 nursing homes - more than 25% of facilities nationwide - whose residents are physically restrained, or have pressure sores, or both, in excessive numbers. This should be a call to action to both Congress and the Centers for Medicare & Medicaid Services.

"What's needed to avoid pressure ulcers and physical restraints is a sufficient number of well-trained certified nurse assistants, accompanied and supervised by a sufficient number of registered nurses," said Senior Policy Attorney Toby S. Edelman with the Center for Medicare Advocacy. "With CMS reporting that more than 90% of nursing homes do not have sufficient staff to meet residents' needs, it is time for Congress to enact legislation mandating comprehensive and meaningful nurse staffing ratios," continued Edelman. "For its part, CMS needs to take stronger enforcement action whenever it finds facilities short-changing their residents and providing them with less care than they need."

Effects of Cash and Counseling on Personal Care and Well-Being

Medicaid beneficiaries who have disabilities and receive traditional support services from Medicaid agencies often have little control over their care. Cash and Counseling is a flexible, consumer-driven program that gives Medicaid beneficiaries a monthly allowance. With this allowance they can purchase goods and services that facilitate independence, and they can hire whomever they like as caregivers, including family members and friends. This paper examines the effects of Cash and Counseling on the types and amount of personal assistance services Medicaid beneficiaries received, on the beneficiaries’ satisfaction with their care, and on their overall well-being.

Federal Government Encourages States to Make Self-Directed Personal Care an Option for Disabled Medicaid Consumer Who Need Help at Home

Centers for Medicare & Medicaid Services allows state Medicaid programs to offer a "Cash & Counseling" state plan option without first obtaining a federal waiver. This change comes after evaluation found that Cash & Counseling improves quality of life, reduces unmet needs for care, and helps disabled consumers maintain health without costing Medicaid substantially more than traditional services.

Proposed Legislation Strips Nursing Home Residents Of Their Legal Protections, USA

Can Michigan look forward to much the same?

Just four years since the National Healthcare Corporation (NHC) nursing home fires killed 16 residents in Nashville - and in a year when nursing home violations and admission suspensions are at an all time high - Tennessee nursing homes are seeking unprecedented legal protection from residents who are abused or neglected.

The move came two days after Governor Phil Bredesen announced he will fundamentally restructure how long-term care is handled in Tennessee by expanding alternatives to nursing homes.

State Sen. Jim Tracy (R-Shelbyville) and state Rep. Randy Rinks (D-Savannah) introduced the bill last week that would severely restrict the rights of nursing home victims and their families to seek justice no matter how bad the injury they suffer and no matter how bad the conduct of the home. The type of neglect and abuse recently documented in Tennessee nursing homes ranges from maggots in wounds to untreated broken bones to rape.

NHC, which reported more than $500 million in annual gross profits in 2006 and whose CEO Robert G. Adams makes more than $1.3 million a year, is one of the supporters of the legislation. NHC is the same corporation that owned the Nashville nursing home where 16 residents perished in September 2003, and that owns a nursing home in Milan, Tenn. that put residents "at risk of injury or death from a fire," according to a June 20, 2007 inspection report of the Tennessee Department of Health.

The legislation would ensure that:

- Residents would have little to no recourse against nursing homes no matter how bad the conduct of a home.

- Nursing homes can demand that residents sign arbitration agreements in order to live there, making nursing home residents the least protected class in the state.

Older Americans Suffer Serious Access Limitations to Exercise their Right to Vote

The US Senate Special Committee on Aging held a hearing yesterday in Washington, DC, on older Americans and the significant barriers they face in exercising their right to vote.

Jason Karlawish, MD, associate professor of Medicine and Medical Ethics at the University of Pennsylvania School of Medicine, testified before the Committee, citing results from a series of his studies examining voting rights for the elderly.

Karlawish, a member of Penn's Institute on Aging who specializes in older adult health care and related issues, recommends that to help break down the logistical and geographical voting barriers many older Americans face, the United States must develop a model for mobile polling.

"Elderly voters -- especially elderly voters who live in long-term care settings -- are at the mercy of others when it comes to exercising their right to vote," said Karlawish.

"Mobile polling means election officials or equivalent groups visit long-term facilities in their district prior to registration deadlines to encourage and solicit registrations," said Karlawish.

Time for Companies to Offer Long-Term Care Benefits?

Along with Medicare, Social Security, pensions and health care, here's another disaster coming straight at us: long-term health care. Since we're not having much luck solving the other issues, many people and policymakers just prefer to not even think about long-term care -- and that's reflected by the low numbers of people insuring themselves and their family for the very likely visit they will take to a nursing home in old age. Besides, most of us can't afford the coverage or the care itself and are banking on the government to pay for it -- even if we or our loved ones have to spend down their assets first. But Medicaid is already straining and will be unable to absorb the crush of Baby Boomers coming and headed for nursing homes over the next 30 to 40 years.

In a paper entitled Long-term Care Coverage: The Missing Element in the Employee Safety Net the consulting group Milliman suggests that it's time for employers to consider adding long-term care insurance as a benefit -- with some help paying for it.

OIG Solicits Comments on Nursing Facility Compliance Program Guidance

On January 24, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) published a Notice in Federal Register soliciting comments, recommendations and suggestions on how to best revise the nursing facility compliance program guidance. Specifically, the OIG is seeking comments addressing any changes to existing risk areas and introducing new risk areas. Comments must be delivered to the OIG by no later than 5 p.m. on February 25, 2008. The Notice explains how to submit any comments.

OIG Reports on Government-Long Term Care Industry Roundtable

On January 31, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) and the Health Care Compliance Association released a report arising from a recent government-industry roundtable called Driving for Quality in Long-Term Care: A Board of Directors Dashboard. The roundtable was held on December 6, 2007 and provided the long-term care industry with an opportunity to inform the OIG of issues surrounding board of directors' oversight of quality of care.

The report includes written summaries of the discussions that took place in breakout groups designed around the following 3 perspectives on the oversight of quality of care: (i) organizational commitment to quality; (ii) processes related to monitoring and improving quality; and (iii) outcome measures related to quality. In the report, a fourth breakout group also considered the benefits of, and challenges to, developing a Quality of Care Dashboard (i.e., a management tool that may provide a way to access and oversee performance on quality of care issues).